Ambetter Balanced Care 1 is a Silver Level health insurance plan offered by Ambetter Health Insurance Company. It has an annual medical deductible of $5,650 for individual plans and $11,300 for family plans. With a 20% medical coinsurance, the plan also offers vision benefits for adults and children and dental benefits for adults. Ambetter Balanced Care 1 offers prescription drug coinsurance of up to 30% with a maximum annual out-of-pocket of $6,950 for individuals and $13,900 for family plans.
Popular Benefits of Ambetter Balanced Care 1
Now we will see what benefits Ambetter Balanced Care 1 has to offer to its customers and their pricing in detail:
Emergency Services:
Emergency Services | Your Cost (In-Network Providers Only) | Out-of-Network |
| Emergency Room Services | 20% Coinsurance after deductible | 20% Coinsurance after deductible |
| Emergency Transportation/Ambulance (Air or Ground) | 20% Coinsurance after deductible | 20% Coinsurance after deductible |
| Urgent Care | $60 Copay | Not covered |
Provider Services:
Provider Services | Your Cost (In-Network Providers Only) | Out-of-Network |
| Annual Well Visit/Screening/Immunization/Well Baby | No charge | Not covered |
| Primary Care Visit to treat an injury or illness and Maternity | $30 Copay | Not covered |
| Specialist Visit (e.g., Cardiology, Podiatry, Chiropractic Care) | $60 Copay | Not covered |
| Imaging (CT/PET Scans, MRIs) | 20% Coinsurance after deductible | Not covered |
| X-rays & Diagnostic Imaging | 20% Coinsurance after deductible | Not covered |
| Diagnostic Test* Lab-work/Other (i.e., EKG, Stress Test) | 20% Coinsurance after deductible | Not covered |
Inpatient and Outpatient Services:
Inpatient & Outpatient Services | Your Cost (In-Network Providers Only) | Out-of-Network |
| Inpatient Facility Fee (Includes Mental Health, Substance Use, and Maternity) | 20% Coinsurance after deductible | Not covered |
| Inpatient Hospital Physician & Surgical Services | 20% Coinsurance after deductible | Not covered |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | 20% Coinsurance after deductible | Not covered |
| Outpatient Surgery Physician/Surgical Services | 20% Coinsurance after deductible | Not covered |
Other Medical Services:
Other Medical Services | Your Cost (In-Network Providers Only) | Out-of-Network |
| Mental/Behavioral Health & Substance Use Disorder Outpatient Services | $30 Copay/Office Visit (deductible does not apply); 20% Coinsurance after deductible for all other outpatient services | Not covered |
| Rehabilitation Outpatient Services (includes Speech, Occupational and Physical Therapy) | 20% Coinsurance after deductible | Not covered |
Pediatric Vision:
| Pediatric Vision | Your Cost (In-Network Providers Only) | Out-of-Network |
| Routine Eye Exam (1 visit per year) | 100% Covered | Not covered |
| Eyeglasses (frames, 1 item per year) | 100% Covered | Not covered |
| Lenses (per pair) | 100% Covered | Not covered |
Prescription Drugs:
Prescription Drugs | Your Cost (In-Network Providers Only) | Out-of-Network |
| Generics* | $10 Copay | Not covered |
| Preferred Brand Drugs | $55 Copay | Not covered |
| Non-preferred Brand Drugs | 30% Coinsurance after deductible | Not covered |
| Specialty Drugs | 30% Coinsurance after deductible | Not covered |
Pediatric Vision (0 – 19 years):
Pediatric Vision | Your Cost (In-Network Providers Only) | Out-of-Network |
| Exams and Eyewear: Routine Eye Exam (1 visit per year) | 100% Covered | Not covered |
| Eyeglasses (frames, 1 item per year) | 100% Covered | Not covered |
| Lenses (per pair): Single | 100% Covered | Not covered |
| Bifocal | 100% Covered | Not covered |
| Trifocal | 100% Covered | Not covered |
| Lenticular | 100% Covered | Not covered |
| Contact Lenses: Contact lenses (instead of glasses) | 100% Covered | Not covered |
| Contact lens fitting | 100% Covered | Not covered |
| Specialty lens fitting | 100% Covered | Not covered |
Adult Vision (19 and above):
| Adult Vision | Your Cost (In-Network Providers Only) | Out-of-Network |
| Exams and Eyewear: Routine Eye Exam (1 visit per year) | 100% Covered | Not covered |
| Eyeglasses (frames, 1 item per year) | Covered up to $130 | Not covered |
| Lenses (per pair): Single | 100% Covered | Not covered |
| Bifocal | 100% Covered | Not covered |
| Trifocal | 100% Covered | Not covered |
| Lenticular | 100% Covered | Not covered |
| Contact Lenses: Contact lenses (instead of glasses) | Covered up to $130 | Not covered |
| Contact lens fitting | 100% Covered | Not covered |
| Specialty lens fitting | Covered up to $50 | Not covered |
Adult Dental:
Ambetter Balanced Care 1 offers dental benefits for people 19 years old and above. It has a maximum annual benefit of $1,000 per person.
