Clear Bronze + Vision + Adult Dental

58594MI0040001
Bronze
HMO

Clear Bronze + Vision + Adult Dental is a Bronze HMO plan by Ambetter from Meridian.

IMPORTANT: You are viewing the 2023 version of Clear Bronze + Vision + Adult Dental 58594MI0040001. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Clear Bronze + Vision + Adult Dental is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Clear Bronze + Vision + Adult Dental 58594MI0040001.
Insurer: Ambetter from Meridian
Network Type: HMO
Metal Type: Bronze
HSA Eligible?: No
Plan ID: 58594MI0040001

Cost-Sharing Overview

Clear Bronze + Vision + Adult Dental 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 Clear Bronze + 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

Clear Bronze + 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 Clear Bronze + 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

Clear Bronze + 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
No Charge after deductible 100.00% Unlimited Virtual Care Visits received from Ambetter Telehealth covered at No Charge, except for HSAs.
Specialist Visit
Covered
No Charge after deductible 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
No Charge after deductible 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
No Charge after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
No Charge after deductible 100.00%
Hospice Services
Covered
No Charge after deductible 100.00%
Routine Dental Services (Adult)
Covered
No Charge 100.00%1000 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults
Infertility Treatment
Covered
No Charge after deductible 100.00% 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
Long Term Acute Care is a covered benefit. Long Term Nursing Care/ Custodial Care is not a covered benefit.
Private-Duty Nursing
Routine Eye Exam (Adult)
Covered
No Charge 100.00%1 Visit(s) per Year
Urgent Care Centers or Facilities
Covered
$60.00 100.00%
Home Health Care Services
Covered
No Charge after deductible 100.00%
Emergency Room Services
Covered
No Charge after deductible No Charge after deductible
Emergency Transportation/Ambulance
Covered
No Charge after deductible 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
No Charge after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
No Charge after deductible 100.00%
Bariatric Surgery
Covered
No Charge after deductible 100.00%1 Procedure(s) per Lifetime
Cosmetic Surgery
Skilled Nursing Facility
Covered
No Charge after deductible 100.00%45 Days per Year
Prenatal and Postnatal Care
Covered
No Charge after deductible 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
No Charge after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
No Charge after deductible 100.00%
Mental/Behavioral Health Inpatient Services
Covered
No Charge after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
No Charge after deductible 100.00%
Substance Abuse Disorder Inpatient Services
Covered
No Charge after deductible 100.00%
Generic Drugs
Covered
$22.60 100.00% 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
No Charge after deductible 100.00%
Non-Preferred Brand Drugs
Covered
No Charge after deductible 100.00%
Specialty Drugs
Covered
No Charge after deductible 100.00%
Outpatient Rehabilitation Services
Covered
No Charge after deductible 100.00%30 Visit(s) per Year Limited to 30 combined visits per year (combined for occupational therapy, physical therapy and chiropractic care). Limited to 30 visits per year speech therapy. Limited to 30 visits per year cardiac therapy. Limited to 30 visits per year pulmonary therapy
Habilitation Services
Covered
No Charge after deductible 100.00% Prior authorization may be required. Covered No Limit.
Chiropractic Care
Covered
No Charge after deductible 100.00%30 Visit(s) per Year Limited to 30 combined visits per year (combined for occupational therapy, physical therapy and chiropractic care). Limited to 30 visits per year speech therapy. Limited to 30 visits per year cardiac therapy. Limited to 30 visits per year pulmonary therapy
Durable Medical Equipment
Covered
No Charge after deductible 100.00%
Hearing Aids
Coverage only available for cochlear implants and bone anchored hearing aids (BAHA).
Imaging (CT/PET Scans, MRIs)
Covered
No Charge after deductible 100.00% Cost share is based on place of service.
Preventive Care/Screening/Immunization
Covered
No Charge 100.00% Covered in accordance with ACA guidelines.
Routine Foot Care
Coverage is limited to diabetes care only.
Acupuncture
Weight Loss Programs
Covered
No Charge after deductible 100.00% Weight loss programs under the supervision of a physician & obesity counseling
Routine Eye Exam for Children
Covered
No Charge 100.00%1 Exam(s) per Year
Eye Glasses for Children
Covered
No Charge 100.00%1 Item(s) per Year
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
No Charge after deductible 100.00%30 Visit(s) per Year
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
No Charge after deductible 100.00%30 Visit(s) per Year Limited to 30 combined visits per year (combined for occupational therapy, physical therapy and chiropractic care). Limited to 30 visits per year speech therapy. Limited to 30 visits per year cardiac therapy. Limited to 30 visits per year pulmonary therapy.
Well Baby Visits and Care
Covered
No Charge 100.00% Covered in accordance with ACA guidelines.
Laboratory Outpatient and Professional Services
Covered
No Charge after deductible 100.00% Cost share is based on place of service.
X-rays and Diagnostic Imaging
Covered
No Charge after deductible 100.00% Cost share is based on place of service.
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Covered
50.00% 100.00%1000 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults
Orthodontia – Adult
Major Dental Care – Adult
Covered
50.00% 100.00%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
Transplant
Covered
No Charge after deductible 100.00% Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant.
Accidental Dental
Covered when deemed part of emergent care, resulting from an emergency situation.
Dialysis
Covered
No Charge after deductible 100.00%
Allergy Testing
Covered
No Charge after deductible 100.00%
Chemotherapy
Covered
No Charge after deductible 100.00%
Radiation
Covered
No Charge after deductible 100.00%
Diabetes Education
Covered
No Charge after deductible 100.00%
Prosthetic Devices
Covered
No Charge after deductible 100.00%
Infusion Therapy
Covered
No Charge after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
No Charge after deductible 100.00% Coverage includes medical care or services to treat dysfunction or TMJS resulting from a medical cause or Injury, Office visits for medical evaluation and treatment, X-rays of the temporomandibular joint including contrast studies, but not dental x-rays, Myofunctional therapy and Surgery to the temporomandibular joint, such as condylectomy, meniscectomy, arthrotomy, and arthrocentesis.
Nutritional Counseling
Covered
No Charge after deductible 100.00%6 Visit(s) per Year Weight loss programs under the supervision of a physician & obesity counseling
Reconstructive Surgery
Covered
No Charge after deductible 100.00%
Gender Affirming Care
Covered
No Charge after deductible 100.00%
Mental/Behavioral Health Outpatient Other Services
Covered
No Charge after deductible 100.00%
Substance Use Disorder Outpatient Other Services
Covered
No Charge after deductible 100.00%
Mental/Behavioral Health Emergency Room
Covered
No Charge after deductible No Charge after deductible
Substance Use Disorder Emergency Room
Covered
No Charge after deductible No Charge after deductible
Mental/Behavioral Health ER Physician Fee
Covered
No Charge after deductible No Charge after deductible
Substance Use Disorder ER Physician Fee
Covered
No Charge after deductible No Charge after deductible
Mental/Behavioral Health Emergency Transportation/Ambulance
Covered
No Charge after deductible No Charge after deductible
Substance Use Disorder Emergency Transportation/Ambulance
Covered
No Charge after deductible No Charge after deductible
Mental/Behavioral Health Urgent Care
Covered
No Charge 100.00%
Substance Use Disorder Urgent Care
Covered
No Charge 100.00%
Eyeglasses
Covered
No Charge 100.00%1 Item(s) per Year Covered up to $130

Free Preventive Services

There is no copayment or coinsurance for any of the following Clear Bronze + 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.

Additional Resources

Below are additional resources for Clear Bronze + 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 Clear Bronze + 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

Table of Contents