CMS Standard Gold

62141AR0080034
Gold
PPO

CMS Standard Gold is a Gold PPO plan by Ambetter from Arkansas Health & Wellness.

IMPORTANT: You are viewing the 2023 version of CMS Standard Gold 62141AR0080034. 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.

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Plan Overview

This is a plan overview for 2023 version of CMS Standard Gold 62141AR0080034.
Insurer: Ambetter from Arkansas Health & Wellness
Network Type: PPO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 62141AR0080034

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 50.00%
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 Prior authorization may be required – please contact the number listed on your ID card.
Outpatient Surgery Physician/Surgical Services
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Hospice Services
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible180 Days per Year Benefits for hospice inpatient, home or outpatient care are available to a terminally ill covered person for one continuous period up to 180 days in a covered person’s lifetime. Prior authorization may be required – please contact the number listed on your ID card.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Prior authorization may be required. Coverage includes testing to diagnose infertility, infertility counseling and planning services; also, in vitro fertilization procedures are covered.
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 50.00%
Home Health Care Services
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible50 Visit(s) per Year Prior authorization may be required – please contact the number listed on your ID card.
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 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Inpatient Physician and Surgical Services
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible60 Days per Year 60 days per year in a facility. Prior authorization may be required – please contact the number listed on you ID card.
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 Prior authorization may be required – please contact the number listed on your ID card.
Mental/Behavioral Health Outpatient Services
Covered
$30.00 50.00% Prior authorization may be required – please contact the number listed on your ID card. (PCP and Other Practitioner visits do not require Prior Authorization)
Mental/Behavioral Health Inpatient Services
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Substance Abuse Disorder Outpatient Services
Covered
$30.00 50.00% Prior authorization may be required – please contact the number listed on your ID card. (PCP and Other Practitioner visits do not require Prior Authorization)
Substance Abuse Disorder Inpatient Services
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Generic Drugs
Covered
$15.00 100.00% Prior authorization may be required – please contact the number listed on your ID card. 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 Prior authorization may be required – please contact the number listed on your ID card. (Including Speech. Occupational, and Physical Therapy). Combined 30 visit limit per year for PT, OT, ST and Chiropractic Care.
Habilitation Services
Covered
$30.00 50.00% Coinsurance after deductible30 Visit(s) per Year 30 visits per year for outpatient habilatative services. 180 visits per year for developmental services. Prior authorization may be required – please contact the number on your ID card.
Chiropractic Care
Covered
$60.00 50.00%30 Visit(s) per Year Combined 30 visit limit per year for Chiropractic Care, PT, OT and ST.
Durable Medical Equipment
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Hearing Aids
Covered
25.00% 50.00%2 Item(s) per 3 Years 1 pair every 3 years. Prior authorization may be required – please contact the number listed on your ID card.
Imaging (CT/PET Scans, MRIs)
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card. Cost share is based on place of service.
Preventive Care/Screening/Immunization
Covered
0.00% 50.00%
Routine Foot Care
Covered
$60.00 50.00% Prior authorization may be required. Covered no limit.
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge No Charge 1 Exam(s) per Year Up to $38.50 OON
Eye Glasses for Children
Covered
No Charge No Charge 1 Item(s) per Year OON: Up to $50 for frames, $37.50 for lenses and $91 for contacts in lieu of eyeglasses. See EOC for lens limits.
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$30.00 50.00% Coinsurance after deductible30 Visit(s) per Year Combined 30 visit limit per year for PT, OT, ST and Chiropractic Care. Prior authorization may be required – please contact the number on your ID card.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$30.00 50.00% Coinsurance after deductible30 Visit(s) per Year 60 inpatient days/year. 30 visit limit is combined with PT, OT, speech and Chiropractic Care. Prior authorization may be required – please contact the number on your ID card.
Well Baby Visits and Care
Covered
No Charge 50.00%
Laboratory Outpatient and Professional Services
Covered
25.00% Coinsurance after deductible 50.00% Prior authorization may be required – please contact the number listed on your ID card. Cost share is based on place of service.
X-rays and Diagnostic Imaging
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card. 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 Prior authorization may be required – please contact the number listed on your ID card.
Accidental Dental
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Dialysis
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Allergy Testing
Covered
$60.00 50.00% Prior authorization may be required – please contact the number listed on your ID card.
Chemotherapy
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Radiation
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Diabetes Education
Covered
$60.00 50.00% Prior authorization may be required – please contact the number listed on your ID card.
Prosthetic Devices
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Infusion Therapy
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Treatment for Temporomandibular Joint Disorders
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Nutritional Counseling
Covered
$60.00 50.00% When provided in conjunction with Diabetic Self-Management Training, for services needed by Members in connection with cleft palate management and for nutritional assessment programs provided in and by a Hospital. Prior authorization may be required – please contact the number listed on your id card.
Reconstructive Surgery
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible 1. Treatment provided for the correction of defects incurred in an Accidental Injury sustained by the Member; 2. Surgery performed on a child for the correction of a cleft palate or cleft lip, removal of a port-wine stain or hemangioma (only on the face), or correction of a congenital abnormality… 3. Treatment provided when it is incidental to disease or for reconstructive surgery following neoplastic (cancer) surgery; 4. In connection with a mastectomy resulting from cancer surgery, services for (a) reconstruction of the breast on which the cancer-related surgery was performed; (b) surgery to reconstruct the other breast to produce a symmetrical appearance; and (c) prostheses and services to correct physical complications for all stages of the mastectomy, including lymphedemas; 5. Reduction mammoplasty, if such reduction mammoplasty meets Coverage Criteria. Prior Authorization may be required – please contact the number listed on your ID card.
Gender Affirming Care
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Diabetes Care Management
Covered
$60.00 50.00% Covered based on medical necessity. Prior authorization may be required – please contact the number listed on your ID card.
Inherited Metabolic Disorder – PKU
Covered
25.00% Coinsurance after deductible 50.00% Prior authorization may be required – please contact the number listed on your ID card.
Off Label Prescription Drugs
Covered
$250.00 100.00%
Dental Anesthesia
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Person under 7 requiring dental treatment w/o delay. Prior authorization may be required – please contact the number listed on your ID card.
Gastric Electrical Stimulation
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Well Child Care
Covered
No Charge 50.00%
Applied Behavior Analysis Based Therapies
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Person with diagnosis of serious mental or physical condition; Person certified by a PCP to have significant behavioral problem. Prior authorization may be required – please contact the number listed on your ID card.
Cochlear Implants
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Cardiac Rehabilitation
Covered
$30.00 50.00% Coinsurance after deductible36 Visit(s) per Year Prior authorization may be required – please contact the number listed on your ID card.
Craniofacial Surgery
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Preventative Drugs
Covered
No Charge 100.00%
Mental/Behavioral Health Outpatient Other Services
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Substance Use Disorder Outpatient Other Services
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
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%

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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