Centene Ambetter Adult Vision Dental Coverage

Network and access criteria

Network access and member obligations to obtain benefits

Members must designate a network Primary Care Physician (PCP) for each member to obtain benefits; if not selected one will be assigned.

Members may change PCP (no more frequently than once a month); PCP changes become effective no later than 30 calendar days after request or may be made effective the next business day when selected through Member Services.

A current provider directory is available online and on request at no charge; Member Services will respond to provider-network status inquiries within one business day.

If services are received from a non-network provider because of inaccurate provider directory information or inaccurate network-status information provided by the plan, and the services are otherwise covered, the member will be held to network cost sharing (network deductible and network out‑of‑pocket) and will not be balance billed by the non‑network provider.

Members will receive a member identification card after enrollment and payment of initial premium; a temporary ID can be downloaded online.

Balance billing, emergency services, and eligible expense criteria

Covered when federal balance-billing protections or emergency-service rules apply; member cost-share and eligible expense rules summarized below.

Under federal law (No Surprises Act) non-network providers are prohibited from balance billing members for services subject to balance billing protections; member responsibility is only the cost share calculated as if services were received from a network provider based on the recognized/eligible amount.

Balance-billing protections apply to emergency services, certain non-emergency services provided at a network hospital/ASC absent valid notice-and-consent, and air ambulance services by non-network providers.

When balance-billing protections apply, eligible expense for non-network providers is the negotiated fee if mutually agreed; if no negotiated fee exists, eligible expense is reimbursement as determined by the plan and as required by applicable law.

Emergency services are covered without prior authorization; continuation of care beyond stabilization requires authorization and must be medically necessary to remain covered.

Dependent Eligibility and Coverage Rules

Dependent enrollment and initial coverage provisions

Dependents included on the subscriber's initial enrollment are covered on the subscriber's effective date.

An eligible newborn is covered from time of birth until the 31st day after birth; additional premium and enrollment action are required to continue coverage beyond that 31‑day period.

An eligible child legally placed for adoption is covered from date of placement until the 31st day after placement; additional premium is required to continue coverage beyond the 31‑day period and coverage may terminate retroactively to day 31 if timely premium and notice are not received (90‑day rule for placement premium in some cases).

For off‑exchange policies, when a subscriber applies in writing and pays required premium to add a dependent, the insurer will confirm the effective date and issue member ID cards for added dependents.

Coverage criteria and operational rules

Operational coverage rules: enrollment windows, premium expectations, and prior authorization requirements and consequences.

Open enrollment and special enrollment periods apply as described in the Schedule of Benefits and policy (open enrollment example: Nov 1, 2024–Jan 15, 2025; enroll by Dec 15 for Jan 1 effective date).

Qualified individuals generally have 60 calendar days to report qualifying events for a Special Enrollment Period; 90 days allowed for loss of Medicaid/CHIP coverage.

Initial premium is due before the effective date; members receiving premium subsidy have a 90‑day grace period with specific claims handling rules; non‑subsidized members must pay monthly premiums in advance per policy terms.

If a member is inpatient on the policy effective date and prior coverage continues to pay for that inpatient stay, this policy will not cover those services until discharge or exhaustion of prior benefits; members must notify the plan as soon as reasonably possible (within two calendar days if applicable).

Network and non-network coverage rules

Network protections, when non‑network coverage is allowed, and member liabilities for non‑network care.

Services from non‑network providers are generally not covered unless authorized when covered services cannot be obtained from a network provider within a reasonable distance or other exceptions apply; prior authorization is required for non‑network services when coverage is authorized.

Non‑network providers may balance bill members for amounts above the plan's eligible expense; such amounts typically do not count toward deductible or maximum out‑of‑pocket unless balance‑billing protections apply.

Hospital/ancillary non‑network situations

When receiving care at a network facility, some hospital‑based providers may be non‑network; if a member gives valid notice‑and‑consent to waive balance‑billing protections, the member may be responsible for balance bills and those amounts will not apply to deductible or OOP limits.

Out‑of‑area Ambetter providers may require prior authorization for non‑emergency services; members should contact Member Services for out‑of‑area prior authorization details.

Cost sharing and claims processing

How member cost‑sharing and claim adjudication are applied.

Benefits are paid subject to the Schedule of Benefits; applicable deductibles, copayments, and coinsurance apply as specified.

Deductible amounts must be met before some benefits are payable; copayments do not count toward the deductible but do count toward the maximum out‑of‑pocket.

Coinsurance is the member's percentage share and applies toward the maximum out‑of‑pocket but not toward the deductible unless otherwise specified.

After an individual reaches the individual maximum out‑of‑pocket, the plan pays 100% of covered services; the family OOP equals two times the individual OOP and can be met by a combination of members' eligible expenses.

Each claim is processed and adjudicated separately upon receipt and coverage is only provided for eligible expenses subject to policy limits and eligible-expense determinations.

PCP, access, and continuity of care

Primary care, access expectations, and continuity protections.

Members must designate a network PCP for each member; acceptable provider types and that selecting a nurse practitioner does not change coverage or copayments are specified.

A referral is not required for mental/behavioral health or OB/GYN services; certain specialties (e.g., dermatology) may require a PCP referral, which can permit continued access for up to six months or four visits for the referred issue.

Members may change PCP no more frequently than once a month; PCP change requests are effective no later than 30 calendar days after receipt of the request (or sooner as noted elsewhere).

Members have access to a 24/7 nurse advice line for after‑hours care; in emergencies call 911. Members should bring ID and member card to appointments and contact Member Services for appointment assistance.

Continuity of care: if a provider leaves the network and a member is a continuing care patient, the member will be timely notified, given an opportunity to request transitional care, and may continue benefits for the course of treatment for up to 90 days or until no longer a continuing care patient.

