Ambetter Balanced Care 28 + Vision + Adult Dental
70893GA0030034
Silver
HMO
Ambetter Balanced Care 28 + Vision + Adult Dental is a Silver HMO plan by Ambetter from Peach State Health Plan.
Locations
Ambetter Balanced Care 28 + Vision + Adult Dental is offered in the following counties.
Plan Overview
This is a plan overview for 2022 version of Ambetter Balanced Care 28 + Vision + Adult Dental 70893GA0030034.
| Insurer: | Ambetter from Peach State Health Plan |
| Network Type: | HMO |
| Metal Type: | Silver |
| HSA Eligible?: | No |
| Plan ID: | 70893GA0030034 |
Cost-Sharing Overview
Ambetter Balanced Care 28 + Vision + Adult Dental offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for Ambetter Balanced Care 28 + Vision + Adult Dental includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | 8200 | 16400 |
| Deductible: | 0 | 0 |
| Coinsurance: | 0 | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Ambetter Balanced Care 28 + Vision + Adult Dental 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: | 10 |
| Copayment: | 600 |
| Coinsurance: | 4400 |
| Limit: | 60 |
| Deductible: | 1500 |
| Copayment: | 700 |
| Coinsurance: | 1400 |
| Limit: | 20 |
| Deductible: | 10 |
| Copayment: | 300 |
| Coinsurance: | 1200 |
| 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 28 + Vision + Adult Dental?
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 28 + Vision + Adult Dental 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 28 + Vision + Adult Dental 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 28 + Vision + Adult Dental 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 | $50.00 / N/A | / | Unlimited Virtual Care Visits received from Ambetter Telehealth covered at No Charge, except for HSAs. |
| Specialist Visit Covered | $90.00 / N/A | / | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $50.00 / N/A | / | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | N/A / 50.00% | / | |
| Outpatient Surgery Physician/Surgical Services Covered | N/A / 50.00% | / | |
| Hospice Services Covered | N/A / 50.00% | / | |
| Routine Dental Services (Adult) Covered | No Charge / N/A | / | 1000 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults |
| 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) Covered | No Charge / N/A | / | 1 Exam(s) per Year |
| Urgent Care Centers or Facilities Covered | $60.00 / N/A | / | |
| Home Health Care Services Covered | N/A / 50.00% | / | 120 Visit(s) per Year |
| Emergency Room Services Covered | N/A / 50.00% | / | Note: Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. |
| Emergency Transportation/Ambulance Covered | N/A / 50.00% | / | |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | N/A / 50.00% | / | |
| Inpatient Physician and Surgical Services Covered | N/A / 50.00% | / | |
| Bariatric Surgery Not Covered | / | / | |
| Cosmetic Surgery Covered | N/A / 50.00% | / | Limited to reconstruction due to bodily injury, infection or disease and congenital anomaly. |
| Skilled Nursing Facility Covered | N/A / 50.00% | / | 60 Days per Year |
| Prenatal and Postnatal Care Covered | $50.00 / N/A | / | |
| Emergency Transportation/Ambulance Covered | N/A / 50.00% | / | |
| Delivery and All Inpatient Services for Maternity Care Covered | N/A / 50.00% | / | |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | N/A / 50.00% | / | |
| Mental/Behavioral Health Outpatient Services Covered | $50.00 / N/A | / | |
| Inpatient Physician and Surgical Services Covered | N/A / 50.00% | / | |
| Mental/Behavioral Health Inpatient Services Covered | N/A / 50.00% | / | |
| Bariatric Surgery Not Covered | / | / | |
| Cosmetic Surgery Covered | N/A / 50.00% | / | Limited to reconstruction due to bodily injury, infection or disease and congenital anomaly. |
| Skilled Nursing Facility Covered | N/A / 50.00% | / | 60 Days per Year |
| Prenatal and Postnatal Care Covered | $50.00 / N/A | / | |
| Delivery and All Inpatient Services for Maternity Care Covered | N/A / 50.00% | / | |
| Mental/Behavioral Health Outpatient Services Covered | $50.00 / N/A | / | |
| Mental/Behavioral Health Inpatient Services Covered | N/A / 50.00% | / | |
| Substance Abuse Disorder Outpatient Services Covered | $50.00 / N/A | / | |
| Substance Abuse Disorder Inpatient Services Covered | N/A / 50.00% | / | |
| Generic Drugs Covered | $27.00 / 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 | N/A / 50.00% Coinsurance after deductible | / | |
