Everyday Silver + Vision + Adult Dental

26289NE0030039
Silver
HMO

Everyday Silver + Vision + Adult Dental is a Silver HMO plan by Ambetter from Nebraska Total Care.

IMPORTANT: You are viewing the 2023 version of Everyday Silver + Vision + Adult Dental 26289NE0030039. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Everyday Silver + Vision + Adult Dental is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Everyday Silver + Vision + Adult Dental 26289NE0030039.
Insurer: Ambetter from Nebraska Total Care
Network Type: HMO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 26289NE0030039

Cost-Sharing Overview

Everyday Silver + 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 Everyday Silver + 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

Everyday Silver + 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 Everyday Silver + 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

Everyday Silver + 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
$35.00 100.00% Unlimited Virtual Care Visits received from Ambetter Telehealth covered at No Charge, except for HSAs.
Specialist Visit
Covered
$70.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$35.00 100.00%
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 Covered Person must have a life expectancy of six months or less as documented in writing by the attending Physician. The Hospice Services must be ordered by a Physician. Services provided must be appropriate for palliative support or management of a Covered Person with terminal medical Illness.
Routine Dental Services (Adult)
Covered
No Charge 100.00%1000 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults
Infertility Treatment
Not Covered
Note: Coverage is available for diagnosis and services required to correct underlying medical causes of infertility
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 100.00%1 Exam(s) per Year
Urgent Care Centers or Facilities
Covered
$55.00 100.00%
Home Health Care Services
Covered
40.00% Coinsurance after deductible 100.00%60 Days per Year
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 100.00%
Inpatient Physician and Surgical Services
Covered
40.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
40.00% Coinsurance after deductible 100.00%60 Days per Year
Prenatal and Postnatal Care
Covered
$35.00 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
40.00% Coinsurance after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$35.00 100.00%
Mental/Behavioral Health Inpatient Services
Covered
40.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$35.00 100.00%
Substance Abuse Disorder Inpatient Services
Covered
40.00% Coinsurance after deductible 100.00%
Generic Drugs
Covered
$22.60 100.00% 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
$60.00 100.00%
Non-Preferred Brand Drugs
Covered
50.00% Coinsurance after deductible 100.00%
Specialty Drugs
Covered
50.00% Coinsurance after deductible 100.00%
Outpatient Rehabilitation Services
Covered
40.00% Coinsurance after deductible 100.00%45 Treatment(s) per Year Limits apply to rehab and hab combined: Physical, occupational or speech therapy services, chiropractic or osteopathic physiotherapy (combined limit to 45 sessions per Calendar Year).
Habilitation Services
Covered
40.00% Coinsurance after deductible 100.00%45 Treatment(s) per Year Nebraska supplemented this EHB category for Habilitative Services: ‘Health care Services that help a person keep, learn, or improve skills and functioning for daily living. 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.’ Quantitative limits on services apply to outpatient, only.
Chiropractic Care
Covered
$70.00 100.00%20 Visit(s) per Year Chiropractic physiotherapy has a combined limit with PT, OT and speech therapies of 45 sessions per calendar year. Chiropractic manipulative adjustments have a combined limit with osteopathic physiotherapy of 20 sessions per calendar year.
Durable Medical Equipment
Covered
40.00% Coinsurance after deductible 100.00%
Hearing Aids
Covered
40.00% Coinsurance after deductible 100.00%1 Item(s) per 3 Years
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
No Charge 100.00%
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
Eye Glasses for Children
Covered
No Charge 100.00%1 Item(s) per Year
Dental Check-Up for Children
Not Covered
2 Exam(s) per Year
Rehabilitative Speech Therapy
Covered
40.00% Coinsurance after deductible 100.00%45 Visit(s) per Year Limits apply to rehab and hab combined: Physical, occupational or speech therapy services, chiropractic or osteopathic physiotherapy (combined limit to 45 sessions per Calendar Year).
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
40.00% Coinsurance after deductible 100.00%45 Visit(s) per Year Limits apply to rehab and hab combined: Physical, occupational or speech therapy services, chiropractic or osteopathic physiotherapy (combined limit to 45 sessions per Calendar Year).
Well Baby Visits and Care
Covered
No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
$35.00 100.00% 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
Covered
50.00% 100.00%1000 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
50.00% 100.00%1000 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
40.00% Coinsurance after deductible 100.00%
Accidental Dental
Covered
40.00% Coinsurance after deductible 100.00%
Dialysis
Covered
40.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
$70.00 100.00%
Chemotherapy
Covered
40.00% Coinsurance after deductible 100.00%
Radiation
Covered
40.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
$70.00 100.00%
Prosthetic Devices
Covered
40.00% Coinsurance after deductible 100.00%
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
$70.00 100.00% Only for diabetes management as provided by the plan.
Reconstructive Surgery
Covered
40.00% Coinsurance after deductible 100.00% Available only post-mastectomy or when required to restore, reconstruct or correct any bodily function that was lost, impaired or damaged as a result of Injury or Illness.
Gender Affirming Care
Covered
40.00% Coinsurance after deductible 100.00%
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
$35.00 100.00%
Substance Use Disorder Urgent Care
Covered
$35.00 100.00%
Eyeglasses for Adults
Covered
No Charge 100.00%1 Item(s) per Year Covered up to $130

Free Preventive Services

There is no copayment or coinsurance for any of the following Everyday Silver + 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 Everyday Silver + 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 Everyday Silver + 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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