Service-specific coverage criteria

Service‑specific coverage criteria and limits across major benefit areas.

Continuity and emergency coverage: Emergency services outside the service area are covered without prior authorization; members should report emergencies promptly; continuation of care post‑stabilization requires authorization.

Ambulance (air, ground, water): emergency transport covered to nearest appropriate facility; non‑emergency ambulance services require prior authorization; air ambulance covered for neonatal transfer, interfacility transport when authorized, and transfers required by plan; balance‑billing protections apply for covered air ambulance services.

Autism spectrum disorder services (including applied behavior analysis) are covered when prescribed and are not subject to a numeric lifetime or visit cap, but are subject to prior authorization for medical necessity determinations; same‑day multiple provider visits may incur separate cost sharing per provider.

Clinical trials: routine patient care costs for eligible phase III/IV (and certain qualifying trials) are covered when trial and provider meet listed approval and expertise requirements; participation is subject to prior authorization; investigational items themselves and items provided free by sponsor are excluded.

Clinical trial coverage

Clinical trial routine care coverage and participation requirements

Routine patient care costs incurred as a result of approved phase III/IV clinical trials (and certain qualifying trials) for prevention, early detection, or treatment of cancer or other life‑threatening conditions are covered when the trial meets specified approval/funding criteria.

Excluded from coverage are the investigational item/service itself, items provided solely for data collection not used in direct clinical management, and items customarily provided free by the research sponsor.

Eligible trials and providers must meet specified criteria (e.g., approved/funded by NIH, CDC, FDA IND, CMS, VA/DoD/DOE, qualified non‑governmental entities, or state IRB with HHS assurance) and the treating facility/personnel must have appropriate expertise and volume; informed consent must be obtained.

Participation in clinical trials is subject to prior authorization as outlined in this policy.

Colorectal cancer screening

Colorectal cancer screening coverage criteria

Colorectal cancer screening is covered for asymptomatic members in accordance with current American Cancer Society guidelines, with baseline screening beginning at age 45 and earlier screening for high‑risk individuals.

Adult dental (age 19+)

Adult dental benefits and exclusions for members age 19 and older

Diagnostic/preventive, basic, and major dental services are covered for adults age 19 and older as detailed in the Schedule of Benefits (diagnostic exams, cleanings, X‑rays, restorative fillings, endodontics, periodontics, oral surgery, prosthodontics, crowns/bridges, dentures, etc.).

Numerous dental services are excluded, including cosmetic procedures, many hospital/facility charges, prescription drugs dispensed in the dental office, orthodontics, TMJ appliances, certain implant services, and other services listed in the policy's exclusions; refer to the Schedule of Benefits and non‑covered section for full details.

Diabetic care and supplies

Diabetic care coverage criteria and limits

Medically necessary diabetic supplies and services prescribed by a provider are covered per the Diabetes Initiative of South Carolina and include examinations, self‑management equipment (monitors, strips, lancets, syringes), orthotics/diabetic shoes, laboratory testing, and education/counseling.

The total amount a member is required to pay for a covered insulin drug will not exceed state or federal mandated limits.

Dialysis services

Dialysis coverage and equipment rules

Medically necessary acute and chronic dialysis (in‑facility and home hemodialysis and peritoneal dialysis) are covered unless another payer (e.g., Medicare) is primary.

After appropriate training at a designated dialysis facility, equipment and supplies for home dialysis are covered limited to standard items; plan will determine rental vs purchase and may authorize purchase when cost‑effective, with prior authorization as required.

Supplies and DME

Durable and disposable medical supplies and DME coverage rules

Disposable medical supplies with a primary medical purpose are covered subject to reasonable quantity limits and member cost‑sharing as provided in the Schedule of Benefits.

Durable medical equipment (DME) is covered when prescribed and medically necessary; reimbursement is limited to a standard item when luxury features exceed medical necessity; repair, adjustment, and replacement covered when medically necessary with justification.

Rental cost must not exceed purchase price and rental will not be paid for longer than the purchase cost period; delivery and installation costs are covered. DME and supplies are subject to prior authorization as outlined in the policy.

Medical/surgical supplies and orthotics

Medical/surgical supplies and orthotics coverage and limits

Coverage for non‑durable medical/surgical supplies for disease management is provided (examples: glucometer strips, lancets, needles/syringes); supplies are subject to listed exclusions and quantity limits.

Custom rigid or semi‑rigid orthotics (initial purchase, fitting, repair) are covered, with casting/fitting costs included when billed with the device; orthotics may be replaced once per year when medically necessary, with additional replacements allowed for members under 18 or when item is damaged beyond repair.

Foot support devices (arch supports) and other non‑custom items are excluded unless integral to a leg brace; other listed exclusions apply.

Prosthetics

Prosthetics coverage, examples, and general purchasing rules

Prosthetic devices that replace function or body parts are covered when medically necessary and include purchase, fitting, adjustments, repairs, and replacements; prosthetic devices should be purchased rather than rented and applicable taxes/shipping are covered.

Examples of covered prosthetics include LVAD as bridge to transplant, internal heart valves, pacemakers, intraocular lenses with associated eyewear, breast prosthesis (plus surgical bras), artificial limbs/eyes, ostomy supplies, restoration facial prosthesis, cochlear implants, and wigs (one per calendar year when purchased through a network provider).

Prosthetics coverage and exclusions

Prosthetics coverage scope and notable exclusions/limits

Covered prosthetic services include purchase, fitting, adjustments, repairs and replacements when medically necessary; replacement/repair criteria and limits described in DME/prosthetics provisions apply.

