CMS Standard Silver
62141AR0080033
Silver
PPO
CMS Standard Silver is a Silver PPO plan by Ambetter from Arkansas Health & Wellness.
IMPORTANT: You are viewing the 2023 version of CMS Standard Silver 62141AR0080033. 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.
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Plan Overview
This is a plan overview for 2023 version of CMS Standard Silver 62141AR0080033.
| Insurer: | Ambetter from Arkansas Health & Wellness |
| Network Type: | PPO |
| Metal Type: | Silver |
| HSA Eligible?: | No |
| Plan ID: | 62141AR0080033 |
Cost-Sharing Overview
CMS Standard Silver offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
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% | |
Out-of-Network Cost-Sharing
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: | $12,500.00 | $12500 per person | $25000 per group |
| Out-of-Network Deductible: | $7,500.00 | $7500 per person | $15000 per group |
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: | $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.
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 |
|---|---|---|---|
| Primary Care Visit to Treat an Injury or Illness Covered | $40.00 | 60.00% | |
| Specialist Visit Covered | $80.00 | 60.00% | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $40.00 | 60.00% | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | Prior authorization may be required – please contact the number listed on your ID card. |
| Outpatient Surgery Physician/Surgical Services Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | Prior authorization may be required – please contact the number listed on your ID card. |
| Hospice Services Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | 180 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 | 40.00% Coinsurance after deductible | 60.00% 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 | $60.00 | 60.00% | |
| Home Health Care Services Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | 50 Visit(s) per Year Prior authorization may be required – please contact the number listed on your ID card. |
| 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 | 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 | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | Prior authorization may be required – please contact the number listed on your ID card. |
| Inpatient Physician and Surgical Services Covered | 40.00% Coinsurance after deductible | 60.00% 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 | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | 60 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 | $40.00 | 60.00% | |
| Delivery and All Inpatient Services for Maternity Care Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | Prior authorization may be required – please contact the number listed on your ID card. |
| Mental/Behavioral Health Outpatient Services Covered | $40.00 | 60.00% | 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 | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | Prior authorization may be required – please contact the number listed on your ID card. |
| Substance Abuse Disorder Outpatient Services Covered | $40.00 | 60.00% | 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 | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | Prior authorization may be required – please contact the number listed on your ID card. |
| Generic Drugs Covered | $20.00 | 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 | $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 | 60.00% Coinsurance after deductible | 30 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 | $40.00 | 60.00% Coinsurance after deductible | 30 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 | $80.00 | 60.00% | 30 Visit(s) per Year Combined 30 visit limit per year for Chiropractic Care, PT, OT and ST. |
| Durable Medical Equipment Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | Prior authorization may be required – please contact the number listed on your ID card. |
| Hearing Aids Covered | 40.00% | 60.00% | 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 | 40.00% Coinsurance after deductible | 60.00% 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% | 60.00% | |
| Routine Foot Care Covered | $80.00 | 60.00% | 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 | $40.00 | 60.00% Coinsurance after deductible | 30 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 | $40.00 | 60.00% Coinsurance after deductible | 30 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 | 60.00% | |
| Laboratory Outpatient and Professional Services Covered | 40.00% Coinsurance after deductible | 60.00% | 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 | 40.00% Coinsurance after deductible | 60.00% 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 | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | Prior authorization may be required – please contact the number listed on your ID card. |
| Accidental Dental Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | Prior authorization may be required – please contact the number listed on your ID card. |
| Dialysis Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | Prior authorization may be required – please contact the number listed on your ID card. |
| Allergy Testing Covered | $80.00 | 60.00% | Prior authorization may be required – please contact the number listed on your ID card. |
| Chemotherapy Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | Prior authorization may be required – please contact the number listed on your ID card. |
| Radiation Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | Prior authorization may be required – please contact the number listed on your ID card. |
| Diabetes Education Covered | $80.00 | 60.00% | Prior authorization may be required – please contact the number listed on your ID card. |
| Prosthetic Devices Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | Prior authorization may be required – please contact the number listed on your ID card. |
| Infusion Therapy Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | Prior authorization may be required – please contact the number listed on your ID card. |
| Treatment for Temporomandibular Joint Disorders Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | Prior authorization may be required – please contact the number listed on your ID card. |
| Nutritional Counseling Covered | $80.00 | 60.00% | 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 | 40.00% Coinsurance after deductible | 60.00% 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 | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | |
| Diabetes Care Management Covered | $80.00 | 60.00% | Covered based on medical necessity. Prior authorization may be required – please contact the number listed on your ID card. |
| Inherited Metabolic Disorder – PKU Covered | 40.00% Coinsurance after deductible | 60.00% | Prior authorization may be required – please contact the number listed on your ID card. |
| Off Label Prescription Drugs Covered | $350.00 Copay after deductible | 100.00% | |
| Dental Anesthesia Covered | 40.00% Coinsurance after deductible | 60.00% 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 | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | Prior authorization may be required – please contact the number listed on your ID card. |
| Well Child Care Covered | No Charge | 60.00% | |
| Applied Behavior Analysis Based Therapies Covered | 40.00% Coinsurance after deductible | 60.00% 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 | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | Prior authorization may be required – please contact the number listed on your ID card. |
| Cardiac Rehabilitation Covered | $40.00 | 60.00% Coinsurance after deductible | 36 Visit(s) per Year Prior authorization may be required – please contact the number listed on your ID card. |
| Craniofacial Surgery Covered | 40.00% Coinsurance after deductible | 60.00% 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 | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | Prior authorization may be required – please contact the number listed on your ID card. |
| Substance Use Disorder Outpatient Other Services Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | Prior authorization may be required – please contact the number listed on your ID card. |
| Mental/Behavioral Health Emergency Room Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | |
| Substance Use Disorder Emergency Room Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | |
| Mental/Behavioral Health ER Physician Fee Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | |
| Substance Use Disorder ER Physician Fee Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | |
| Mental/Behavioral Health Emergency Transportation/Ambulance Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | |
| Substance Use Disorder Emergency Transportation/Ambulance Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | |
| Mental/Behavioral Health Urgent Care Covered | $60.00 | 60.00% | |
| Substance Use Disorder Urgent Care Covered | $60.00 | 60.00% |
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 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 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