[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-302924-105":3,"detail-sidebar-cat-1-en-105":80,"doc-detail-302924-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":73,"head_meta":75,"extra_data":77,"updated_unix":79},105,"en","ca-iex-silver-70-ambetter-hmo-ambetter-hmo-sbc-2025","CA IEX Silver 70 Ambetter HMO - Ambetter HMO SBC 2025","","Summary of Benefits and Coverage (SBC) for a CA IEX Silver 70 Ambetter HMO plan explains how covered health care costs are shared between the plan and the member. It clarifies that premium information is provided separately and outlines deductible status, out-of-pocket limits, and items not counted toward the limit. The document includes network vs. out-of-network payment differences, referral requirements for specialists, and copay/coinsurance rules after any applicable deductible, plus common medical event cost examples.",{"@graph":14,"@context":72},[15,34,55],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/ca-iex-silver-70-ambetter-hmo-ambetter-hmo-sbc-2025/302924/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/ca-iex-silver-70-ambetter-hmo-ambetter-hmo-sbc-2025/302924.png","ImageObject",442,249,{"name":42,"@type":43},"Đào","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-09-24","2026-09-19",true,{"@type":52,"interactionType":53,"userInteractionCount":22},"InteractionCounter",{"@type":54},"ViewAction",{"@type":56,"mainEntity":57},"FAQPage",[58,64,68],{"name":59,"@type":60,"acceptedAnswer":61},"What does the SBC document explain for this health plan?","Question",{"text":62,"@type":63},"It explains how you and the plan share the cost for covered health care services. It also provides key limits and example costs for common medical events.","Answer",{"name":65,"@type":60,"acceptedAnswer":66},"Does this plan have a deductible?",{"text":67,"@type":63},"The document indicates there is no deductible and no other deductibles for specific services.",{"name":69,"@type":60,"acceptedAnswer":70},"What is the out-of-pocket limit, and what is excluded from it?",{"text":71,"@type":63},"The out-of-pocket limit is $6,100 for members and $12,200 for the family per calendar year. Premiums and health care this plan doesn’t cover do not count toward the limit.","https://schema.org",{"og:url":32,"og:type":74,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":76,"canonical":32},"index,follow",{"doc_id":78,"site_id":7},302924,1790209660,{"code":4,"msg":81,"data":82},"success",[83,88,93,98,103,108,112,117,122],{"id":84,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},11,"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":81,"data":127},{"doc_id":78,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":33,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":89,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":139,"read_time":33},1374402968488,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary.  \nFor more information about your coverage, or to get a copy of the complete terms of coverage, [visit](visit www.myhealthnetca.com)[ ](visit www.myhealthnetca.com)[www.myhealthnetca.com](visit www.myhealthnetca.com) or call 1-800-839-2172 . For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at [https://www.healthcare.gov/sbc-glossary/](https://www.healthcare.gov/sbc-glossary/ or www.myhealthnetca.com or you)[ or](https://www.healthcare.gov/sbc-glossary/ or www.myhealthnetca.com or you)[ ](https://www.healthcare.gov/sbc-glossary/ or www.myhealthnetca.com or you)[www.myhealthnetca.com](https://www.healthcare.gov/sbc-glossary/ or www.myhealthnetca.com or you)[ or you](https://www.healthcare.gov/sbc-glossary/ or www.myhealthnetca.com or you) can call 1-800-839-2172 to request a copy.  \n\n| Important Questions | Answers | Why This Matters |\n| --- | --- | --- |\n| What is the overall deductible? | $0. | See the Common Medical Events chart below for your costs for services this plan covers. |\n| Are there services covered before you meet your deductible? | There is no deductible. | There is no deductible. |\n| Are there other deductibles for specific services? | No. | You don’t have to meet deductibles for specific services. |\n| What is the out-ofpocket limit for this plan? | $6,100 member/$12,200 family per calendar year. | The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. |\n| What is not included in the out-of-pocket limit? | Premiums and health care this plan doesn’t cover. | Even though you pay these expenses, they don’t count toward the out-of-pocket limit. |\n| Will you pay less if you use a network provider? | Yes. For a list of non-IHCP preferred providers, see [www.myhealthnetca.com/findadoctor](www.myhealthnetca.com/findadoctor or call)[ or call](www.myhealthnetca.com/findadoctor or call)[ ](www.myhealthnetca.com/findadoctor or call)1-800-839-2172. | This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing) . Be aware, your network provider might use an out-of-network provider for some services (such as lab work) . Check with your provider before you get services. |\n| Do you need a referral to see a specialist? | Yes. Requires written prior authorization. | This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist. |\n\nPage 1 of 7  \nMAU_NO_MD_C0  \n\n| All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n|  |  |  |  |  |  |\n| Common Medical Event | Services You May Need | What You Will Pay Indian Health Care Provider (IHCP)(You will pay the least) | What You Will Pay Non-IHCP\u003Cbr>In-network Provider (You will pay more) | What You Will Pay Non-IHCP\u003Cbr>Out-of-Network Provider (You will pay the most) | Limitations, Exceptions & Other Important Information |\n| \u003Cbr>If you visit a health care provider’s office or clinic | Primary care visit to treat an injury or illness | No charge | $35 copay/visit | Not covered | None |\n|  | Specialist visit | No charge | $85 copay/visit ","cbCaia3PRHlw59cj","https://ap.wps.com/l/cbCaia3PRHlw59cj","pdf",1005873,"English","# Key Terms and Plan Overview\n## Premiums and Access to Full Terms\n# Important Questions\n## Deductible and Pre-Deductible Services\n## Out-of-Pocket Limit Rules\n## Network Provider vs Out-of-Network Costs\n## Specialist Referral Requirements\n# Common Medical Event Cost Chart\n## Office Visits, Specialist Visits, and Preventive Care\n## Diagnostic Tests and Imaging\n## Prescription Drug Tiers and Requirements","[{\"question\":\"What does the SBC document explain for this health plan?\",\"answer\":\"It explains how you and the plan share the cost for covered health care services. It also provides key limits and example costs for common medical events.\"},{\"question\":\"Does this plan have a deductible?\",\"answer\":\"The document indicates there is no deductible and no other deductibles for specific services.\"},{\"question\":\"What is the out-of-pocket limit, and what is excluded from it?\",\"answer\":\"The out-of-pocket limit is $6,100 for members and $12,200 for the family per calendar year. Premiums and health care this plan doesn’t cover do not count toward the limit.\"}]","CA IEX Silver 70 Ambetter HMO - Ambetter HMO SBC 2025 | PDF",1789798625]