Specific prosthetic items listed as covered include LVAD (bridge to transplant), implantable cardiac devices, breast prosthesis (with four surgical bras per benefit period), intraocular lenses with first corrective lenses, artificial limbs/eyes, ostomy supplies, facial restoration prostheses, cochlear implants, and wigs (limited to one per calendar year when purchased through a network provider).

Certain items such as dentures, non‑rigid elastic supports, and some cosmetic or non‑medically necessary prosthetics are excluded or limited; refer to policy exclusions for detailed lists.

Emergency services

Emergency services coverage and balance‑billing protections

Emergency services are covered 24/7; emergency services provided by non‑network providers are subject to balance‑billing protections and non‑network emergency providers may not balance bill members for amounts beyond the member's applicable cost share when protections apply.

Contraception and family planning (preventive care)

Contraception and family planning preventive coverage

Contraceptive services are covered under preventive care without cost sharing when provided by a network provider and legal under applicable law; coverage includes the full range of FDA‑identified contraceptives and associated screening, counseling, provision, and follow‑up services.

Covered methods include implantable rods, female sterilization, copper and progestin IUDs, injectables, oral contraceptives (combined, progestin‑only, extended), patches, diaphragms, rings, sponges, condoms, spermicides, cervical caps, and emergency contraception (levonorgestrel and ulipristal), as well as any FDA‑approved contraceptives deemed medically appropriate.

Rehabilitation and skilled nursing

Rehabilitation, habilitation, and skilled nursing facility coverage criteria

Rehabilitation, habilitation services and skilled nursing facility confinement are covered when medically necessary; covered services include facility charges, professional rehabilitation practitioner services, cardiac/pulmonary rehab, and outpatient PT/OT/speech therapy per the Schedule of Benefits.

Care ceases to be covered rehabilitation when the member has reached maximum therapeutic benefit, further treatment cannot restore function, no measurable progress toward goals, or care becomes primarily custodial.

Home health care

Home health care coverage and limits

Home health care is covered when a physician indicates the member cannot travel for office appointments and includes skilled nursing, professional therapist fees, IV medications, hemodialysis, rental of medically necessary DME, and necessary medical supplies; services are subject to prior authorization.

Home health aide services are covered only when provided in conjunction with skilled nursing services; see Schedule of Benefits for any limits and home health exclusions (e.g., respite, custodial, educational care are excluded).

Hospice services

Hospice coverage and applicable limitations

Hospice benefits for terminally ill members include inpatient, home and outpatient hospice care, respite, room and board, therapies, palliative/supportive care, rental of medical equipment while in hospice, counseling and bereavement services; benefits are subject to prior authorization and Schedule of Benefits limits.

Medical necessity and other policy exclusions or limitations apply; expenses for other persons are not payable under hospice benefits.

Hospital coverage

Hospital coverage criteria

Covered hospital services include daily room and board up to the hospital's semiprivate rate, private room when medically necessary, operating/recovery room use inpatient and outpatient, ICU room/board/nursing, emergency services even if not admitted, and routine inpatient drugs and supplies; all subject to Schedule of Benefits and policy terms.

Infertility coverage limits

Infertility coverage is limited to medically necessary services for diagnosis and to correct underlying medical conditions causing infertility; treatments to achieve conception (e.g., artificial insemination, in‑vitro fertilization) and related drugs are excluded.

LTACH criteria and coverage

LTACH coverage criteria and clinical thresholds

LTACH care may be covered when medically necessary and approved; indications include medically complex patients requiring extended hospital‑level care when needs cannot be met in other facilities.

Examples of LTACH clinical criteria include prolonged ventilator support (e.g., ≥21 consecutive days for ≥6 hours/day), ventilator management at least every 4 hours, hemodynamic stability without vasopressor dependence, PEEP ≤10 cm H2O and FiO2 ≤60% with SpO2 ≥90%, and inability to transition to an alternate level of care.

LTACH benefits are subject to prior authorization requirements as outlined in this policy.

Lymphedema benefit

Lymphedema treatment coverage

Treatment of lymphedema is covered when rendered or prescribed by a licensed physician or provided in an authorized facility and includes multilayer compression bandaging systems and custom or standard‑fit gradient compression garments.

Mammography screening and diagnostic coverage

Routine screening mammography intervals: one screening for high‑risk persons ages 35–39; one screening every two years or annually for ages 40–49 (per provider guidance); and annual screening for persons age 50 and over. Diagnostic mammography is covered when referred by a medical practitioner regardless of age.

Maternity and surrogacy — hospital stay minimums and surrogate notification timing

Maternity coverage, minimum inpatient stay, and surrogate notification requirement

Maternity benefits cover outpatient, inpatient and postpartum care including prenatal testing, education, counseling, physician home visits, and breastfeeding support; inpatient minimums apply: 48 hours following vaginal delivery and 96 hours following cesarean delivery (delivery itself does not require prior authorization, though some maternity‑related services may require notification or authorization).

Members acting as surrogates must notify the plan in writing within 30 calendar days of enrollment or agreement to participate in a surrogacy arrangement; failure to notify may result in recoupment and other remedies, and services related to surrogacy are excluded.

Benefit-specific coverage criteria across multiple services

Benefit‑specific coverage highlights and notable limits across medical, surgical, vision, behavioral health, medications, and specialized supplies.

Medical and surgical services include pre/post surgical testing, advanced imaging, genetic/molecular testing, reconstructive surgery, implants, anesthesia, hemodialysis, DME, and rehabilitation services when medically necessary and subject to utilization management and Schedule of Benefits limits.

Medical/dental overlap: certain oral/maxillofacial services (cleft lip/palate, oral surgery, dental anesthesia for specified populations) may be covered as medical services when medically necessary; some dental services remain excluded unless specifically covered.