Routine Dental (Class 1):
| Routine Dental (Class 1) | Your Cost (In-Network Providers Only) | Out-of-Network |
| Routine Oral Exam (1 per 6 months) | No charge, subject to Annual Maximum | Not covered |
| Routine Cleaning (1 per 6 months) | No charge, subject to Annual Maximum | Not covered |
| Bite-wing X-ray (1 per 12 months) | No charge, subject to Annual Maximum | Not covered |
| Full Mouth X-ray (1 per 60 months) | No charge, subject to Annual Maximum | Not covered |
| Panoramic Film (1 per 60 months) | No charge, subject to Annual Maximum | Not covered |
| Topical Fluoride Application (2 per 12 months) | No charge, subject to Annual Maximum | Not covered |
| Palliative Treatment for relief of pain (minor procedures) | No charge, subject to Annual Maximum | Not covered |
Basic Dental (Class 2):
Basic Dental (Class 2) | Your Cost (In-Network Providers Only) | Out-of-Network |
| Basic Services: Silver Fillings (1 per 2 years) | 50% coinsurance, subject to Annual Maximum | Not covered |
| Tooth-Colored Fillings (1 per 2 years, front teeth only) | 50% coinsurance, subject to Annual Maximum | Not covered |
| Endodontics: Therapeutic Pulpotomy on permanent teeth (1 per lifetime per tooth) | 50% coinsurance, subject to Annual Maximum | Not covered |
| Periodontics: Scaling and Root Planning (1 per 24 months) | 50% coinsurance, subject to Annual Maximum | Not covered |
| Periodontal Maintenance (4 in 12 months) | 50% coinsurance, subject to Annual Maximum | Not covered |
| Oral Surgery: Simple Extractions | 50% coinsurance, subject to Annual Maximum | Not covered |
| Surgical Extractions | 50% coinsurance, subject to Annual Maximum | Not covered |
| Removal of Impacted Teeth | 50% coinsurance, subject to Annual Maximum | Not covered |
| Alveoloplasty | 50% coinsurance, subject to Annual Maximum | Not covered |
| Prosthodontics: Relins (1 per 36 months) | 50% coinsurance, subject to Annual Maximum | Not covered |
| Rebase (1 per 36 months) | 50% coinsurance, subject to Annual Maximum | Not covered |
| Adjustments | 50% coinsurance, subject to Annual Maximum | Not covered |
| Repairs | 50% coinsurance, subject to Annual Maximum | Not covered |
Ambetter provides health insurance plans with amazing benefits and at an affordable price. You can choose the plan that best fits your medical needs. For more information regarding insurance plans, you can contact your nearest insurance providers or agents. You can visit their website to get more information according to your demand.
Frequently Asked Questions
Q. Does Ambetter offer dental benefits for children?
Ambetter does not offer any dental benefits for children. They offer dental benefits for people of 19 years age and above.
Q. Does Ambetter offer any benefit for mental and behavioral health?
Ambetter offers various benefits for people with mental and behavioral health disorders. They also provide support for substance abuse disorder and rehabilitation. For more information, contact your local agents.
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