Ambetter Balanced Care 12
34368KS0110012
Silver
EPO
Ambetter Balanced Care 12 is a Silver EPO plan by Ambetter from Sunflower Health Plan.
Locations
Ambetter Balanced Care 12 is offered in the following counties.
Plan Overview
This is a plan overview for 2022 version of Ambetter Balanced Care 12 34368KS0110012.
| Insurer: | Ambetter from Sunflower Health Plan |
| Network Type: | EPO |
| Metal Type: | Silver |
| HSA Eligible?: | No |
| Plan ID: | 34368KS0110012 |
Cost-Sharing Overview
Ambetter Balanced Care 12 offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for Ambetter Balanced Care 12 includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | 8400 | 16800 |
| Deductible: | 6500 | 13000 |
| Coinsurance: | 13000 | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Ambetter Balanced Care 12 will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | ||
| Out-of-Network Deductible: |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | 6500 |
| Copayment: | 500 |
| Coinsurance: | 900 |
| Limit: | 60 |
| Deductible: | 800 |
| Copayment: | 1500 |
| Coinsurance: | 0 |
| Limit: | 20 |
| Deductible: | 2500 |
| Copayment: | 200 |
| Coinsurance: | 0 |
| Limit: | 0 |
Notes:
- Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
- You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Ambetter Balanced Care 12?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904
Plan Features
Ambetter Balanced Care 12 offers the following features and referral requirements.
| Wellness Program: | No |
| Disease Program: | Asthma, Heart Disease, Diabetes, Pregnancy |
| Notice Pregnancy: | Yes |
| Referral Specialist: | No |
| Specialist Requiring Referral: | |
| Plan Exclusions: | |
| Child Only Option?: | Allows Adult and Child-Only |
Network Details
The following network details will help you understand what Ambetter Balanced Care 12 covers when you are out of the service area or out of the country.
| Out of Country Coverage: | No |
| Out of Country Coverage Description: | |
| Out of Service Area Coverage: | No |
| Out of Service Area Coverage Description: | |
| National Network: | No |
Additional Benefits and Cost-Sharing
Ambetter Balanced Care 12 includes the following benefits at the cost sharing rates listed below.
| Service | In-Network Copay / Coinsurance | Out-of-Network Copay / Coinsurance | Limits and Explanation |
|---|---|---|---|
| Mental/Behavioral Health ER Physician Fee Covered | N/A / 40.00% Coinsurance after deductible | / | |
| Substance Use Disorder ER Physician Fee Covered | N/A / 40.00% Coinsurance after deductible | / | |
| Mental/Behavioral Health Emergency Transportation/Ambulance Covered | N/A / 40.00% Coinsurance after deductible | / | |
| Substance Use Disorder Emergency Transportation/Ambulance Covered | N/A / 40.00% Coinsurance after deductible | / | |
| Mental/Behavioral Health Urgent Care Covered | $55.00 / N/A | / | |
| Substance Use Disorder Urgent Care Covered | $55.00 / N/A | / | |
| Primary Care Visit to Treat an Injury or Illness Covered | $35.00 / N/A | / | Unlimited Virtual Care Visits received from Ambetter Telehealth covered at No Charge, except for HSAs. |
| Specialist Visit Covered | $70.00 / N/A | / | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $35.00 / N/A | / | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | N/A / 40.00% Coinsurance after deductible | / | |
| Outpatient Surgery Physician/Surgical Services Covered | N/A / 40.00% Coinsurance after deductible | / | |
| Hospice Services Covered | N/A / 40.00% Coinsurance after deductible | / | |
| Routine Dental Services (Adult) Not Covered | / | / | |
| Infertility Treatment Covered | N/A / 40.00% Coinsurance after deductible | / | Plan covers Diagnosis and treatment of cause of infertility. Benefits are available for covered services such as office visits, laboratory tests, and radiological studies to diagnose the cause of infertility. Benefits are also provided for the necessary treatment of the condition unless the treatment is identified as non-covered (see exclusions). For example, corrective surgical procedures, therapeutic injections, and drug therapy regimens (Pregnyl, Clomid, Clomiphene, Ovidrel, Gonal, Follistim and Cetrotide) are all covered services when medically necessary. Benefits are also available for tests, such as ultrasound, performed to monitor the effectiveness of the fertility drug therapy. Also for any necessary pregnancy testing performed as an integral part of the overall infertility treatment program. Benefits are excluded, however, for any procedures, tests, or other services that are exclusively provided to monitor the effectiveness of non-covered fertilization procedures. |
| Long-Term/Custodial Nursing Home Care Not Covered | / | / | Long Term Acute Care is a covered benefit.? Long Term Nursing Care/ Custodial Care is not a covered benefit. |
| Private-Duty Nursing Covered | N/A / 40.00% Coinsurance after deductible | / | |
| Routine Eye Exam (Adult) Not Covered | / | / | |