Medical foods and specialized nutrition coverage includes TPN, elemental formulas, outpatient TPN, and low‑protein modified foods for specified inherited metabolic diseases; pasteurized donor human milk is covered up to two months when prescribed and medically necessary.

Vision and pediatric benefits: medical vision services for disease/injury covered; children under 19 receive routine vision benefits (exam, lenses, frames, contact lenses) through end of plan year they turn 19; adult vision benefits differ per Schedule of Benefits.

Coverage criteria and utilization controls — pediatric vision highlights

Pediatric vision highlights, covered items and exclusions

Routine ophthalmological examination (including refraction and dilation), prescription lenses, frames, lens options, and contact lenses/contact lens fitting (in lieu of glasses) are covered for children under 19 through the end of the plan year they turn 19; refer to Schedule of Benefits for limits and cost sharing.

Exclusions and limitations include visual therapy (see medical coverage), deluxe/frame upgrades, LASIK, replacement eyewear, and two pairs in place of bifocals; refer to Schedule of Benefits for specifics.

Prostate Specific Antigen Testing

PSA testing frequency criteria

Prostate cancer screening includes an annual digital rectal exam and PSA for members age 50 and older; annual PSA also covered for members under 50 who are high risk per American Cancer Society guidelines.

Diagnostic Imaging

Diagnostic imaging coverage and billing considerations

Medically necessary radiology, imaging and other diagnostic tests are covered; prior authorization may be required for certain tests as specified in the Schedule of Benefits.

Technical and professional components may be billed separately and each may be subject to applicable member cost sharing; when balance‑billing protections apply, non‑network providers should not bill the member beyond applicable cost share.

Transplant Services

Transplant services: authorization, covered elements, donor rules, and ancillary travel/lodging reimbursement

Transplants are covered when the member is accepted as a transplant candidate and preauthorized through a designated Center of Excellence prior to evaluation and any related services; Medical Management criteria apply.

Coverage includes pre‑transplant evaluation and stabilization, transplant surgery (including authorized acquisition cost for organ/bone marrow), outpatient services related to transplant, LVAD as bridge to transplant, and post‑transplant follow up; donor medical expenses may be covered as specified and are coordinated per policy rules.

When travel to a Center of Excellence exceeds 60 miles, member (and donor/companions) may be eligible for reimbursement up to $10,000 per transplant for transportation, lodging and approved related expenses with required receipts and mileage documentation and submission timelines.

Certain transplant‑related items and services (e.g., donor search testing when no transplant occurs, transplants at unauthorized facilities, some trial‑phase transplants) are excluded as specified in the policy.

Urgent Care

Urgent care coverage and member guidance

Urgent care by network providers and network urgent care centers is covered, including facility costs and supplies; care needed after PCP hours is considered urgent care.

Zero‑cost‑sharing preventive benefits may not be used at a network urgent care center; members are encouraged to contact their PCP first and may use the 24/7 Nurse Advice Line for guidance when PCP is unavailable.

Vision Benefits (Adults 19+)

Vision benefits for adults (age 19+)

Routine ophthalmological exam, dilation, refraction, frames, prescription lenses (single, bifocal, trifocal, lenticular), and contact lenses/contact lens fitting (in lieu of glasses) are covered for adults 19 and older per the Schedule of Benefits.

Excluded vision services include visual therapy, low‑vision devices/hardware, and LASIK surgery; refer to Schedule of Benefits for cost‑sharing and limits.

Wellness Programs

Wellness programs and member offerings

Voluntary wellness programs and offerings (e.g., Health Pays, Ambetter Health Perks) are available at no additional cost to members and may include screenings, vaccinations, incentives, discounts, and other supports; program specifics vary by market and may change or be discontinued.

Members unable to participate due to medical conditions may be required to provide physician verification to receive incentives; Ambetter Health Perks offers discounts and optional financial tools but vendor relationships are between the member and vendors.

Non-covered Services and Exclusions

Non‑covered services and common exclusions

Services not expressly identified as covered are not payable under the policy; the policy contains an extensive list of exclusions including many cosmetic procedures, most dental services except as specified, experimental or investigational treatments, hearing aids (except as stated), alternative treatments, private duty nursing, and other items listed in the non‑covered section.

Charges in excess of the plan's eligible expense, services provided outside the effective dates of coverage, services for which another payer is primary (workers' compensation, Medicare Part D where applicable), and many miscellaneous items (transportation not specified, home test kits, health club memberships, nutritional supplements) are excluded as described.

Surrogacy‑related services and any child born from a surrogacy arrangement are excluded; other transplant‑related charges are excluded except as expressly provided under the transplant services provision.

Foreign emergency claims — submission and reimbursement limits

Foreign emergency claim submission and reimbursement requirements

Emergency services incurred while traveling outside the United States are covered for up to 90 consecutive days from the start of travel; if travel exceeds 90 consecutive days, no coverage is provided for the entire period of travel.

Foreign emergency claims must be submitted in English or with an English translation at the member's expense within 180 calendar days of service and must include medical records and the Member Reimbursement Medical Claim Form; reimbursement is based on member cost share at date of service, member eligibility on date of service, and currency exchange rate at time of transaction.

Medicare coordination

Coordination rules when Medicare is involved

When a member is enrolled in Medicare and Medicare is primary, Medicare primary/secondary payer rules determine payment; the policy's payment is reduced by the Medicare primary payment and the plan will pay secondary up to the Medicare allowable but not more than it would have paid as primary.

Medicare allowable amount is treated as the highest allowable expense when Medicare is primary; charges applied to satisfy Medicare Part B deductible are applied in the order received.

