CMS Standard Gold
29418TX0140109
Gold
EPO
CMS Standard Gold is a Gold EPO plan by Ambetter from Superior HealthPlan.
IMPORTANT: You are viewing the 2023 version of CMS Standard Gold 29418TX0140109. 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 29418TX0140109.
| Insurer: | Ambetter from Superior HealthPlan |
| Network Type: | EPO |
| Metal Type: | Gold |
| HSA Eligible?: | No |
| Plan ID: | 29418TX0140109 |
Cost-Sharing Overview
CMS Standard Gold offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for CMS Standard Gold includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $8,700.00 | $8700 per person | $17400 per group |
| Deductible: | $2,000.00 | $2000 per person | $4000 per group |
| Coinsurance: | 25.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for CMS Standard Gold will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | Not Applicable | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | Not Applicable | per person not applicable | per group not applicable |
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: | $2,000.00 |
| Copayment: | $40.00 |
| Coinsurance: | $2,000.00 |
| Limit: | $60.00 |
| Deductible: | $900.00 |
| Copayment: | $900.00 |
| Coinsurance: | $0.00 |
| Limit: | $20.00 |
| Deductible: | $2,000.00 |
| Copayment: | $300.00 |
| Coinsurance: | $20.00 |
| Limit: | $0.00 |
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% | |
| 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 | $45.00 | 100.00% | |
| Home Health Care Services Covered | 25.00% Coinsurance after deductible | 100.00% | 60 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% | |
| 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% | 25 Visit(s) 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% | 35 Visit(s) per Year Limited to combined 35 visits per year, including Chiropractic. |
| Habilitation Services Covered | $30.00 | 100.00% | 35 Visit(s) per Year Limited to combined 35 visits per year, including Chiropractic. Note: This visit limit does not apply when treatment is provided for a mental health/substance use disorder diagnosis or developmental delays. |
| Chiropractic Care Covered | $60.00 | 100.00% | 35 Visit(s) per Year Limited to combined 35 visits per year, including Chiropractic. |
| Durable Medical Equipment Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Hearing Aids Covered | 25.00% Coinsurance after deductible | 100.00% | Coverage includes Cochlear Implants and Bone Anchored Hearing Aids. |
| 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% | Covered in accordance with ACA guidelines. |
| Routine Foot Care Covered | $60.00 | 100.00% | Prior authorization may be required. Covered no limit. |
| 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 | $30.00 | 100.00% | |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | $30.00 | 100.00% | |
| 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% | 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% | |
| 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% | Coverage is limited to diabetes care only. |
| 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% | |
| Reconstructive Surgery Covered | 25.00% Coinsurance after deductible | 100.00% | |
| 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 | $35.00 | 100.00% | |
| Substance Use Disorder Urgent Care Covered | $35.00 | 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.
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 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