| 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 / 50.00% | / | 40 Visit(s) per Year Limited to a combined maximum of 40 visits per year for speech therapy, physical therapy and occupational therapy. |
| Habilitation Services Covered | N/A / 50.00% | / | 40 Visit(s) per Year Limited to a combined maximum of 40 visits per year for speech therapy, physical therapy and occupational therapy. |
| Chiropractic Care Covered | $90.00 / N/A | / | 40 Visit(s) per Year Limited to a combined maximum of 40 visits per year for speech therapy, physical therapy and occupational therapy. |
| Durable Medical Equipment Covered | N/A / 50.00% | / | |
| Hearing Aids Not Covered | / | / | Coverage is only for Cochlear Implants and Bone Anchored Hearing Aids. |
| Imaging (CT/PET Scans, MRIs) Covered | N/A / 50.00% | / | 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 Exam(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 / 50.00% | / | 40 Visit(s) per Year Limited to a combined maximum of 40 visits per year for chiropractic care, speech therapy, physical therapy and occupational therapy. |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | N/A / 50.00% | / | 40 Visit(s) per Year Limited to a combined maximum of 40 visits per year for chiropractic care, speech therapy, physical therapy and occupational therapy. |
| Well Baby Visits and Care Covered | No Charge / N/A | / | Covered in accordance with ACA guidelines. |
| Laboratory Outpatient and Professional Services Covered | $50.00 / N/A | / | Cost share is based on place of service. |
| X-rays and Diagnostic Imaging Covered | N/A / 50.00% | / | 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 Covered | N/A / 50.00% | / | 1000 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults |
| Orthodontia – Adult Not Covered | / | / | |
| Major Dental Care – Adult Covered | N/A / 50.00% | / | 1000 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults |
| Abortion for Which Public Funding is Prohibited Not Covered | / | / | |
| Transplant Covered | N/A / 50.00% | / | 10000 Dollars per Procedure Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant. |
| Accidental Dental Covered | N/A / 50.00% | / | |
| Dialysis Covered | N/A / 50.00% | / | |
| Allergy Testing Covered | $90.00 / N/A | / | |
| Chemotherapy Covered | N/A / 50.00% | / | |
| Radiation Covered | N/A / 50.00% | / | |
| Diabetes Education Covered | $90.00 / N/A | / | |
| Prosthetic Devices Covered | N/A / 50.00% | / | |
| Infusion Therapy Covered | N/A / 50.00% | / | |
| Treatment for Temporomandibular Joint Disorders Covered | N/A / 50.00% | / | |
| Nutritional Counseling Covered | $90.00 / N/A | / | 4 Visit(s) per Year |
| Reconstructive Surgery Covered | N/A / 50.00% | / | |
| Autism Spectrum Disorders Covered | N/A / 50.00% | / | |
| Bone Marrow Transplant Covered | N/A / 50.00% | / | |
| Clinical Trials Covered | N/A / 50.00% | / | |
| Dental Anesthesia Covered | N/A / 50.00% | / | |
| Diabetes Care Management Covered | $90.00 / N/A | / | |
| Heart Transplant Covered | N/A / 50.00% | / | |
| Off Label Prescription Drugs Covered | N/A / 50.00% Coinsurance after deductible | / | |
| Well Child Care Covered | No Charge / N/A | / | |
| Mental/Behavioral Health Outpatient Other Services Covered | N/A / 50.00% | / | |
| Substance Use Disorder Outpatient Other Services Covered | N/A / 50.00% | / | |
| Mental/Behavioral Health Emergency Room Covered | N/A / 50.00% | / | |
| Substance Use Disorder Emergency Room Covered | N/A / 50.00% | / | |
| Mental/Behavioral Health ER Physician Fee Covered | N/A / 50.00% | / | |
| Substance Use Disorder ER Physician Fee Covered | N/A / 50.00% | / | |
| Mental/Behavioral Health Emergency Transportation/Ambulance Covered | N/A / 50.00% | / | |
| Substance Use Disorder Emergency Transportation/Ambulance Covered | N/A / 50.00% | / | |
| Mental/Behavioral Health Urgent Care Covered | $60.00 / N/A | / | |
| Substance Use Disorder Urgent Care Covered | $60.00 / N/A | / | |
| Eyeglasses for Adults Covered | $0.00 / N/A | / | 1 Item(s) per Year Covered up to $130 |
Free Preventive Services
There is no copayment or coinsurance for any of the following Ambetter Balanced Care 28 + Vision + Adult Dental 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 28 + Vision + Adult Dental 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 28 + Vision + Adult Dental?
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