Medicaid coordination

Medicaid coordination guidance

Policy benefits will not be changed or limited because a member is eligible for state Medicaid; the insurer may pay the state if proper proof of loss and notice of payment under the state's Medicaid program are received, and payment to the state will be limited to the policy amount payable for the covered service.

Custodial parent provisions

Custodial parent rights relating to coverage and claims

Upon receipt of a custody order, the custodial parent may submit claims, receive policy information, and receive claim payments; insurer may make claim payments directly to the custodial parent and accept enrollment requests from custodial parents as specified.

Insurer will permit enrollment of an eligible child under family coverage upon request by the custodial parent, certain state agencies, or the child's other parent and continue coverage unless written evidence shows otherwise as specified.

Appeals and external review — internal appeals, timelines, and external review processes

Internal appeals, timelines, documentation requirements, and external review pathways

Claimants have 180 calendar days to file an internal appeal from the date of an adverse benefit determination; grievances may be filed at any time.

Upon receipt of an appeal, the insurer will notify the claimant of any information needed within five calendar days; standard appeal decision timeframes (pre‑service: up to 30 days; post‑service: up to 60 days) apply with a possible 14‑day extension if additional information is needed; expedited appeals decided within 72 hours.

Written appeal decisions must include disposition, reasons, corrective actions, specific policy provisions relied upon, access to documents, explanation of clinical rationale or offer to provide it, identification of medical experts consulted, service date, claim amount, provider name, diagnosis/procedure codes or statement of availability, denial codes, external review info, and translation assistance info.

After exhausting internal appeals, claimants may request external review (standard request within four months after internal response); external review decisions are binding on the plan (45 days standard; 72 hours expedited) and the plan will pay the external review costs.

External review and grievance criteria

Scope and eligibility for external review and expedited external review criteria

External review is available for adverse benefit determinations involving medical judgment (medical necessity, appropriateness, level of care), experimental/investigational determinations, rescissions, and surprise billing disputes regarding applicability of balance‑billing protections and member cost‑sharing, subject to eligibility rules.

Standard external review requests must be filed within four months after the internal response; expedited external review may be requested concurrently with an internal expedited grievance (or when internal timeframes would seriously jeopardize life/health or ability to regain maximum function) and is decided within 72 hours.

External review procedure includes preliminary completeness review within five business days (immediate for expedited), plan provision of documents to the IRO within five business days of assignment, and the IRO decision binding and implemented by the plan upon reversal.

Language and auxiliary services access

Member rights to language assistance and auxiliary aids and how to obtain them

Members who are not proficient in English have the right to receive help and information in their language at no cost and in a timely manner; members with auditory or visual conditions have the right to auxiliary aids and services at no cost.

To request translation or auxiliary services, contact Member Services at 1-833-270-5443 (Relay 711); additional information and nondiscrimination resources are available at AmbetterHealth.com.

Provider responsibilities, prior authorization, and operational alerts

Billing Rule

Notice and Consent / Balance Billing protections

If a member receives services from a non‑network provider based on incorrect directory information or an inquiry to Member Services that indicated the provider was in‑network, contact Member Services immediately. If the services would otherwise be covered, the member will only be responsible for network cost‑sharing and will not be balance billed by the non‑network provider. Non‑network providers must provide written notice and obtain the member's voluntary written consent as required by applicable law before balance billing protections may be waived for non‑emergency services or post‑stabilization care. Notice must include a good‑faith estimate of charges, identify any required prior authorizations or limitations, state that consent is optional, and be provided in the timeframe required by law (generally at least 72 hours prior to scheduled services or at least 3 hours prior when scheduled within 72 hours). A copy of the signed notice and consent must be given to the member and kept separate from other paperwork.

Members who can document they received incorrect network status information will have network cost‑sharing applied and network deductible/OOP protections preserved.
Non‑emergency post‑stabilization balance billing protections are not waived unless the member (or authorized representative) is able to provide informed consent and the non‑network provider meets all legal requirements.

Prior Authorization

Prior Authorization Required

Certain services and supplies require prior authorization (PA) before they are provided. Network providers must obtain PA as shown on the Schedule of Benefits and when: the member receives services from a non‑network provider; the member is admitted to a network facility by a non‑network provider; or the member is referred by a non‑network provider to a network provider. Emergency services from non‑network providers are covered without prior authorization, but you must notify us as soon as reasonably possible after an emergency.

Prior authorization applies to medical and behavioral health services listed on the Schedule of Benefits.
Emergency services are covered without PA; post‑stabilization care requires authorization to continue coverage.

Prior Authorization

Prior Authorization timelines and decision windows

Prior authorization requests (medical and behavioral health) must be submitted by phone, fax, or provider portal. Required submission timelines (unless otherwise required by law): elective inpatient admissions, extended care/rehab/hospice/residential treatment — at least 5 calendar days prior to admission; organ transplant initial evaluation — at least 30 calendar days prior to initial evaluation; clinical trial services — at least 30 calendar days prior to receiving services; home health (except post‑discharge) — at least 5 calendar days prior to start of care; inpatient admissions — within 24 hours of admission. When additional information is needed, PA decision timeframes may be extended as permitted by law.

Urgent pre‑service reviews: decision within the lesser of 2 working days or 3 calendar days from receipt.
Urgent concurrent reviews: decision within 1 calendar day of receipt.
Non‑urgent pre‑service reviews: decision within 2 working days of receipt.
Post‑service/retrospective reviews: decision within 2 working days of receipt.

Denial Risk

Failure to Obtain Prior Authorization / Billing protections

Failure to obtain required prior authorization will result in reduced benefits; however, network providers may not balance bill members for services when the provider failed to obtain required prior authorization. These protections do not apply to emergency services (where prior authorization is not required) — members must contact us as soon as reasonably possible after emergency care.

