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CMS Standard Silver

91450AZ0080123
Silver
HMO

CMS Standard Silver is a Silver HMO plan by Health Net.

IMPORTANT: You are viewing the 2023 version of CMS Standard Silver 91450AZ0080123. 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 91450AZ0080123.
Insurer: Health Net
Network Type: HMO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 91450AZ0080123

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
Primary Care Visit to Treat an Injury or Illness
Covered
$40.00 100.00% Unlimited Virtual Care Visits received from Ambetter Telehealth covered at No Charge, except for HSAs.
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% The Plan covers hospice care services which are provided under an approved hospice care program when provided to a Member who has been diagnosed by a Participating Provider as having a terminal illness with a prognosis of six (6) months or less to live. Respite Care is not a covered benefit.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not 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
Covered
40.00% Coinsurance after deductible 100.00% Private hospital rooms and/or private duty nursing are only available during inpatient stays and determined to be medically appropriate by the Plan. Private duty nursing is available only in an inpatient setting when skilled nursing is not available from the facility. Custodial Nursing is not covered by the Plan.
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$60.00 100.00%
Home Health Care Services
Covered
40.00% Coinsurance after deductible 100.00%42 Visit(s) per Year 1. The physician must have determined a medical need for home health care and developed a plan of care that is reviewed at thirty day intervals by the physician.; 2. The care described in the plan of care must be for intermittent skilled nursing, therapy, or speech services.; 3. The patient must be homebound unless services are determined to be medically necessary by the Medical Management Organization.; 4. The home health agency delivering care must be certified within the state the care is received.; 5. The care that is being provided is not custodial care. A Home Health visit is considered to be up to four hours of services.
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 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 100.00%
Inpatient Physician and Surgical Services
Covered
40.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Covered
40.00% Coinsurance after deductible 100.00% 1. The patient must have a body-mass index (BMI) greather than equal to 35.; 2. Have at least one co-morbidity related to obesity.; 3. Previously unsuccessful with medical treatment for obesity. The following medical information must be documented in the patient’s medical record: Active participation within the last two years in one physician?supervised weight-management program for a minimum of six months without significant gaps. The weight-management program must include monthly documentation of all of the following components:a. Weight; b. Current dietary program; c. Physical activity (e.g., exercise program); 4. In addition, the procedure must be performed at an approved Center of Excellence facility that is credentialed by your Health Network to perform bariatric surgery.; 5. The member must be 18 years or older, or have reached full expected skeletal growth.
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
40.00% Coinsurance after deductible 100.00%90 Days per Year
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% Newborn benefits do not apply to the newly born child of an Eligible Dependent daughter unless placement with the Employee is confirmed through a court order or legal guardianship.
Mental/Behavioral Health Outpatient Services
Covered
$40.00 100.00%
Mental/Behavioral Health Inpatient Services
Covered
40.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$40.00 100.00%
Substance Abuse Disorder Inpatient Services
Covered
40.00% Coinsurance after deductible 100.00%
Generic Drugs
Covered
$20.00 100.00% 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
$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%60 Visit(s) per Year Short-term rehabilitative therapy includes services in an outpatient facility or physician?s office that is part of a rehabilitation program, including physical, speech, occupational, cardiac rehabilitation and pulmonary rehabilitation therapy. Visit limit is for all therapy types combined.
Habilitation Services
Covered
$40.00 100.00% Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.
Chiropractic Care
Covered
$80.00 100.00%20 Visit(s) per Year HMOs may limit chiropractic visits to 20; PPOs must cover medically necessary chiropractic visits.
Durable Medical Equipment
Covered
40.00% Coinsurance after deductible 100.00%
Hearing Aids
Covered
40.00% Coinsurance after deductible 100.00%2 Item(s) per Benefit Period Hearing aid devices limited to one per ear, per Plan Year when determined to be medically necessary by the Medical Management Organization.
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%1 Exam(s) per Year Covered in accordance with ACA guidelines.
Routine Foot Care
Covered
$80.00 100.00% Prior authorization may be required. Covered no limit.
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge 100.00%1 Visit(s) per Year
Eye Glasses for Children
Covered
No Charge 100.00%1 Item(s) per Year
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$40.00 100.00%60 Visit(s) per Year Visit limit is for all therapy types combined (PT, OT, ST).
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$40.00 100.00%60 Visit(s) per Year Visit limit is for all therapy types combined (PT, OT, ST).