| Urgent Care Centers or Facilities Covered | $55.00 / N/A | / | |
| Home Health Care Services Covered | N/A / 40.00% Coinsurance after deductible | / | Includes educational visits with a limit of three per year on educational visits. |
| Emergency Room Services Covered | N/A / 40.00% Coinsurance after deductible | / | |
| Emergency Transportation/Ambulance Covered | N/A / 40.00% Coinsurance after deductible | / | Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | N/A / 40.00% Coinsurance after deductible | / | |
| Inpatient Physician and Surgical Services Covered | N/A / 40.00% Coinsurance after deductible | / | |
| Bariatric Surgery Not Covered | / | / | |
| Cosmetic Surgery Not Covered | / | / | |
| Skilled Nursing Facility Not Covered | / | / | |
| Prenatal and Postnatal Care Covered | $35.00 / N/A | / | |
| Delivery and All Inpatient Services for Maternity Care Covered | N/A / 40.00% Coinsurance after deductible | / | |
| Mental/Behavioral Health Outpatient Services Covered | $35.00 / N/A | / | |
| Mental/Behavioral Health Inpatient Services Covered | N/A / 40.00% Coinsurance after deductible | / | |
| Substance Abuse Disorder Outpatient Services Covered | $35.00 / N/A | / | |
| Substance Abuse Disorder Inpatient Services Covered | N/A / 40.00% Coinsurance after deductible | / | |
| Generic Drugs Covered | $22.60 / N/A | / | Most Ambetter Plans offer Preferred Generic Drugs at $5 or less. Please see plan’s Summary of Benefits and Coverage (SBC) or policy document for Preferred Generic and Generic prescription drug cost. |
| Preferred Brand Drugs Covered | $60.00 / N/A | / | |
| Non-Preferred Brand Drugs Covered | N/A / 50.00% Coinsurance after deductible | / | |
| Specialty Drugs Covered | N/A / 50.00% Coinsurance after deductible | / | |
| Outpatient Rehabilitation Services Covered | N/A / 40.00% Coinsurance after deductible | / | 90 Visit(s) per Year These therapies include but are not limited to PT, OT, and ST. Further, ‘(Rehab) services are covered only if they are expected to result in significant improvement in the Insured’s condition. The Company, with appropriate medical consultation, will determine whether significant improvement has occurred’. ‘Speech Therapy’, limited to one service per day up to a maximum benefit of 90 daily services per Insured per Benefit Period. This limitation is N/A to Mental Illness or Substance Use Disorders. |
| Habilitation Services Covered | N/A / 40.00% Coinsurance after deductible | / | Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. |
| Chiropractic Care Covered | $70.00 / N/A | / | |
| Durable Medical Equipment Covered | N/A / 40.00% Coinsurance after deductible | / | |
| Hearing Aids Not Covered | / | / | Hearing Aids are a non-covered benefit. Coverage is available only for Cochlear Implants and Bone Anchored Hearing Aids. |
| Imaging (CT/PET Scans, MRIs) Covered | N/A / 40.00% Coinsurance after deductible | / | Cost share is based on place of service. |
| Preventive Care/Screening/Immunization Covered | No Charge / N/A | / | |
| Routine Foot Care Covered | $70.00 / N/A | / | Covered when systemic conditions such as metabolic, neurologic, or peripheral vascular disease exists and results in medically significant circulatory deficits or decreased sensation to the foot. |
| Acupuncture Not Covered | / | / | |
| Weight Loss Programs Not Covered | / | / | |
| Routine Eye Exam for Children Covered | No Charge / N/A | / | 1 Visit(s) per Year |
| Eye Glasses for Children Covered | No Charge / N/A | / | 3 Item(s) per Year |
| Dental Check-Up for Children Not Covered | / | / | |
| Rehabilitative Speech Therapy Covered | N/A / 40.00% Coinsurance after deductible | / | 90 Visit(s) per Year Limited to one service per day up to a maximum benefit of 90 daily services per Insured per Benefit Period. |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | N/A / 40.00% Coinsurance after deductible | / | |
| Well Baby Visits and Care Covered | No Charge / N/A | / | |
| Laboratory Outpatient and Professional Services Covered | $35.00 / N/A | / | Cost share is based on place of service. |
| X-rays and Diagnostic Imaging Covered | N/A / 40.00% Coinsurance after deductible | / | Cost share is based on place of service. |
| Basic Dental Care – Child Not Covered | / | / | |
| Orthodontia – Child Not Covered | / | / | Orthodontic services require prior authorization and are only covered for eligible children with cases of severe orthodontic abnormality caused by genetic deformity (such as cleft lip or cleft palate) or traumatic facial injury resulting in serious health impairment to the beneficiary at the present time. |
| Major Dental Care – Child Not Covered | / | / | |
| Basic Dental Care – Adult Not Covered | / | / | |
| Orthodontia – Adult Not Covered | / | / | |
| Major Dental Care – Adult Not Covered | / | / | |
| Abortion for Which Public Funding is Prohibited Not Covered | / | / | |
