Ambetter Balanced Care 28

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Benefits and Coverage (assuming you use preferred providers) (Note: For a more detailed and accurate explanation of the benefits offered by this plan please refer to the Summary of Benefits and Coverage [SBC]. The benefits are described in more detail in the SBC and it will include additional information about those benefits. Some nuances about the benefits like visit limits and other details are not listed below. You should refer to the SBC for those details about the plan. Click on the "View Summary of Benefits and Coverage" link above to view the SBC.)
Plan id	39006NM0010005-00
CSR Variation Type	Standard Silver Off Exchange Plan
Insurance Company	Ambetter
Plan Type	HMO
Plan Metal Level	Silver
Link to Plan's Doctor Directory	View Plan's Doctor Directory
List of Hospitals in Plan's Network	Show Hospitals
Summary of Benefits and Coverage	View Summary of Benefits and Coverage
Estimated Monthly Premium Savings (APTC)
Monthly Premium Cost after Subtracting the Estimated Subsidy (Subsidies are not available for Catastrophic Plans)
Cost in a Good Year: Estimated Yearly Cost to You if Your Health Care Usage is Low (for Very Healthy Consumers "Low" is Defined as Only Preventive Care)	Use 2021 New Mexico Plan Comparison Tool to find out.
Your Chances of Having a Good Year--a Year with No More Than Low-Usage
Cost in an Average Year: Average for People Like You
Cost in a Bad Year: Estimate for People Like You in a High-Health Care Usage Year
Your Chances of Having a Bad Year--a Year with Very High Usage
Actual Maximum Out-of-Pocket (includes premiums)
In-Network Deductible (Note: Unless excepted in the plan's benefit description, you must pay all the costs up to the deductible amount before the plan begins to pay for covered services you use. There may be additional details about the deductible that are not shown below. Please refer to the SBC for additional details.)	$0
Extra Deductible for Drugs	$1,500
Doctor Visits
Doctor Visit - Preventive Care	No Charge
Doctor Visit - Primary Care	$50 Copay
Doctor Visit - Specialist	$90 Copay
Doctor Visit - Well Baby Visits and Care	$50 Copay
Other Practitioner Office Visit (Nurse, Physician Assistant)	$50 Copay
Hospital
Inpatient Hospital Facility	50% Coinsurance
Inpatient Hospital Physician/Surgeon	50% Coinsurance
Outpatient Hospital Facility	50% Coinsurance
Outpatient Hospital Physician/Surgeon	50% Coinsurance
Inpatient Maternity Services	50% Coinsurance
Emergency
Emergency Room Services	50% Coinsurance
Emergency Medical Transportation	50% Coinsurance
Urgent Care Centers or Facilities	$60 Copay
Drugs
Plan's Drug Formulary	View Plan's Drug Formulary
Generic Drug on Formulary in a Local Pharmacy	$30 Copay
Preferred Brand Drug on Formulary in a Local Pharmacy	50% Coinsurance after deductible
Non-Preferred Brand Drug on Formulary in a Local Pharmacy	50% Coinsurance after deductible
Specialty Drug on Formulary in a Local Pharmacy	50% Coinsurance after deductible
Tests & Imaging
Diagnostic Tests (Blood work)	$50 Copay
X-Rays	50% Coinsurance
Imaging (CT/PET Scans, MRI, etc)	50% Coinsurance
Mental/Behavioral Health
Mental/Behavioral Health Inpatient Services	50% Coinsurance
Mental/Behavioral Health Outpatient Services	$50 Copay
Substance Use Disorder Inpatient	50% Coinsurance
Substance Use Disorder Outpatient	$50 Copay
Vision/Hearing Aids
Routine Eye Exam for Child	No Charge
Eye Glasses for Child	No Charge
Routine Eye Exam - Adult
Hearing Aids	50% Coinsurance
Child Dental Coverage
Dental Check-Up for Children
Basic Dental Care – Child
Major Dental Care – Child
Orthodontia – Child
Adult Dental Coverage
Basic Dental Care – Adult
Major Dental Care – Adult
Orthodontia – Adult
Accidental Dental	50% Coinsurance
Home and Nursing Care
Home Health Care Services	50% Coinsurance
Skilled Nursing Care - Facility	50% Coinsurance
Rehabilitative and habilitative services
Habilitation Services	$50 Copay
Outpatient Rehabilitation Services	$50 Copay
Rehabilitative Occupational and Rehabilitative Physical Therapy	$50 Copay
Rehabilitative Speech Therapy	$50 Copay
Other Services
Is HSA Eligible?	No
Allergy Testing	$90 Copay
Chemotherapy	50% Coinsurance
Chiropractic	$90 Copay
Diabetes Education	$90 Copay
Dialysis	50% Coinsurance
Durable Medical Equipment	50% Coinsurance
Hospice Service	50% Coinsurance
Infusion Therapy	50% Coinsurance
Nutritional Counseling	$90 Copay
Prosthetic Devices	50% Coinsurance
Radiation	50% Coinsurance
Reconstructive Surgery	50% Coinsurance
Routine Foot Care
Treatment for Temporomandibular Joint Disorders	50% Coinsurance
Transplant	50% Coinsurance
Weight Loss Programs
Wellness Programs
Asthma Program	Available
Heart Disease Program	Available
Depression Program	Not Available
Diabetes Program	Available
High Blood Pressure & Cholesterol Program	Not Available
Low Back Pain Program	Not Available
Pain Management Program	Not Available
Pregnancy Program	Available
Weight Loss Programs	Not Available
Out-of-Network - See Summary of Benefits and Coverage	View Summary of Benefits and Coverage