Ambetter Silver 5 + Vision Coverage Period:
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type:HMO
Questions: Call 877-687-1187, TTY/TDD 877-941-9235 or visit us at
http://ambetter.magnolia healthplan.com/.
If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at
www.cciio.cms.gov or call 877-687-1187, TTY/TDD 877-941-9235 to request a copy.
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This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or
plan document at
http://ambetter.magnolia healthplan.com/ or by calling 877-687-1187, TTY/TDD 877-941-9235
Important Questions Answers Why this Matters:
What is the overall
deductible? $0 See the chart starting on page 2 for your costs for services this plan covers.
Are there other
deductibles for specific
services?
No You don’t have to meet deductibles for specific services, but see the chart starting on
page 2 for other costs for services this plan covers.
Is there an out-ofpocket-
limit on my
expenses?
Yes, for in-network providers
$2,250 individual/$4,500 family.
No, for out-of-network providers.
The out-of-pocket limit is the most you could pay during a coverage period (usually one
year) for your share of the cost of covered services. This limit helps you plan for health
care expenses.
What is not included in
the out-of-pocket limit?
Premiums, balance-billed charges,
and out-of-network services this
plan doesn't cover.
Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Is there an overall
annual limit on what the
plan pays?
No The chart starting on page 2 describes any limits on what the plan will pay for specific
covered services, such as office visits.
Does this plan use a
network of providers?
Yes. See
http://ambetter.
magnoliahealthplan.com/
findadoc or call 1-877-687-1187
for a list of participating
providers.
If you use an in-network doctor or other health care provider, this plan will pay some or
all of the costs of covered services. Be aware, your in-network doctor or hospital may use
an out-of-network provider for some services. Plans use the term in-network, preferred,
or participating for providers in their network. See the chart starting on page 2 for how
this plan pays different kinds of providers.
Do I need a referral to
see a specialist?
No, you don't need a referral to
see a specialist. You can see the specialist you choose without permission from this plan.
Are there services this
plan doesn’t cover? Yes Some of the services this plan doesn't cover are listed on page 5. See your policy or
plan document for additional information about excluded services.
That is from the downloadable PDF they sent me from the insurance company.