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Complete Gold + Vision + Adult Dental

79222SC0020001
Gold
HMO

Complete Gold + Vision + Adult Dental is a Gold HMO plan by Ambetter from Absolute Total Care.

IMPORTANT: You are viewing the 2024 version of Complete Gold + Vision + Adult Dental 79222SC0020001. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

Complete Gold + Vision + Adult Dental is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of Complete Gold + Vision + Adult Dental 79222SC0020001.
Insurer: Ambetter from Absolute Total Care
Network Type: HMO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 79222SC0020001

Cost-Sharing Overview

Complete Gold + Vision + Adult Dental 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 Complete Gold + Vision + Adult Dental?

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

Complete Gold + Vision + Adult Dental 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 Complete Gold + Vision + Adult Dental 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

Complete Gold + Vision + Adult Dental 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
$15.00 Not ApplicableNot Applicable 100.00% Unlimited Virtual 24/7 Care Visits received from Ambetter?s designated telehealth provider covered at No Charge, except for HSAs.
Specialist Visit
Covered
$35.00 Not ApplicableNot Applicable 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$15.00 Not ApplicableNot Applicable 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Hospice Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00% Respite care covered in conjunction with hospice services.
Routine Dental Services (Adult)
Covered
No Charge Not ApplicableNot Applicable 100.00%1000.0 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults
Infertility Treatment
Not Covered
Limited to services for diagnostic tests to find the cause of infertility. Services to treat the underlying medical conditions that cause infertility are covered (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency).
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)
Covered
No Charge Not ApplicableNot Applicable 100.00%1.0 Exam(s) per Year Benefit also includes 1 pair of eye glasses or contacts per year, covered up to $130 In-Network for frames or $130 In-Network for contacts in lieu of eyeglasses.
Urgent Care Centers or Facilities
Covered
$35.00 Not ApplicableNot Applicable 100.00%
Home Health Care Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%60.0 Visit(s) per Year
Emergency Room Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 20.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 20.00% Coinsurance after deductible Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing.
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Inpatient Physician and Surgical Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%60.0 Days per Year
Prenatal and Postnatal Care
Covered
$15.00 Not ApplicableNot Applicable 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$15.00 Not ApplicableNot Applicable 100.00% Cost sharing shown applies to outpatient office visits only.?See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization.
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00% Prior authorization may be required – please contact the number listed on your ID card.
Substance Abuse Disorder Outpatient Services
Covered
$15.00 Not ApplicableNot Applicable 100.00% Cost sharing shown applies to outpatient office visits only.?See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization.
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00% Prior authorization may be required – please contact the number listed on your ID card.
Generic Drugs
Covered
$3.00 Not ApplicableNot Applicable 100.00% Cost sharing shown applies to Tier 2-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 3-Generic Drugs, which may apply a higher cost share. Up to a 30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. Refer to the prescription drug list for more information.
Preferred Brand Drugs
Covered
$30.00 Not ApplicableNot Applicable 100.00%
Non-Preferred Brand Drugs
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Specialty Drugs
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Rehabilitation Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%30.0 Visit(s) per Year Limited to 30 visits per year per therapy (occupational, physical and speech therapy); no limit applies for cardiac or pulmonary therapy. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.
Habilitation Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%30.0 Visit(s) per Year Limited to 30 visits per year per therapy (occupational, physical and speech therapy); no limit applies for cardiac or pulmonary therapy. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.
Chiropractic Care
Covered
$35.00 Not ApplicableNot Applicable 100.00%
Durable Medical Equipment
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge Not ApplicableNot Applicable 100.00% Covered in accordance with ACA guidelines.
Routine Foot Care
Covered
$35.00 Not ApplicableNot Applicable 100.00%
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge Not ApplicableNot Applicable 100.00%1.0 Exam(s) per Year
Eye Glasses for Children
Covered
No Charge Not ApplicableNot Applicable 100.00%1.0 Item(s) per Year
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%30.0 Visit(s) per Year Limited to 30 visits per year per therapy (occupational, physical and speech therapy); no limit applies for cardiac or pulmonary therapy. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%30.0 Visit(s) per Year Limited to 30 visits per year per therapy (occupational, physical and speech therapy); no limit applies for cardiac or pulmonary therapy. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.
Well Baby Visits and Care
Covered
No Charge Not ApplicableNot Applicable 100.00% Covered in accordance with ACA guidelines.
Laboratory Outpatient and Professional Services
Covered
$15.00 Not ApplicableNot Applicable 100.00%
X-rays and Diagnostic Imaging
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Covered
Not Applicable 50.00%Not Applicable 100.00%1000.0 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Covered
Not Applicable 50.00%Not Applicable 100.00%1000.0 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00% Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant.
Accidental Dental
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Dialysis
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Allergy Testing
Covered
$35.00 Not ApplicableNot Applicable 100.00%
Chemotherapy
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Radiation
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Diabetes Education
Covered
$35.00 Not ApplicableNot Applicable 100.00%
Prosthetic Devices
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Infusion Therapy
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Nutritional Counseling
Covered
$35.00 Not ApplicableNot Applicable 100.00%
Reconstructive Surgery
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00% 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
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Mental/Behavioral Health Outpatient Other Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Substance Use Disorder Outpatient Other Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Mental/Behavioral Health Emergency Room
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 20.00% Coinsurance after deductible
Substance Use Disorder Emergency Room
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 20.00% Coinsurance after deductible
Mental/Behavioral Health ER Physician Fee
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 20.00% Coinsurance after deductible
Substance Use Disorder ER Physician Fee
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 20.00% Coinsurance after deductible
Mental/Behavioral Health Emergency Transportation/Ambulance
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 20.00% Coinsurance after deductible
Substance Use Disorder Emergency Transportation/Ambulance
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 20.00% Coinsurance after deductible
Mental/Behavioral Health Urgent Care
Covered
$15.00 Not ApplicableNot Applicable 100.00%
Substance Use Disorder Urgent Care
Covered
$15.00 Not ApplicableNot Applicable 100.00%
Tier 3 Generic Drugs
Covered
$15.00 Not ApplicableNot Applicable 100.00% Up to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90 day Retail Pharmacy. Refer to the prescription drug list for more information.

Free Preventive Services

There is no copayment or coinsurance for any of the following Complete Gold + Vision + Adult Dental 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 Complete Gold + Vision + Adult Dental 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 Complete Gold + Vision + Adult Dental?

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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