Ambetter Virtual Access Gold – Virtual PCP selection required

76179IN0170003
Gold
EPO

Ambetter Virtual Access Gold – Virtual PCP selection required is a Gold EPO plan by Ambetter from MHS.

IMPORTANT: You are viewing the 2023 version of Ambetter Virtual Access Gold – Virtual PCP selection required 76179IN0170003. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Ambetter Virtual Access Gold – Virtual PCP selection required is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Ambetter Virtual Access Gold – Virtual PCP selection required 76179IN0170003.
Insurer: Ambetter from MHS
Network Type: EPO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 76179IN0170003

Cost-Sharing Overview

Ambetter Virtual Access Gold – Virtual PCP selection required 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 Virtual Access Gold - Virtual PCP selection required?

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 Virtual Access Gold – Virtual PCP selection required 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 Virtual Access Gold – Virtual PCP selection required 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 Virtual Access Gold – Virtual PCP selection required 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
$55.00 100.00% Unlimited Virtual Care Visits received from Ambetter Telehealth covered at No Charge, except for HSAs.
Specialist Visit
Covered
$90.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$55.00 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
25.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
25.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
25.00% Coinsurance after deductible 100.00%
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
Covered
25.00% Coinsurance after deductible 100.00%82 Visit(s) per Year
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$55.00 100.00%
Home Health Care Services
Covered
25.00% Coinsurance after deductible 100.00%100 Visit(s) per Year
Emergency Room Services
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance 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
25.00% Coinsurance after deductible 100.00% Maximum 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis). Limit is combined both In and Out of Network.
Inpatient Physician and Surgical Services
Covered
25.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
25.00% Coinsurance after deductible 100.00%90 Days per Year
Prenatal and Postnatal Care
Covered
$55.00 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
25.00% Coinsurance after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
No Charge 100.00%
Mental/Behavioral Health Inpatient Services
Covered
25.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
No Charge 100.00%
Substance Abuse Disorder Inpatient Services
Covered
25.00% Coinsurance after deductible 100.00%
Generic Drugs
Covered
$13.80 100.00% No Copayment/Coinsurance will apply to orally administered cancer chemotherapy when obtained from a Network Pharmacy, Mail Service Program, or Specialty Pharmacy Network. 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
$50.00 100.00% No Copayment/Coinsurance will apply to orally administered cancer chemotherapy when obtained from a Network Pharmacy, Mail Service Program, or Specialty Pharmacy Network.
Non-Preferred Brand Drugs
Covered
25.00% Coinsurance after deductible 100.00% No Copayment/Coinsurance will apply to orally administered cancer chemotherapy when obtained from a Network Pharmacy, Mail Service Program, or Specialty Pharmacy Network.
Specialty Drugs
Covered
25.00% Coinsurance after deductible 100.00% No Copayment/Coinsurance will apply to orally administered cancer chemotherapy when obtained from a Network Pharmacy, Mail Service Program, or Specialty Pharmacy Network.
Outpatient Rehabilitation Services
Covered
25.00% Coinsurance after deductible 100.00%60 Visit(s) per Year Cost share is driven by provider/setting. Coverage for Speech Therapy is limited to 20 visits per benefit period, Occupational Therapy is limited to 20 visits per benefit period, and Physical Therapy is limited to 20 visits per benefit period. These limits are combined in and out of network. Benefit includes an Inpatient maximum of 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis). Limit is combined both In and Out of Network. Cardiac Rehabilitation limited to 36 visits when rendered as Physician Home Visits and Office Services or Outpatient Services, combined Network and Non-Network when rendered in the home, Home Care Services limits apply.Pulmonary Rehabilitation limited to 20 visits when rendered as Physician Home Visits and Office Services or Outpatient Services, combined Network and Non-Network. When rendered in the home, Home Care Services limits apply. When rendered as part of physical therapy, the Physical Therapy limit will apply instead of the limit indicated.