Well Baby Visits and Care
Covered
No Charge 100.00% Well Child visits and immunizations are covered through 47 months as recommended by the American Academy of Pediatrics.
Laboratory Outpatient and Professional Services
Covered
40.00% Coinsurance after deductible 100.00% Cost share is based on place of service.
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% Travel & lodging expenses are limited to $10,000 per transplant. Travel and lodging are not covered if the Member is a donor. Organ transplant services include the recipient?s medical, surgical and hospital services; inpatient immunosuppressive medications; and costs for organ procurement. Transplant services are covered only if they are required to perform human to human organ or tissue transplants, such as:1. Allogeneic bone marrow/stem cell;2. Autologous bone marrow/stem cell;3. Cornea;4. Heart;5. Heart/lung;6. Kidney;7. Kidney/pancreas;8. Liver;9. Lung;10. Pancreas;11. Small bowel/liver; or 12. Kidney/liver. Organ transplant coverage will apply only to non-experimental transplants for the specific diagnosis. Coverage for organ procurement costs are limited to costs directly related to the procurement of an organ, from a cadaver or a live donor. Organ procurement costs shall consist of surgery necessary for organ removal, organ transportation and the transportation, hospitalization and surgery of a live donor. Compatibility testing undertaken prior to procurement is covered if Medically Necessary.
Accidental Dental
Covered
40.00% Coinsurance after deductible 100.00% Benefits are payable for the services of a Physician, dentist, or dental surgeon, provided the services are rendered for treatment of an accidental injury to sound natural teeth where the continuous course of treatment is started within six (6) months of the accident.
Dialysis
Covered
40.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
$80.00 100.00%
Chemotherapy
Covered
40.00% Coinsurance after deductible 100.00%
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% The Plan covers the initial purchase and fitting of external prosthetic devices which are used as a replacement or substitute for a missing body part and are necessary for the alleviation or correction of illness, injury, congenital defect, or alopecia as a result of chemotherapy, radiation therapy, and second or third degree burns. External prosthetic appliances shall include artificial arms and legs, wigs, hair pieces and terminal devices such as a hand or hook. Wigs and hair pieces are limited to one per Plan Year and $150 maximum. Members must provide a valid prescription verifying diagnosis of alopecia as a result of chemotherapy, radiation therapy, second or third degree burns with a submitted claim for coverage. All other diagnosis are excluded. Replacement of artificial arms and legs and terminal devices are covered only if necessitated by normal anatomical growth or as a result of wear and tear.
Infusion Therapy
Covered
40.00% Coinsurance after deductible 100.00% Infusion/IV Therapy in an Outpatient setting including, but not limited to: Inflixima/b (Remicade), Alefacept (Amevive), and Etanercept (Enbrel).
Treatment for Temporomandibular Joint Disorders
Covered
40.00% Coinsurance after deductible 100.00% Benefits are payable for covered services and supplies which are necessary to treat TMJ disorder which is a result of: 1. An accident; 2. Trauma; 3. A congenital defect; 4. A developmental defect; or 5. A pathology.
Nutritional Counseling
Covered
$80.00 100.00% Covered when dietary adjustment has a therapeutic role of a diagnosed chronic disease/condition, including but not limited to:1. Morbid obesity 2. Diabetes3. Cardiovascular disease 4. Hypertension 5. Kidney disease 6. Eating disorders 7. Gastrointestinal disorders 8. Food allergies 9. Hyperlipidemia
Reconstructive Surgery
Covered
40.00% Coinsurance after deductible 100.00% Following a mastectomy, the following services and supplies are covered:1. Surgical services for reconstruction of the breast on which the mastectomy was performed;2. Surgical services for reconstruction of the non-diseased breast to produce symmetrical appearance;3. Post-operative breast prostheses; and 4. Mastectomy bras/camisoles and external prosthetics that meet external prosthetic placement needs.During all stages of mastectomy, treatments of physical complications, including lymphedema, are covered. Cosmetic Surgery is covered for reconstructive surgery that constitutes necessary care and treatment of medically diagnosed services required for the prompt repair of accidental injury. Congenital defects and birth abnormalities are covered for Eligible Dependent children.
Gender Affirming Care
Covered
40.00% Coinsurance after deductible 100.00%
Clinical Trials
Covered
40.00% Coinsurance after deductible 100.00%
Diabetes Care Management
Covered
$80.00 100.00%
Inherited Metabolic Disorder – PKU
Covered
40.00% Coinsurance after deductible 100.00%
Off Label Prescription Drugs
Covered
$350.00 Copay after deductible 100.00%
Prescription Drugs Other
Covered
$350.00 Copay after deductible 100.00%
Wigs
Covered
40.00% Coinsurance after deductible 100.00%1 Item(s) per Year
Mental/Behavioral Health Outpatient Other Services
Covered
40.00% Coinsurance after deductible 100.00%
Substance Use Disorder Outpatient Other Services
Covered
40.00% Coinsurance after deductible 100.00%
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
$60.00 100.00%
Substance Use Disorder Urgent Care
Covered
$60.00 100.00%

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.

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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