CMS Standard Silver

41047OH0010070
Silver
HMO

CMS Standard Silver is a Silver HMO plan by Ambetter from Buckeye Health Plan.

IMPORTANT: You are viewing the 2023 version of CMS Standard Silver 41047OH0010070. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

CMS Standard Silver is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of CMS Standard Silver 41047OH0010070.
Insurer: Ambetter from Buckeye Health Plan
Network Type: HMO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 41047OH0010070

Cost-Sharing Overview

CMS Standard Silver 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 Silver?

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 Silver 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 Silver 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 Silver includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Radiation
Covered
40.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
$80.00 100.00%
Prosthetic Devices
Covered
40.00% Coinsurance after deductible 100.00% Benefits for artificial substitutes for body parts and tissues and materials inserted into tissue for functional or therapeutic purposes. Limited to 4 mastecomy bras per year. Limited to 1 wig per year.
Infusion Therapy
Covered
40.00% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
40.00% Coinsurance after deductible 100.00%
Nutritional Counseling
Covered
$80.00 100.00% Covered benefit under home health services and covered as USPSTF A or B recommendation under preventive health services (includes diet counseling for adults at higher risk for chronic disease, obesity screening and counseling for all adults, and healthy diet counseling for adults with cardiovascular risk factors).
Reconstructive Surgery
Covered
40.00% Coinsurance after deductible 100.00% Benefits include reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance. Benefits include surgery performed to restore symmetry after a mastectomy.
Gender Affirming Care
Covered
40.00% Coinsurance after deductible
ER Diagnostic Test (X-Ray)
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Primary Care Visit to Treat an Injury or Illness
Covered
$40.00 100.00% Unlimited Primary Virtual Care Visits received from Ambetter Telehealth covered at No Charge. Primary Virtual Care Visits are only availble for adult members (18 years of age and older).
Specialist Visit
Covered
$80.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$40.00 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
40.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
40.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
40.00% Coinsurance after deductible 100.00%
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Covered
40.00% Coinsurance after deductible 100.00% Infertility and voluntary family planning services are required benefits under state law for HMO plans only per ORC section 1751.01 (A)(1)(h), and must be provided in accordance with Ohio Department of Insurance Bulletin No. 2009-07. For the diagnosis and treatment of medical condition causing infertility, Not covered ? in vitro (IVF), GIFT or ZIFT.
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
40.00% Coinsurance after deductible 100.00%90 Visit(s) per Year
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$60.00 100.00% Unlimited Virtual Care Visits received from Ambetter Telehealth covered at No Charge.
Home Health Care Services
Covered
40.00% Coinsurance after deductible 100.00%100 Visit(s) per Year When therapy services are provided in the home (including physical, speech, and occupational therapy) as part of home health care services, they are not subject to separate visit limits for therapy services. The 100 visit/year limit is also not applicable to home infusion therapy or private duty nursing rendered in the home setting.
Emergency Room Services
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
40.00% Coinsurance after deductible 100.00% There are specific exceptions to certain exclusions and/or additional exclusions that are detailed in plan document; inpatient hospital services include charges from a hospital, skilled nursing facility or other provider for room, board, general nursing services; and ancillary (related) services. 60 visits/year for Inpatient Rehabilitation Services
Inpatient Physician and Surgical Services
Covered
40.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
“Directly related means that the treatment or surgery occurred as a direct result of, and would not have taken place in the absence of, the cosmetic surgery. This exclusion does not apply to conditions including but not limited to: myocardial infarction; pulmonary embolism, thrombophlebitis, and exacerbation of co-morbid conditions during the procedure or in the immediate post-operative time frame.
Skilled Nursing Facility
Covered
40.00% Coinsurance after deductible 100.00%90 Days per Year All medically necessary Basic Health Care services must be covered by an HMO plan. Complications from a non-covered procedure that require the need for any medically necessary Basic Health Care Service must be covered same as any other services.”
Prenatal and Postnatal Care
Covered
$40.00 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
40.00% Coinsurance after deductible 100.00% Coverage for the Inpatient postpartum stay for mother and newborn child in a hospital will be, at a minimum, 48 hours for a vaginal delivery and 96 hours for a cesarean section. Coverage will be for the length of stay recommended by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists in their Guidelines for Prenatal Care.
Mental/Behavioral Health Outpatient Services
Covered
$40.00 100.00% Unlimited Virtual Visits received from Ambetter Telehealth covered at No Charge.
Mental/Behavioral Health Inpatient Services
Covered
40.00% Coinsurance after deductible 100.00% Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.
Substance Abuse Disorder Outpatient Services
Covered
$40.00 100.00% Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.
Substance Abuse Disorder Inpatient Services
Covered
40.00% Coinsurance after deductible 100.00% Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.
Generic Drugs
Covered