Habilitation Services
Covered
25.00% Coinsurance after deductible 100.00%60 Visit(s) per Year Cost share is driven by provider/setting. Habilitation and rehabilitation visits count toward the rehabilitation limit. PT, OT and ST include an additional 20 visits each for habilitative services. Limits are combined both In and Out of Network.
Chiropractic Care
Covered
$90.00 100.00%12 Visit(s) per Year
Durable Medical Equipment
Covered
25.00% Coinsurance after deductible 100.00%
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
25.00% Coinsurance 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
Not Covered
$90.00 100.00% Coverage is limited to diabetes care only.
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge 100.00%1 Visit(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
25.00% Coinsurance after deductible 100.00%20 Visit(s) per Year Outpatient rehabilitation limits apply. Limited to 60 combined visits per year (20 visits each for outpatient physical, speech and occupational therapy); limited to 36 visits per year for cardiac rehabilitation; limited to 20 visits per year for pulmonary rehabilitation.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
25.00% Coinsurance after deductible 100.00%40 Visit(s) per Year Outpatient rehabilitation limits apply. Limited to 60 combined visits per year (20 visits each for outpatient physical, speech and occupational therapy); limited to 36 visits per year for cardiac rehabilitation; limited to 20 visits per year for pulmonary rehabilitation.
Well Baby Visits and Care
Covered
No Charge 100.00% Covered in accordance with ACA guidelines.
Laboratory Outpatient and Professional Services
Covered
$20.00 100.00% Cost share is based on place of service.
X-rays and Diagnostic Imaging
Covered
25.00% Coinsurance after deductible 100.00% 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
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
25.00% Coinsurance after deductible 100.00% Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant.
Accidental Dental
Covered
25.00% Coinsurance after deductible 100.00%3000 Dollars per Episode The limit will not apply to Outpatient facility charges, anesthesia billed by a Provider other than the Physician performing the service, or to services that we are required by law to cover. Cost share is driven by provider/setting. Limited to $3,000/accident; combined In and Out of network. Benefits for Accidental Dental are based on the setting in which Covered Services are recommended.
Dialysis
Covered
25.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
$90.00 100.00%
Chemotherapy
Covered
25.00% Coinsurance after deductible 100.00%
Radiation
Covered
25.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
$90.00 100.00%
Prosthetic Devices
Covered
25.00% Coinsurance after deductible 100.00%
Infusion Therapy
Covered
25.00% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
25.00% Coinsurance after deductible 100.00%
Nutritional Counseling
Covered
$90.00 100.00%
Reconstructive Surgery
Covered
25.00% Coinsurance after deductible 100.00% Certain reconstructive services required to correct a deformity caused by disease, trauma, congenital anomalies, or previous therapeutic process are covered. Coverage includes breast reconstruction on which a mastectomy has been performed. Reconstructive services required due to prior therapeutic process are payable only if the original procedure would have been a covered service under this plan.
Gender Affirming Care
Covered
25.00% Coinsurance after deductible 100.00%
Mental/Behavioral Health Outpatient Other Services
Covered
25.00% Coinsurance after deductible 100.00%
Substance Use Disorder Outpatient Other Services
Covered
25.00% Coinsurance after deductible 100.00%
Mental/Behavioral Health Emergency Room
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible
Substance Use Disorder Emergency Room
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible
Mental/Behavioral Health ER Physician Fee
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible
Substance Use Disorder ER Physician Fee
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible
Mental/Behavioral Health Emergency Transportation/Ambulance
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible
Substance Use Disorder Emergency Transportation/Ambulance
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible
Mental/Behavioral Health Urgent Care
Covered
No Charge 100.00%
Substance Use Disorder Urgent Care
Covered
No Charge 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following Ambetter Virtual Access Gold – Virtual PCP selection required 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 Virtual Access Gold – Virtual PCP selection required 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 Virtual Access Gold - Virtual PCP selection required?

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