CMS Standard Silver
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
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.
Cost-sharing for CMS Standard Silver includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
Cost Sharing Type | Individual | Family |
---|---|---|
Out-of-Pocket Maximum: | $8,900.00 | $8900 per person | $17800 per group |
Deductible: | $5,800.00 | $5800 per person | $11600 per group |
Coinsurance: | 40.00% |
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for CMS Standard Silver 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 |
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
Deductible: | $5,800.00 |
Copayment: | $50.00 |
Coinsurance: | $1,700.00 |
Limit: | $60.00 |
Deductible: | $900.00 |
Copayment: | $1,100.00 |
Coinsurance: | $0.00 |
Limit: | $20.00 |
Deductible: | $2,100.00 |
Copayment: | $400.00 |
Coinsurance: | $0.00 |
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.
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.
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
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
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 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 |
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