Benefits may be reduced for failure to comply with PA requirements.
Network providers cannot bill members for services for which they failed to obtain required PA.

Prior Authorization

Autism services prior authorization

Applied Behavior Analysis (ABA) and other autism services (evaluation, assessment, behavior training/management, occupational, speech, physical therapy, behavioral health counseling, and related medications or supplements) are covered when prescribed by a physician or behavioral health practitioner. There is no overall limit on ABA services, but ABA and related autism services are subject to prior authorization to determine medical necessity. When multiple providers deliver services on the same day, separate cost‑sharing may apply to each provider.

ABA services are covered but require prior authorization for medical necessity determination.
Multiple same‑day services by different providers may result in separate copayments/coinsurance.

Prior Authorization

Drug exception and prior authorization process

If a requested drug is not on the formulary, members, authorized representatives, or prescribing physicians may request a formulary exception. Standard exception requests will be decided within 72 hours of receipt; expedited (exigent) requests will be decided within 24 hours when the member's health or ability to regain maximum function is at serious risk or the member is undergoing current treatment with the non‑formulary drug. If an exception is granted, coverage will be provided for the duration of the prescription (or for the duration of the exigency for expedited approvals). Denials of exception requests may be appealed and are eligible for external review.

Standard drug exception: decision within 72 hours of request.
Expedited drug exception: decision within 24 hours of request.
If external review of a denied exception is requested, timelines for IRO review apply (see external review provisions).

Billing Rule

Assignment and reimbursement

Assignment of benefits must be submitted in writing by the member. We will reimburse a hospital or health care provider if we approve the assignment. Assignment does not convey any rights beyond the right to receive benefit payments we determine to be due and payable.

Providers must have an approved written assignment to be reimbursed directly by the plan.
Assignment approval by the plan is required before direct payment will be made to the provider.

Note

Expedited appeal filing and timeline

A claimant may file an expedited appeal (pre‑service adverse determination) when the requested service would seriously jeopardize life or health or the ability to regain maximum function; clinical documentation is required. Expedited appeals may be filed by phone through Member Services or in writing to Ambetter Health, Attn: Grievances and Appeals Department. We will decide expedited appeals within 72 hours and notify the member (or authorized representative) and the provider. Because of the 72‑hour timeframe, some standard notice and acknowledgement procedures do not apply. Claimants have the right to access and receive copies of all documents relevant to the claim and will be provided any new evidence or rationale with 10 calendar days to respond.

Expedited appeal decision timeframe: 72 hours from receipt.
Expedited appeals may be submitted by phone or in writing to the Grievances and Appeals Department.
Claimants may request and receive copies of all relevant documents free of charge and will have opportunity to respond to new evidence or rationale prior to determination.

Key definitions and term clarifications

Pronoun definitions ('you'/'your' = member; 'we'/'our' = Ambetter)

'You' / 'Your'Refers to the member or any dependent members enrolled in this policy

'We' / 'Our'Refers to Ambetter Health (issuer/administrator) underwritten by Celtic Insurance Company as applicable

ContextThese party definitions apply throughout the Evidence of Coverage and Schedule of Benefits

Guaranteed renewable — renewal conditions and exceptions

Guaranteed renewable — general rulePolicy generally renews annually provided required premiums are paid on time

Non-renewal exceptionsIssuer may decline renewal if it discontinues offering the form in the state, withdraws from service area, or for fraud/intentional material misrepresentation; non-payment and material breach may also permit cancellation

Premium changesPremium rates may change annually and will be guaranteed for a calendar year once set

Balance billing protections definition

Balance billing protections — definitionProtections under the federal No Surprises Act prohibit non-network providers from balance billing members for services subject to those protections; member pays only the cost share calculated as if services were from a network provider

When protections applyApplies to emergency services, certain non-emergency services at network facilities absent valid notice-and-consent, and specified air ambulance services

Member action on balance billingIf balance billed for protected services, contact Member Services immediately (number on member ID card)

Acute rehabilitation definition and intensity requirement

Acute rehabilitation — definitionAn intensive, multidisciplinary rehabilitation program where rehabilitation services are performed three or more hours per day, five to seven days per week while the patient is an inpatient

Typical therapiesMay include physical, occupational, and speech therapy as needed and medical management by specially trained physicians

Coverage criteriaServices must be medically necessary and provided in an appropriate inpatient setting to qualify

Allowed amount / Eligible expense definition

Allowed amount / Eligible expenseAllowed amount (eligible expense) is the maximum amount the plan will pay a provider and is subject to cost sharing; for network providers it is the contracted fee

Non-network eligible expenseWhen balance billing protections apply to non-network services, eligible expense is the negotiated fee if agreed; otherwise reimbursement as determined by the plan consistent with law

Effect on cost sharingEligible expense determines member cost share and may affect deductible and MOOP application

Medically necessary definition (clinical standard)

Medically necessary — core definitionServices, items, supplies, or treatment provided according to generally accepted standards of medical practice and consistent with the symptoms or diagnosis

Exclusions from necessityNot considered medically necessary if custodial, experimental/investigational, exceeding needed scope/duration/intensity, or could be safely provided in a less restrictive setting

Hospital confinement criterionFor hospital confinement, medically necessary means the diagnosis and treatment cannot be safely provided as an outpatient

Medically necessary (alternate phrasing duplicate)

Medically necessary — alternate phrasingCare that is consistent with accepted standards of medical practice, likely to improve functional ability, cost‑effective, and not custodial or experimental

Decision basisDetermination based on clinical evidence and appropriateness of setting, scope, duration and intensity of care

Payment impactCharges for services not medically necessary are not eligible expenses

Network provider / Network eligible expense definition

Network provider — definitionA licensed person or entity that has entered into a contract (directly or indirectly) with Ambetter Health to provide covered services

