CMS Standard Gold

26289NE0020041
Gold
HMO

CMS Standard Gold is a Gold HMO plan by Ambetter from Nebraska Total Care.

IMPORTANT: You are viewing the 2023 version of CMS Standard Gold 26289NE0020041. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

CMS Standard Gold is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of CMS Standard Gold 26289NE0020041.
Insurer: Ambetter from Nebraska Total Care
Network Type: HMO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 26289NE0020041

Cost-Sharing Overview

CMS Standard Gold 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 CMS Standard Gold?

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

CMS Standard Gold 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 CMS Standard Gold 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

CMS Standard Gold 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
$30.00 100.00% Unlimited Virtual Care Visits received from Ambetter Telehealth covered at No Charge, except for HSAs.
Specialist Visit
Covered
$60.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$30.00 100.00%
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% The Covered Person must have a life expectancy of six months or less as documented in writing by the attending Physician. The Hospice Services must be ordered by a Physician. Services provided must be appropriate for palliative support or management of a Covered Person with terminal medical Illness.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Note: Coverage is available for diagnosis and services required to correct underlying medical causes of infertility
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
$45.00 100.00%
Home Health Care Services
Covered
25.00% Coinsurance after deductible 100.00%60 Days 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%
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%60 Days per Year
Prenatal and Postnatal Care
Covered
$30.00 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
25.00% Coinsurance after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$30.00 100.00%
Mental/Behavioral Health Inpatient Services
Covered
25.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$30.00 100.00%
Substance Abuse Disorder Inpatient Services
Covered
25.00% Coinsurance after deductible 100.00%
Generic Drugs
Covered
$15.00 100.00% 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
$30.00 100.00%
Non-Preferred Brand Drugs
Covered
$60.00 100.00%
Specialty Drugs
Covered
$250.00 100.00%
Outpatient Rehabilitation Services
Covered
$30.00 100.00%45 Treatment(s) per Year Limits apply to rehab and hab combined: Physical, occupational or speech therapy services, chiropractic or osteopathic physiotherapy (combined limit to 45 sessions per Calendar Year).
Habilitation Services
Covered
$30.00 100.00%45 Treatment(s) per Year Nebraska supplemented this EHB category for Habilitative Services: ‘Health care Services that help a person keep, learn, or improve skills and functioning for daily living. 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.’ Quantitative limits on services apply to outpatient, only.
Chiropractic Care
Covered
$60.00 100.00%20 Visit(s) per Year Chiropractic physiotherapy has a combined limit with PT, OT and speech therapies of 45 sessions per calendar year. Chiropractic manipulative adjustments have a combined limit with osteopathic physiotherapy of 20 sessions per calendar year.
Durable Medical Equipment
Covered
25.00% Coinsurance after deductible 100.00%
Hearing Aids
Covered
25.00% Coinsurance after deductible 100.00%1 Item(s) per 3 Years
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
0.00% 100.00%
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 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
$30.00 100.00%45 Visit(s) per Year Limits apply to rehab and hab combined: Physical, occupational or speech therapy services, chiropractic or osteopathic physiotherapy (combined limit to 45 sessions per Calendar Year).
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$30.00 100.00%45 Visit(s) per Year Limits apply to rehab and hab combined: Physical, occupational or speech therapy services, chiropractic or osteopathic physiotherapy (combined limit to 45 sessions per Calendar Year).
Well Baby Visits and Care
Covered
No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
25.00% Coinsurance after deductible 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%
Accidental Dental
Covered
25.00% Coinsurance after deductible 100.00%
Dialysis
Covered
25.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
$60.00 100.00%
Chemotherapy
Covered
25.00% Coinsurance after deductible 100.00%
Radiation
Covered
25.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
$60.00 100.00%
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
$60.00 100.00% Only for diabetes management as provided by the plan.
Reconstructive Surgery
Covered
25.00% Coinsurance after deductible 100.00% Available only post-mastectomy or when required to restore, reconstruct or correct any bodily function that was lost, impaired or damaged as a result of Injury or Illness.
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
$45.00 100.00%
Substance Use Disorder Urgent Care
Covered
$45.00 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following CMS Standard Gold 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 CMS Standard Gold 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 CMS Standard Gold?

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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