$20.00 100.00% Most Ambetter Plans offer Preferred Generic Drugs at $5 or less.
Preferred Brand Drugs
Covered
$40.00 100.00%
Non-Preferred Brand Drugs
Covered
$80.00 Copay after deductible 100.00%
Specialty Drugs
Covered
$350.00 Copay after deductible 100.00%
Outpatient Rehabilitation Services
Covered
$40.00 100.00%116 Visit(s) per Year Therapy Services rendered in the home as part of Home Care Services will be subject to the Home Care Services visit limits; outpatient rehabilitation services visit limits will not apply. If different types of Therapy Services are performed during one Physician Home Visit, Office Service, or Outpatient Service, then each different type of Therapy Service performed will be considered a separate Therapy Visit. Each Therapy Visit will count against the applicable maximum visits per Benefit Period listed below: Physical, Occupational and Speech Therapy limited to 20 visits each. Cardiac Rehabilitation limited to 36 visits. Pulmonary Rehabilitation limited to 20 visits, except if rendered as part of Physical Therapy, the Physical Therapy visit limit will apply. Benefit also includes Physical Medicine and Rehabilitation Day Rehabilitation Therapy services on an Outpatient basis. Services may be used for Intensive Day Rehabilitation.
Habilitation Services
Covered
$40.00 100.00%
Chiropractic Care
Covered
$80.00 100.00%12 Visit(s) per Year Limited to 12 visits per year. Benefit limit applies for Osteopathic/Chiropractic Manipulation Therapy.
Durable Medical Equipment
Covered
40.00% Coinsurance after deductible 100.00%
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
40.00% Coinsurance after deductible 100.00% Cost share is based on place of service.
Preventive Care/Screening/Immunization
Covered
0.00% 100.00% Services with an ‘A’ or ‘B’ rating from the United States Preventive Services Task Force (USPSTF); Immunizations for children, adolescents, and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; Preventive care and screenings for infants, children and adolescents as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. Additional preventive care and screening for women provided for in the guidelines supported by the Health Resources and Services Administration.
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 Coverage includes benefits specified in the FEDVIP FEP Blue Vision – High Option plan, including low vision benefits.
Eye Glasses for Children
Covered
No Charge 100.00%1 Item(s) per Year Coverage includes benefits specified in the FEDVIP FEP Blue Vision – High Option plan, including low vision benefits.
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$40.00 100.00%20 Visit(s) per Year 20 visits/year for Speech
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$40.00 100.00%40 Visit(s) per Year 20 visits/year each for Physical & Occupational
Well Baby Visits and Care
Covered
No Charge 100.00% Covered in accordance with ACA guidelines.
Laboratory Outpatient and Professional Services
Covered
40.00% Coinsurance after deductible 100.00% Cost share is based on place of service. Lab or blood work at Preferred Laboratories is No Charge.
X-rays and Diagnostic Imaging
Covered
40.00% 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
40.00% Coinsurance after deductible 100.00% Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant.
Accidental Dental
Covered
40.00% Coinsurance after deductible 100.00%3000 Dollars per Episode Limited to $3,000 per occurrence. Quantitative Limit represents established actuarial equivalent of benchmark plan annual dollar limits. Annual and lifetime dollar limits will no longer apply. Coverage for dental services resulting from an accidental injury when treatment is performed within 12 months after the injury. The benefit limit will not apply to outpatient facility charges, anesthesia billed by a provider other than the physician performing the service, or to covered services required by law; coverage includes oral examinations, x-rays, tests and laboratory examinations, restorations, prosthetic services, oral surgery, mandibular/maxillary reconstruction, anesthesia and include facility charges for outpatient services for the removal of teeth or for other dental processes if the patient?s medical condition or the dental procedure requires a hospital setting to ensure the safety of the patient.
Dialysis
Covered
40.00% Coinsurance after deductible 100.00% Benefits include supportive use of an artificial kidney machine.
Allergy Testing
Covered
$80.00 100.00%
Chemotherapy
Covered
40.00% Coinsurance after deductible 100.00%
ER Diagnostic Test Lab-work/Other
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible
ER Imaging Test
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible
ER Physician Fee
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Other Services
Covered
40.00% Coinsurance after deductible 100.00% Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.
Substance Use Disorder Outpatient Other Services
Covered
40.00% Coinsurance after deductible 100.00% Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.
Mental/Behavioral Health Emergency Room
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.
Substance Use Disorder Emergency Room
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.
Mental/Behavioral Health ER Physician Fee
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible Unlimited Virtual Care Visits received from Ambetter Telehealth covered at No Charge, except for HSAs.
Substance Use Disorder ER Physician Fee
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.
Mental/Behavioral Health Emergency Transportation/Ambulance
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.
Substance Use Disorder Emergency Transportation/Ambulance
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.
Mental/Behavioral Health Urgent Care
Covered
$60.00 100.00% Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.
Substance Use Disorder Urgent Care
Covered
$60.00 100.00% Unlimited Virtual Care Visits received from Ambetter Telehealth covered at No Charge, except for HSAs.

Free Preventive Services

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

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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