| Transplant Covered | N/A / 40.00% Coinsurance after deductible | / | Prior authorization may be required. Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant. |
| Accidental Dental Covered | N/A / 40.00% Coinsurance after deductible | / | Oral Surgical Services and Services for Accidental Injuries to Sound Natural Teeth, limited to: (1) Surgical procedures of the jaw and gums. (2) Removal of tumors and cysts of the jaws, cheeks, lips, tongue, roof and floor of the mouth. (3) Removal of exostoses (bony growths) of the jaw and hard palate. (4) Treatment of fractures and dislocations of the jaw and facial bones. (5) Surgical removal of impacted teeth. (6) Treatment of Sound Natural Teeth caused by an Accidental Injury. This includes replacement of Sound Natural Teeth lost due to the Accidental Injury. (7) Intra oral dental imaging services in connection with covered oral surgery if treatment begins within 30 days. (8) General anesthesia for covered oral surgery. (9) Cylindrical endosseous dental implants, mandibular staple implants, subperiosteal implants and the associated fixed and/or removable prosthetic appliance when provided because of an Accidental Injury. (10) Cylindrical endosseous dental implants, mandibular staple implants, subperiosteal implants andthe associated fixed and/or removable prosthetic appliances following surgical resection of either benign or malignant lesions (NOT including inflammatory lesions). |
| Dialysis Covered | N/A / 40.00% Coinsurance after deductible | / | Plan cover Hemodialysis. |
| Allergy Testing Covered | $70.00 / N/A | / | Allergy testing and treatment. |
| Chemotherapy Covered | N/A / 40.00% Coinsurance after deductible | / | |
| Radiation Covered | N/A / 40.00% Coinsurance after deductible | / | |
| Diabetes Education Covered | $70.00 / N/A | / | Outpatient self-management training and education, including medical nutrition therapy, for insulin dependent diabetes, insulin-using diabetes, gestational diabetes and noninsulin using diabetes when provided by a certified, registered or licensed health care professional with expertise in diabetes and the diabetic (1) is treated at a program approved by the American Diabetes Association; (2) is treated by a person certified by the national certification board of diabetes educators; or (3) is, as to nutritional education, treated by a licensed dietitian pursuant to a treatment plan authorized by such healthcare professional. |
| Prosthetic Devices Covered | N/A / 40.00% Coinsurance after deductible | / | Limited to 4 mastectomy bras per year. Limited to 1 wig per year. |
| Infusion Therapy Covered | N/A / 40.00% Coinsurance after deductible | / | |
| Treatment for Temporomandibular Joint Disorders Covered | N/A / 40.00% Coinsurance after deductible | / | |
| Nutritional Counseling Not Covered | / | / | |
| Reconstructive Surgery Covered | N/A / 40.00% Coinsurance after deductible | / | Cosmetic and reconstructive are generally excluded, but excepted from this exclusion are: a. Cosmetic or reconstructive repair of an Accidental Injury.; b. Reconstructive breast surgery in connection with a Medically Necessary mastectomy that resulted from a medical illness or injury. This includes reconstructive surgery on a breast on which a mastectomy was not performed in order to produce a symmetrical appearance.; c. Repair of congenital abnormalities and hereditary complications or conditions, limited to: (1) Cleft lip or palate. (2) Birthmarks on head or neck. (3) Webbed fingers or toes. (4) Supernumerary fingers or toes.; d. Reconstructive services performed on structures of the body to improve/restore impairments of bodily function resulting from disease, trauma, congenital or developmental anomalies or previous therapeutic processes. For purposes of this provision, the term ‘cosmetic’ means procedures and related services performed to reshape structures of the body in order to alter the individual’s appearance. |
| Mental/Behavioral Health Outpatient Other Services Covered | N/A / 40.00% Coinsurance after deductible | / | |
| Substance Use Disorder Outpatient Other Services Covered | N/A / 40.00% Coinsurance after deductible | / | |
| Mental/Behavioral Health Emergency Room Covered | N/A / 40.00% Coinsurance after deductible | / | |
| Substance Use Disorder Emergency Room Covered | N/A / 40.00% Coinsurance after deductible | / |
Free Preventive Services
There is no copayment or coinsurance for any of the following Ambetter Balanced Care 12 preventive services. This is true even if you haven’t met your yearly deductible.
Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for Ambetter Balanced Care 12 including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.
| Summary of Benefits: | Summary of Benefits Link |
| Plan Brochure: | Plan Brochure Link |
| Formulary: | Formulary Link |
| Premium Payment Website: | Premium Payment Link |
Ready to sign up for Ambetter Balanced Care 12?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904