Ambetter Essential Care 5 (2021) + Vision + Adult Dental Plan Details for 2021- HealthPocket

Ambetter Essential Care 5 (2021) + Vision + Adult Dental

$458.25/mo

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Zip Code28269
Applicant9/18/1986 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameAmbetter Essential Care 5 (2021) + Vision + Adult Dental
Plan IDhhs-77264NC0020028
Plan Year2021
Insurance ProviderAmbetter
Metal LevelExpanded Bronze
Plan TypeHMO
Deductible$8,100
Out-of-Pocket Maximum$8,500
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$40 Copay
Specialist Visit$90 Copay
Laboratory Outpatient and Professional Services$45 Copay
X-rays and Diagnostic Imaging50.00% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans50.00% Coinsurance after deductible
Deductible - Family$16200 per group
Out-of-Pocket Maximum - Family$17000 per group

Prescription drug coverage

Generic Drugs$30 Copay
Preferred Brand Drugs50.00% Coinsurance after deductible
Non-Preferred Brand Drugs50.00% Coinsurance after deductible
Specialty Drugs50.00% Coinsurance after deductible

Access to doctors and hospitals

Provider directory URLhttps://providersearch.ambetterhealth.com/
Does this plan have access to a national provider network?No
Is a referral required to see a Specialist?Not Covered
Does this plan cover services outside plan service area?Not Covered
Does this plan cover services outside the country?Not Covered

Hospital services

Emergency Room Services50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services50.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service50.00% Coinsurance after deductible

Maternity

Prenatal and Postnatal Care$40 Copay
Delivery and all inpatient services for maternity care50.00% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services$40 Copay
Mental/Behavioral Health Inpatient Services50.00% Coinsurance after deductible
Substance use disorder outpatient services$40 Copay
Substance use disorder inpatient services50.00% Coinsurance after deductible

Medical Management Programs

Does this plan offer disease managment programs?Asthma, Diabetes, Heart Disease, Pregnancy
Does this plan offer a wellness program?Not Covered

Vision Coverage

Routine Eye Exam for ChildrenIncluded
Eye Glasses for ChildrenIncluded
Routine Eye Exam for AdultsIncluded

Child Dental Coverage

Child Dental Coverage - Routine Dental CareNot Covered
Child Dental Coverage - Basic Dental CareNot Covered
Child Dental Coverage - OrthodontiaNot Covered
Child Dental Coverage - Major Dental CareNot Covered

Adult Dental Coverage

Adult Dental Coverage - Routine Dental CareIncluded
Adult Dental Coverage - Basic Dental CareIncluded
Adult Dental Coverage - OrthodontiaNot Covered
Adult Dental Coverage - Major Dental CareNot Covered

Exclusions and Limitations

More Included BenefitsOther Practitioner Office Visit (Nurse, Physician Assistant)
Preventive Care/Screening/Immunization
Bariatric Surgery
Private-Duty Nursing
Imaging (CT/PET Scans, MRIs)
Outpatient Surgery Physician/Surgical Services
Urgent Care Centers or Facilities
Inpatient Physician and Surgical Services
Home Health Care Services
Durable Medical Equipment
Hospice Services
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Nutritional Counseling
Prosthetic Devices
Radiation
Reconstructive Surgery
Transplant
Treatment for Temporomandibular Joint Disorders
Well Baby Visits and Care
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Mental/Behavioral Health Emergency Room
Mental/Behavioral Health Emergency Transportation/Ambulance
Mental/Behavioral Health ER Physician Fee
Mental/Behavioral Health Outpatient Other Services
Mental/Behavioral Health Urgent Care
Substance Use Disorder Emergency Transportation/Ambulance
Substance Use Disorder ER Physician Fee
Substance Use Disorder Outpatient Other Services
Substance Use Disorder Urgent Care
Telehealth and Virtual Care
Substance Use Disorder Health Emergency Room
More Limited BenefitsSkilled Nursing Facility
Hearing Aids
Infertility Treatment
Outpatient Rehabilitation Services
Habilitation Services
Chiropractic Care
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
Eyeglasses for Adults
More Excluded BenefitsAcupuncture
Cosmetic Surgery
Weight Loss Programs
Dental Check-Up for Children
Routine Foot Care
Abortion for Which Public Funding is Prohibited
Long-Term/Custodial Nursing Home Care
PremiumPlan NameDeductible
from $339Ambetter Essential Care 1 (2021) + Vision + Adult Dental$8,300.00Select
from $348Ambetter Essential Care 5 (2021)$8,100.00Select
from $403Ambetter Essential Care 1 (2021)$8,300.00Select
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  • Phone Number
    (704) 863-9830
  • Office Locations
    5727 Prosperity Crossing Drive
    Charlotte, NC 28269
5727 Prosperity Crossing Drive Charlotte NC, 28269

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HealthPocket.com is a free information source. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. While on our site, if you click on a plan or link, you may be directed to one of our partners who offers health insurance products. HealthPocket, Inc. is part of the Benefytt Technologies, Inc. family of companies.