Elite Gold + Vision + Adult Dental

99723MO0110069
Gold
EPO

Elite Gold + Vision + Adult Dental is a Gold EPO plan by Ambetter from Home State Health.

IMPORTANT: You are viewing the 2024 version of Elite Gold + Vision + Adult Dental 99723MO0110069. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

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

Plan Overview

This is a plan overview for 2024 version of Elite Gold + Vision + Adult Dental 99723MO0110069.
Insurer: Ambetter from Home State Health
Network Type: EPO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 99723MO0110069

Cost-Sharing Overview

Elite 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 Elite 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

Elite 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 Elite 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

Elite 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
$5.00 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
$60.00 Not ApplicableNot Applicable 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$5.00 Not ApplicableNot Applicable 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
$200.00 Not ApplicableNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
$200.00 Not ApplicableNot Applicable 100.00%
Hospice Services
Covered
Not Applicable 30.00%Not Applicable 100.00% Respite Care is covered as part of hospice services only.
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
Covered
Not Applicable 30.00%Not Applicable 100.00%82.0 Visit(s) per Year
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 eye glasses.
Urgent Care Centers or Facilities
Covered
$35.00 Not Applicable$35.00 Not Applicable
Home Health Care Services
Covered
Not Applicable 30.00%Not Applicable 100.00%100.0 Visit(s) per Year
Emergency Room Services
Covered
Not Applicable 30.00%Not Applicable 30.00%
Emergency Transportation/Ambulance
Covered
Not Applicable 30.00%Not Applicable 30.00% 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 30.00%Not Applicable 100.00%
Inpatient Physician and Surgical Services
Covered
Not Applicable 30.00%Not Applicable 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
Not Applicable 30.00%Not Applicable 100.00%150.0 Days per Year
Prenatal and Postnatal Care
Covered
$5.00 Not ApplicableNot Applicable 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 30.00%Not Applicable 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$5.00 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. Services (excluding emergency services) rendered by an out-of-network?provider are not covered under this plan, with the exception of two (2) sessions per year for diagnosis/assessment by a licensed mental health provider.
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 30.00%Not Applicable 100.00% Prior authorization may be required – please contact the number listed on your ID card.
Substance Abuse Disorder Outpatient Services
Covered
$5.00 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. Services (excluding emergency services) rendered by an out-of-network?provider are not covered under this plan, with the exception of two (2) sessions per year for diagnosis/assessment by a licensed mental health provider.
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 30.00%Not 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
$50.00 Not ApplicableNot Applicable 100.00%
Non-Preferred Brand Drugs
Covered
Not Applicable 50.00%Not Applicable 100.00%
Specialty Drugs
Covered
Not Applicable 50.00%Not Applicable 100.00%
Outpatient Rehabilitation Services
Covered
$5.00 Not ApplicableNot Applicable 100.00%20.0 Visit(s) per Year Limited to 20 visits per year per therapy (occupational therapy, physical therapy). No Limit for speech therapy. Limited to 36 visits per year cardiac therapy. No Limit for pulmonary therapy.
Habilitation Services
Covered
$5.00 Not ApplicableNot Applicable 100.00%20.0 Visit(s) per Year Limited to 20 visits per year per therapy (occupational therapy, physical therapy). No Limit for speech therapy. Limited to 36 visits per year cardiac therapy. No Limit for pulmonary therapy.
Chiropractic Care
Covered
Not Applicable 30.00%Not Applicable 100.00%26.0 Visit(s) per Year Chiropractic visits beyond 26 per benefit period require Prior Authorization.
Durable Medical Equipment
Covered
Not Applicable 30.00%Not Applicable 100.00%
Hearing Aids
Covered
Not Applicable 30.00%Not Applicable 100.00%2.0 Item(s) per Year Cochlear Implants and Bone Anchored Hearing Aids are a covered benefit.
Imaging (CT/PET Scans, MRIs)
Covered
$75.00 Not ApplicableNot 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
$60.00 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 Covered lenses and frames each available at limit of one per year.
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$5.00 Not ApplicableNot Applicable 100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$5.00 Not ApplicableNot Applicable 100.00%20.0 Visit(s) per Year Limited to 20 visits per year per therapy (occupational therapy, physical therapy). No Limit for speech therapy. Limited to 36 visits per year cardiac therapy. No Limit for pulmonary therapy.
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
$40.00 Not ApplicableNot Applicable 100.00%
X-rays and Diagnostic Imaging
Covered
$75.00 Not ApplicableNot 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 30.00%Not Applicable 100.00% Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant.
Accidental Dental
Covered
$200.00 Not ApplicableNot Applicable 100.00%
Dialysis
Covered
$200.00 Not ApplicableNot Applicable 100.00%
Allergy Testing
Covered
$60.00 Not ApplicableNot Applicable 100.00%
Chemotherapy
Covered
$200.00 Not ApplicableNot Applicable 100.00%
Radiation
Covered
$200.00 Not ApplicableNot Applicable 100.00%
Diabetes Education
Covered
$60.00 Not ApplicableNot Applicable 100.00%
Prosthetic Devices
Covered
Not Applicable 30.00%Not Applicable 100.00% Benefits include the purchase, fitting, adjustments, repairs and replacements.
Infusion Therapy
Covered
$200.00 Not ApplicableNot Applicable 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
$200.00 Not ApplicableNot Applicable 100.00% Covered Services include removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services.
Nutritional Counseling
Covered
$60.00 Not ApplicableNot Applicable 100.00%
Reconstructive Surgery
Covered
Not Applicable 30.00%Not Applicable 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.
Gender Affirming Care
Covered
Not Applicable 30.00%Not Applicable 100.00%
Mental/Behavioral Health Outpatient Other Services
Covered
$200.00 Not ApplicableNot Applicable 100.00% Note: Services (excluding emergency services) rendered by an out-of-network?provider are not covered under this plan, with the exception of two (2) sessions per year for diagnosis/assessment by a licensed mental health provider.
Substance Use Disorder Outpatient Other Services
Covered
$200.00 Not ApplicableNot Applicable 100.00%
Mental/Behavioral Health Emergency Room
Covered
Not Applicable 30.00%Not Applicable 30.00%
Substance Use Disorder Emergency Room
Covered
Not Applicable 30.00%Not Applicable 30.00%
Mental/Behavioral Health ER Physician Fee
Covered
Not Applicable 30.00%Not Applicable 30.00%
Substance Use Disorder ER Physician Fee
Covered
Not Applicable 30.00%Not Applicable 30.00%
Mental/Behavioral Health Emergency Transportation/Ambulance
Covered
Not Applicable 30.00%Not Applicable 30.00% 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.
Substance Use Disorder Emergency Transportation/Ambulance
Covered
Not Applicable 30.00%Not Applicable 30.00% 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.
Mental/Behavioral Health Urgent Care
Covered
$35.00 Not Applicable$35.00 Not Applicable
Substance Use Disorder Urgent Care
Covered
$35.00 Not Applicable$35.00 Not Applicable
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.
Eye Glasses for Adults
Not Covered

Free Preventive Services

There is no copayment or coinsurance for any of the following Elite 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 Elite 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 Elite 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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