CMS Standard Gold

44007NC0120006
Gold
PPO

CMS Standard Gold is a Gold PPO plan by WellCare of North Carolina.

IMPORTANT: You are viewing the 2023 version of CMS Standard Gold 44007NC0120006. 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 44007NC0120006.
Insurer: WellCare of North Carolina
Network Type: PPO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 44007NC0120006

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
Imaging (CT/PET Scans, MRIs)
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Cost share is based on place of service.
Preventive Care/Screening/Immunization
Covered
0.00% 50.00% 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 No Charge 1 Visit(s) per Year
Eye Glasses for Children
Covered
No Charge No Charge 1 Item(s) per Year
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$30.00 50.00% Coinsurance after deductible30 Visit(s) per Year
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$30.00 50.00% Coinsurance after deductible30 Visit(s) per Year Limited to 30 visits per year for outpatient speech therapy; limited to a combined 30 visits per year for outpatient occupational therapy, physical therapy and chiropractic care.
Well Baby Visits and Care
Covered
No Charge 50.00% Covered in accordance with ACA guidelines.
Laboratory Outpatient and Professional Services
Covered
25.00% Coinsurance after deductible 50.00% Cost share is based on place of service.
X-rays and Diagnostic Imaging
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible 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 50.00% Coinsurance after deductible Both the recipient and the donor are entitled to benefits of this coverage when the recipient is a MEMBER. Benefits provided to the donor will be charged against the recipient’s coverage.
Accidental Dental
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Dialysis
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Allergy Testing
Covered
$60.00 50.00%
Chemotherapy
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Radiation
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Diabetes Education
Covered
$60.00 50.00%
Prosthetic Devices
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Infusion Therapy
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Nutritional Counseling
Covered
$60.00 50.00% Nutritional counseling visits are separate from the obesity-related office visits.
Reconstructive Surgery
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Gender Affirming Care
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Other Services
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Substance Use Disorder Outpatient Other Services
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
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 50.00%
Substance Use Disorder Urgent Care
Covered
$45.00 50.00%
Primary Care Visit to Treat an Injury or Illness
Covered
$30.00 50.00% Unlimited Virtual Care Visits received from Ambetter Telehealth covered at No Charge.
Specialist Visit
Covered
$60.00 50.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$30.00 50.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Hospice Services
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Benefits for Hospice services for care of a terminally ill Member with a life expectancy of six months or less.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible3 Treatment(s) per Lifetime Infertility Services- Benefits are provided for certain services related to the diagnosis, treatment and correction of any underlying causes of infertility for all members. Benefits are limited to three medical ovulation induction cycles per lifetime per member. Prescription Drug Benefits- Certain prescription drugs related to treatment of infertility. Infertility drugs are limited to benefit lifetime maximums per member.
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 50.00% Coinsurance after deductible
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$45.00 50.00%
Home Health Care Services
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Emergency Room Services
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.
Emergency Transportation/Ambulance
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Bariatric Surgery
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Medically necessary for the treatment of diseases and aliments.
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible60 Days per Year
Prenatal and Postnatal Care
Covered
$30.00 50.00%
Delivery and All Inpatient Services for Maternity Care
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services
Covered
$30.00 50.00%
Mental/Behavioral Health Inpatient Services
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services
Covered
$30.00 50.00%
Substance Abuse Disorder Inpatient Services
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
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 50.00% Coinsurance after deductible30 Visit(s) per Year Limited to 30 visits per year for outpatient speech therapy; limited to a combined 30 visits per year for outpatient occupational therapy, physical therapy and chiropractic care.
Habilitation Services
Covered
$30.00 50.00% Coinsurance after deductible30 Visit(s) per Year Limited to 30 visits per year for outpatient speech therapy; limited to a combined 30 visits per year for outpatient occupational therapy, physical therapy and chiropractic care.
Chiropractic Care
Covered
$60.00 50.00%30 Visit(s) per Year Limited to a combined 30 visits per year for outpatient occupational therapy, physical therapy and chiropractic care.
Durable Medical Equipment
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Orthotic devices for correction of POSITIONAL PLAGIOCEPHALY are limited to 1 device per lifetime.
Hearing Aids
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible1 Item(s) per 3 Years One hearing aid per hearing impaired ear, and replacement hearing aids once every 36 months.

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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