Silver Standard 1829
36194FL0160012
Silver
HMO
Silver Standard 1829 is a Silver HMO plan by Health First – AdventHealth.
IMPORTANT: You are viewing the 2023 version of Silver Standard 1829 36194FL0160012. You can enroll in this plan if you qualify for special enrollment until the end of 2023.
Locations
Silver Standard 1829 is offered in the following counties.
Plan Overview
This is a plan overview for 2023 version of Silver Standard 1829 36194FL0160012.
| Insurer: | Health First – AdventHealth |
| Network Type: | HMO |
| Metal Type: | Silver |
| HSA Eligible?: | No |
| Plan ID: | 36194FL0160012 |
Cost-Sharing Overview
Silver Standard 1829 offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for Silver Standard 1829 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 Silver Standard 1829 will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | Not Applicable | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | Not Applicable | per person not applicable | per group not applicable |
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: | $20.00 |
| Coinsurance: | $2,100.00 |
| Limit: | $0.00 |
| Deductible: | $100.00 |
| Copayment: | $1,400.00 |
| Coinsurance: | $0.00 |
| Limit: | $0.00 |
| Deductible: | $2,200.00 |
| Copayment: | $300.00 |
| 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 Silver Standard 1829?
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
Silver Standard 1829 offers the following features and referral requirements.
| Wellness Program: | No |
| Disease Program: | Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy |
| Notice Pregnancy: | No |
| 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 Silver Standard 1829 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
Silver Standard 1829 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% | Virtual Health provided as a means to receive this benefit. |
| Specialist Visit Covered | $80.00 | 100.00% | Virtual Health provided as a means to receive this benefit. |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $40.00 | 100.00% | Specialist Visit cost-share will apply if visit is in a specialist’s office. |
| 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% | Covered hospice services do not include bereavement counseling, pastoral counseling, financial or legal counseling or custodial care. |
| Routine Dental Services (Adult) Not Covered | |||
| Infertility Treatment Not Covered | |||
| Long-Term/Custodial Nursing Home Care Not Covered | |||
| Private-Duty Nursing Not Covered | |||
| Routine Eye Exam (Adult) Not Covered | |||
| Urgent Care Centers or Facilities Covered | $60.00 | $60.00 | Virtual Health provided as a means to receive this benefit. Virtual Urgent Care cost-share is 50% of In-Office cost-share. |
| Home Health Care Services Covered | 40.00% Coinsurance after deductible | 100.00% | 60 Visit(s) per Year One date of service is equal to one visit. |
| 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 | |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | 40.00% Coinsurance after deductible | 100.00% | Coverage for inpatient rehabilitation services are limited to 21 days per calendar year. |
| 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 | $0.00 | 100.00% | Visits 16+ and visits with a perinatologist are subject to the Specialist Visit cost-share. Birthing classes are covered at $0 copay. |
| Delivery and All Inpatient Services for Maternity Care Covered | 40.00% Coinsurance after deductible | 100.00% | |
| 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% | The “Generic Drugs” benefit reflects the plan’s “Non-Preferred Generic Drugs” copay. The “Preferred Generic Drugs” benefit is added as an additional EHB benefit to reflect the plan’s “Preferred Generic Drugs” copay. |
| 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% | Coverage is limited to 30-day supply from preferred specialty pharmacy. |
| Outpatient Rehabilitation Services Covered | $40.00 | 100.00% | 35 Visit(s) per Year Combined limit for all outpatient rehabilitative physical, occupational and speech therapy. Limit applies per condition. |
| Habilitation Services Covered | $40.00 | 100.00% | 35 Visit(s) per Year 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. Combined limit for all outpatient habilitative physical, occupational and speech therapy. Limit applies per condition. |
| Chiropractic Care Covered | $80.00 | 100.00% | 26 Visit(s) per Year |
| Durable Medical Equipment Covered | 40.00% Coinsurance after deductible | 100.00% | Items that are primarily for convenience or comfort and items available over-the-counter are excluded. The replacement of equipment is also excluded, unless it is non-functional and not practically repairable. |
| Hearing Aids Not Covered | |||
| Imaging (CT/PET Scans, MRIs) Covered | 40.00% Coinsurance after deductible | 100.00% | Cost-share applies per visit, per type |
| Preventive Care/Screening/Immunization Covered | $0.00 | 100.00% | Limited to services recommended with an “A” or “B” rating by the U.S. Preventive Services Task Force (USPSTF), immunizations recommended for routine use by the Centers for Disease Control and Prevention (CDC), and services listed in guidelines of the Health Resources and Services Administration (HRSA) for women and children. |
| Routine Foot Care Covered | $80.00 | 100.00% | Routine foot care, including any service or supply in connection with foot care, is only covered when medically necessary. |
| Acupuncture Not Covered | |||
| Weight Loss Programs Not Covered | |||
| Routine Eye Exam for Children Covered | $0.00 | 100.00% | 1 Exam(s) per Year Covered up through the end of the birth month in which the covered person reaches age nineteen (19). |
| Eye Glasses for Children Covered | $0.00 | 100.00% | 1 Item(s) per Year Covered up through the end of the birth month in which the covered person reaches age nineteen (19). |