Network eligible expenseEligible expense for services or supplies provided by a network provider; includes emergency services even if provided by non-network providers

ExamplesHospitals, specialty hospitals, urgent care centers, physicians, pharmacies, laboratories and other contracted practitioners

Notice and consent definition for waiving balance billing protections

Notice and consent — requirementConditions for a member to waive balance billing protections require a written notice in required format by the non-network provider and the member's voluntary written consent within required timing

Timing specificsNotice must be provided at least 72 hours before services or at least 3 hours before for services scheduled within 72 hours; consent must be voluntary and in required format

LimitationsNotice-and-consent cannot waive protections for emergency services, air ambulance, ancillary services, or when no network provider is available at the facility unless additional criteria are met

Telehealth services / Virtual 24/7 care definition

Telehealth services — definitionDelivery of health care via information and communication technologies including synchronous and asynchronous interactions

Virtual 24/7 careVirtual 24/7 denotes telehealth urgent care and virtual behavioral health provided through the Ambetter‑designated telehealth provider

ExclusionsDoes not include certain provider‑to‑provider telephone consultations or trans‑telephonic monitoring

Newborn and Adopted Child coverage definition (31 days)

Automatic newborn/adopted child coverage periodAn eligible newborn or legally placed adopted child is covered from time of birth or date of placement until the 31st day after birth/placement

Action to continue coverageAdditional premium and enrollment action required to continue coverage beyond the 31-day period

Retroactive terminationCoverage will terminate retroactively to day 31 unless timely notice and premium are received

Pre-service, concurrent, retrospective review definitions

Pre-service (prior authorization)Review that occurs when a medical service must be preapproved by Ambetter before the member obtains the service

Concurrent reviewReview that occurs as services are provided (e.g., inpatient stay) to assess ongoing medical necessity

Retrospective reviewReview conducted after a service has already been provided (post-service) to determine coverage/payment

Special Enrollment Period timing

Special Enrollment Period — general windowQualified individuals generally have 60 calendar days to report a qualifying event and request special enrollment

Medicaid/CHIP lossIf qualifying event is loss of Medicaid or CHIP coverage, up to 90 calendar days may be allowed to enroll

Qualifying events examplesIncludes gain/loss of dependent, marriage, birth, adoption, move, domestic abuse, eligibility changes for APTC/CSR

Non-network provider definition

Non-network provider — definitionA provider who is not contracted (directly or indirectly) with Ambetter Health to provide covered services under this policy

When usedNon-network providers may be authorized in limited situations (e.g., no network provider within reasonable distance) subject to prior authorization

Balance billing exposureCharges in excess of eligible expense may be balance billed unless protections apply

Maximum Out-of-Pocket definition

Maximum Out‑of‑Pocket (MOOP)The most a member must pay in copayments, coinsurance, and deductibles for covered services in a benefit period; after an individual reaches MOOP, plan pays 100% of covered services

Family MOOPFamily maximum out‑of‑pocket equals two times the individual MOOP; once one member meets individual MOOP, remaining family MOOP can be met by combination of members' eligible expenses

Subject to eligible expenseAmounts applied toward MOOP are determined by eligible expenses and specific benefit limits in the policy

Health Savings Account (HSA) note

HSA note — trustee roleAmbetter Health and Celtic Insurance Company are not HSA trustees, custodians, or designated administrators and do not contribute to HSAs

Member responsibilityMembers are solely responsible for HSA eligibility, contributions, tax rules, and notifying their HSA custodian if plan enrollment changes

Consult advisorMembers should consult a professional tax advisor for HSA tax implications

Continuing care patient definition

Continuing care patient — rightA member who is a continuing care patient with respect to a network provider will be notified if that provider leaves the network and may elect transitional care

Transitional care periodMember may continue benefits for the course of treatment until the earlier of 90 days after notice or until no longer a continuing care patient

Member optionsMember may notify the plan of need for transitional care and elect to continue care from the provider

Essential Health Benefits definition

Essential Health Benefits (EHB)Core categories defined by federal and state law including ambulatory services, emergency services, hospitalization, maternity/newborn care, mental health and SUD, prescription drugs, rehabilitative/habilitative services, lab services, preventive/wellness services, chronic disease management, and pediatric services (oral/vision)

No lifetime/annual dollar maxEHB provided within this policy are not subject to lifetime or annual dollar maximums

Subject to policy termsEHB coverage remains subject to policy conditions, exclusions, limitations, and cost sharing as indicated in Schedule of Benefits

Clinical trial routine care definition

Clinical trial routine care — coveredReasonable and medically necessary routine patient care costs incurred as a result of approved Phase III/IV clinical trials for prevention, early detection, or treatment of cancer or other life‑threatening conditions are covered

ExclusionsInvestigational item/service itself, items provided solely for data collection, and items customarily provided free by the sponsor are excluded

Prior authorizationParticipation in clinical trials is subject to prior authorization as outlined in the policy

Orthotic device definition

Orthotic device — definitionCustom made rigid or semi‑rigid supportive device used to support, align, prevent or correct deformities or improve function; casting, fitting, and adjustments included when billed with the device

Replacement frequencyOrthotic devices may be replaced once per year when medically necessary; additional replacements for members under 18 or when item is damaged and unrepairable

ExamplesCervical collars, ankle foot orthosis, splints, corsets, trusses, wristlets, slings, custom shoe inserts, orthopedic shoes

Prosthetics definition

Prosthetics — definitionArtificial substitutes for body parts, tissues, and materials inserted into tissue for functional or therapeutic purposes; includes purchase, fitting, adjustments, repairs, and replacements when medically necessary

Purchase vs rentalProsthetic devices should be purchased rather than rented when medically appropriate

