Ambetter Balanced Care 24

21663FL0130047
Silver
EPO

Ambetter Balanced Care 24 is a Silver EPO plan by Ambetter from Sunshine Health.

Locations

Ambetter Balanced Care 24 is offered in the following counties.

Plan Overview

This is a plan overview for 2022 version of Ambetter Balanced Care 24 21663FL0130047.
Insurer: Ambetter from Sunshine Health
Network Type: EPO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 21663FL0130047

Cost-Sharing Overview

Ambetter Balanced Care 24 offers the following cost-sharing.

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 24?

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 24 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 24 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 24 includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$40.00 / N/A / Unlimited Virtual Care Visits received from Ambetter Telehealth covered at No Charge, except for HSAs.
Specialist Visit
Covered
$80.00 / N/A /
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$40.00 / N/A /
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
N/A / No Charge after deductible /
Outpatient Surgery Physician/Surgical Services
Covered
N/A / No Charge after deductible /
Hospice Services
Covered
N/A / No Charge after deductible /
Routine Dental Services (Adult)
Not Covered
/ /
Infertility Treatment
Not Covered
/ / Limited to services for diagnostic tests to find the cause of infertility. Services to treat the underlying medical conditions that cause infertility are covered (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency).
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
Not Covered
/ /
Routine Eye Exam (Adult)
Not Covered
/ /
Urgent Care Centers or Facilities
Covered
$60.00 / N/A /
Home Health Care Services
Covered
N/A / No Charge after deductible / 20 Visit(s) per Year
Emergency Room Services
Covered
N/A / No Charge after deductible /
Emergency Transportation/Ambulance
Covered
N/A / No Charge after deductible / Note: 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 / No Charge after deductible / Inpatient Rehabilitation limited to 21 days per year.
Inpatient Physician and Surgical Services
Covered
N/A / No Charge after deductible /
Bariatric Surgery
Not Covered
/ /
Cosmetic Surgery
Not Covered
/ /
Skilled Nursing Facility
Covered
N/A / No Charge after deductible / 60 Days per Year
Prenatal and Postnatal Care
Covered
$40.00 / N/A /
Delivery and All Inpatient Services for Maternity Care
Covered
N/A / No Charge after deductible /
Mental/Behavioral Health Outpatient Services
Covered
$40.00 / N/A /
Mental/Behavioral Health Inpatient Services
Covered
N/A / No Charge after deductible /
Substance Abuse Disorder Outpatient Services
Covered
$40.00 / N/A /
Substance Abuse Disorder Inpatient Services
Covered
N/A / No Charge after deductible /
Generic Drugs
Covered
$18.20 / 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 / No Charge after deductible /
Specialty Drugs
Covered
N/A / No Charge after deductible /
Outpatient Rehabilitation Services
Covered
N/A / No Charge after deductible / 35 Visit(s) per Year Outpatient rehabilitation therapy is limited to a combined 35 visits per year, including chiropractic care.
Habilitation Services
Covered
N/A / No Charge after deductible / Outpatient rehabilitation therapy is limited to a combined 35 visits per year, including chiropractic care.
Chiropractic Care
Covered
$80.00 / N/A / 35 Visit(s) per Year Limited to a combined 35 visits per year, including outpatient therapy.
Durable Medical Equipment
Covered
N/A / No Charge after deductible /
Hearing Aids
Not Covered
/ / Neither Hearing Aids, Cochlear Implants or Bone Anchored Hearing Aids are covered benefits.
Imaging (CT/PET Scans, MRIs)
Covered
N/A / No Charge after deductible / Cost share is based on place of service.
Preventive Care/Screening/Immunization
Covered
No Charge / N/A / Covered in accordance with ACA guidelines.
Routine Foot Care
Not Covered
/ / Coverage is limited to diabetes care only.
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 / 1 Item(s) per Year
Dental Check-Up for Children
Not Covered
/ /
Rehabilitative Speech Therapy
Covered
N/A / No Charge after deductible / 35 Visit(s) per Year Outpatient rehabilitation therapy is limited to a combined 35 visits per year, including chiropractic care.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
N/A / No Charge after deductible / 35 Visit(s) per Year Outpatient rehabilitation therapy is limited to a combined 35 visits per year, including chiropractic care.
Well Baby Visits and Care
Covered
No Charge / N/A / Covered in accordance with ACA guidelines.
Laboratory Outpatient and Professional Services
Covered
$40.00 / N/A / Cost share is based on place of service.
X-rays and Diagnostic Imaging
Covered
N/A / No Charge after deductible / Cost share is based on place of service.
Basic Dental Care – Child
Not Covered
/ /
Orthodontia – Child
Not Covered
/ /
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 / No Charge after deductible / Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant.
Accidental Dental
Covered
N/A / No Charge after deductible /
Dialysis
Covered
N/A / No Charge after deductible /
Allergy Testing
Covered
$80.00 / N/A /
Chemotherapy
Covered
N/A / No Charge after deductible /
Radiation
Covered
N/A / No Charge after deductible /
Diabetes Education
Covered
$80.00 / N/A /
Prosthetic Devices
Covered
N/A / No Charge after deductible /
Infusion Therapy
Covered
N/A / No Charge after deductible /
Treatment for Temporomandibular Joint Disorders
Covered
N/A / No Charge after deductible / 2 Procedure(s) per Year
Nutritional Counseling
Covered
$80.00 / N/A / For treatment of Diabetes Mellitus and Maternity.
Reconstructive Surgery
Covered
N/A / No Charge after deductible /
Mental/Behavioral Health Outpatient Other Services
Covered
N/A / No Charge after deductible /
Substance Use Disorder Outpatient Other Services
Covered
N/A / No Charge after deductible /
Mental/Behavioral Health Emergency Room
Covered
N/A / No Charge after deductible /
Substance Use Disorder Emergency Room
Covered
N/A / No Charge after deductible /
Mental/Behavioral Health ER Physician Fee
Covered
N/A / No Charge after deductible /
Substance Use Disorder ER Physician Fee
Covered
N/A / No Charge after deductible /
Mental/Behavioral Health Emergency Transportation/Ambulance
Covered
N/A / No Charge after deductible /
Substance Use Disorder Emergency Transportation/Ambulance
Covered
N/A / No Charge after deductible /
Mental/Behavioral Health Urgent Care
Covered
$60.00 / N/A /
Substance Use Disorder Urgent Care
Covered
$60.00 / N/A /

Free Preventive Services

There is no copayment or coinsurance for any of the following Ambetter Balanced Care 24 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.

Additional Resources

Below are additional resources for Ambetter Balanced Care 24 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 24?

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

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