| Dental Check-Up for Children Covered | $0.00 | 100.00% | 1 Visit(s) per 6 Months Covered up through the end of the birth month in which the covered person reaches age nineteen (19). Basic and major dental care and orthodontic services. |
| Rehabilitative Speech Therapy Covered | $40.00 | 100.00% | 35 Visit(s) per Year Combined limit for all outpatient rehabilitative physical, occupational and speech therapy. Limit applies per condition. |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | $40.00 | 100.00% | 35 Visit(s) per Year Combined limit for all outpatient rehabilitative physical, occupational and speech therapy. Limit applies per condition. |
| Well Baby Visits and Care Covered | $0.00 | 100.00% | |
| Laboratory Outpatient and Professional Services Covered | 40.00% Coinsurance after deductible | 100.00% | |
| X-rays and Diagnostic Imaging Covered | 40.00% Coinsurance after deductible | 100.00% | Cost-share applies per visit, per type |
| Basic Dental Care – Child Covered | $0.00 | 100.00% | Covered up through the end of the birth month in which the covered person reaches age nineteen (19). |
| Orthodontia – Child Covered | $0.00 | 100.00% | Covered up through the end of the birth month in which the covered person reaches age nineteen (19). |
| Major Dental Care – Child Covered | $0.00 | 100.00% | Covered up through the end of the birth month in which the covered person reaches age nineteen (19). |
| 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% | Includes bone marrow transplant |
| Accidental Dental Covered | 40.00% Coinsurance after deductible | 100.00% | Coverage is limited to care and stabilization treatment rendered within 62 calendar days of an accidental dental injury. |
| Dialysis Covered | 40.00% Coinsurance after deductible | 100.00% | |
| Allergy Testing Covered | 40.00% Coinsurance after deductible | 100.00% | |
| Chemotherapy Covered | 40.00% Coinsurance after deductible | 100.00% | |
| Radiation Covered | 40.00% Coinsurance after deductible | 100.00% | |
| Diabetes Education Covered | $0.00 | 100.00% | In order to be covered, diabetes outpatient self-management training and educational services must be provided under the direct supervision of a certified diabetes educator or board certified physician specializing in endocrinology. |
| Prosthetic Devices Covered | 40.00% Coinsurance after deductible | 100.00% | Covered prosthetic devices (except cardiac pacemakers and prosthetic devices incident to a mastectomy) are limited to the first such permanent prosthesis, including the first temporary prosthesis if necessary, prescribed for each condition. Coverage is provided for necessary replacement of a prosthetic device owned by the enrollee when due to irreparable damage, wear, a change in the enrollee’s condition, or when necessitated due to growth of a child. |
| Infusion Therapy Covered | 40.00% Coinsurance after deductible | 100.00% | Includes chemotherapy, infusions, therapeutic injections, allergy immunotherapy, and other medications ordered and administered by a provider. |
| Treatment for Temporomandibular Joint Disorders Covered | 40.00% Coinsurance after deductible | 100.00% | 1 Item(s) per 6 Months One splint in a six (6) month period is covered, unless a more frequent replacement is determined to be medically necessary. Splints are subject to the Durable Medical Equipment cost-share. Medically necessary outpatient surgical procedures are subject to the Outpatient Facility Fee and Outpatient Surgery Physician/Surgical Services cost-share. |
| Nutritional Counseling Covered | $0.00 | 100.00% | |
| Reconstructive Surgery Covered | 40.00% Coinsurance after deductible | 100.00% | Any cosmetic reconstructive surgery is exclused. Surgery performed outpatient is subject to the Outpatient Facility Fee and Outpatient Surgery Physician/Surgical Services cost-share. |
| Gender Affirming Care Not Covered | |||
| Anesthesia Services for Dental Care Covered | 40.00% Coinsurance after deductible | 100.00% | Includes general anesthesia and hospitalization services in connection with dental treatment provided in a hospital or ambulatory surgical center. |
| Enteral/Parenteral and Oral Nutrition Therapy Covered | 40.00% Coinsurance after deductible | 100.00% | |
| Osteoporosis Treatment Covered | $80.00 | 100.00% | Treatment provided at a primary care physician’s office will be subject to the Primary Care Visit cost-share. |
| Cardiac and Pulmonary Rehabilitation Covered | $40.00 | 100.00% | 36 Days per Lifetime |
| Preferred Generic Drugs Covered | $20.00 | 100.00% | |
| Genetic Testing Lab Services Covered | 40.00% Coinsurance after deductible | 100.00% | BRCA Analysis to determine a woman’s genetic risk for breast and ovarian cancer is covered as a preventive benefit when medical necessity criteria are met and authorized in advance by the health plan. |
| Hyperbaric Oxygen Therapy Covered | 40.00% Coinsurance after deductible | 100.00% | |
| Outpatient Observation Covered | 40.00% Coinsurance after deductible | 100.00% | |
| Partial Hospitalization Covered | 40.00% Coinsurance after deductible | 100.00% | A structured program of active treatment for psychiatric care that is more intense than the care performed in a physician?s or therapist?s office. |
| Mental Health Office Visit Covered | $40.00 | 100.00% | Virtual Health provided as a means to receive this benefit. |
| Substance Abuse Office Visit Covered | $40.00 | 100.00% | Virtual Health provided as a means to receive this benefit. |
Free Preventive Services
There is no copayment or coinsurance for any of the following Silver Standard 1829 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 Silver Standard 1829 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 Silver Standard 1829?
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