Covered examplesLVAD (bridge to transplant), internal heart valves, pacemakers, artificial limbs, intraocular lenses, breast prosthesis, cochlear implants, ostomy supplies

LTACH definition

LTACH — definitionLong‑term acute care hospitals that furnish extended medical and rehabilitative care for clinically complex patients requiring hospital‑level care for extended periods

Clinical criteriaExamples include respiratory stability criteria (PEEP ≤10 cm H2O, FiO2 ≤60% with SpO2 ≥90%), ventilator dependence, and inability to transition to alternate level of care

Prior authorizationLTACH benefits are subject to prior authorization requirements

Newborns' and Mothers' Health Protection Act note

Newborns' and Mothers' Health Protection Act noteFederal law generally prohibits restricting hospital stay after childbirth to less than 48 hours (vaginal) or 96 hours (cesarean); provider may discharge earlier after consultation

No authorization requiredPlans may not require authorization for length of stay up to those limits under federal law

ReferenceApplies to mother and newborn rights regarding inpatient stay following delivery

Low-protein food products definition

Low‑protein food products — definitionSpecially formulated foods with less than one gram protein per serving used under physician direction for treating certain inherited metabolic diseases (e.g., PKU, MSUD); excludes natural low‑protein foods

Covered conditionsListed inherited metabolic diseases such as PKU, MSUD, MMA, IVA, propionic acidemia, glutaric acidemia, tyrosinemia, urea cycle defects

ExclusionsOther dietary formulas, oral nutritional supplements, prepared meals, and formula for access problems are excluded

Self-injectable drugs definition

Self‑injectable drugs — definitionDrugs delivered into a muscle or under the skin with a syringe and needle that members or caregivers can administer safely after initial instruction; covered under prescription drug benefits

Cost sharingPrescription cost share applies to self‑injectable drugs

Initial supervisionMedical supervision or instruction may be needed initially before self‑administration

Formulary / Prescription Drug List definition

Formulary / Prescription Drug List — definitionA guide to available generic, brand name, and some OTC medications approved by FDA and covered under the prescription drug benefit; periodically updated

Generic‑first approachGeneric drugs are preferred first-line options; if no generic available, clinically appropriate brand options listed on formulary tiers

Exceptions and updatesFormulary is not exhaustive; drugs may be added/removed or subject to utilization controls; check AmbetterHealth.com for current list

Preventive Care Expense Benefits timing note

Preventive care timing noteNew preventive care recommendations (USPSTF, CDC, HRSA) become covered effective on the plan start or anniversary date one year after issuance, per ACA

State lawPreventive benefits also provided in accordance with applicable state law

ResourcesAmbetter Health Preventive Services Guide available on AmbetterHealth.com contains detailed preventive coverage info

Center of Excellence definition for transplants

Center of Excellence — transplant definitionDesignated transplant facility through which prior authorization is obtained; meeting Center of Excellence criteria triggers transplant coverage and ancillary travel/lodging reimbursement

Ancillary benefit limitsWhen travel >60 miles, reimbursement up to $10,000 per transplant for transportation, lodging, and approved expenses (receipts required within 6 months)

Prior authorization requirementTransplants require prior authorization through the Center of Excellence prior to evaluation and related services

Appeal definition

Appeal — definitionA request for the plan to reconsider a previous adverse benefit determination, including medical necessity and benefit denials

Filing windowClaimants have 180 calendar days to file an internal appeal from the date of the adverse benefit determination

Forms and assistanceAppeals may be filed via the form included with the denial notice, in writing to the Grievances and Appeals Department, or by phone to Member Services

Expedited appeal/external review definition

Expedited appeal/external review — definitionAn accelerated review process for pre‑service adverse determinations that could seriously jeopardize life/health or ability to regain function; expedited appeals decided within 72 hours

External review timingExpedited external review decisions within 72 hours; standard external review within 45 calendar days after receipt

Filing and processExpedited appeals can be filed by phone through Member Services or in writing; external review may be requested after exhausting internal appeal processes or concurrently in specified situations

Grievance definition

Grievance — definitionAn expression of dissatisfaction about anything other than an adverse benefit determination (e.g., quality of care, customer service, provider availability)

Filing methodsGrievances may be filed by calling Member Services or in writing to the Grievances and Appeals Department

Scope exclusionDoes not apply to adverse benefit determinations which are handled via appeals processes

External review definition and binding nature

External review — definition and effectAn independent review by an Independent Review Organization (IRO); the IRO decision is binding on the plan and binding on the claimant except as allowed by law

Filing windowFour months to request a standard external review after receipt of the internal response; no time limit for expedited external review

ImplementationPlan must implement an IRO reversal by approving the benefit; plan pays external review costs

Auxiliary aids and services definition

Auxiliary aids and services — definitionSupports for members with auditory and/or visual conditions that impede communication, provided at no cost and in a timely manner

ExamplesInterpretation, assistive devices, or other auxiliary services as needed to ensure effective communication

How to requestContact Member Services at 1-833-270-5443 (Relay 711) to request translation or auxiliary services

Translation services definition (multiple languages listed)

Translation services — availabilityLanguage assistance provided at no cost to members who are not proficient in English

Languages notedTranslations and multilingual notices are available (examples shown in document include Tagalog, Spanish, Vietnamese, French, and others)

How to requestCall Member Services at 1-833-270-5443 (Relay 711) to receive translation services or other language assistance

OpenPayer

Ambetter Adult Vision + Adult Dental Evidence of Coverage (EOC)

Coverage rules, eligibility, and benefit-specific criteria

Billing, codes, and quick-reference coding tables

Provider responsibilities, prior authorization, and operational alerts

Key definitions and term clarifications