Ground and Water Ambulance - Summary
Covered services and benefit rules across major categories. Each group below summarizes medical necessity, prior authorization, limits, exclusions, and billing notes.
ALL of the following
Ground and water ambulance services are covered for transportation from the scene, home, or during an emergency condition to the nearest appropriate facility; to the nearest neonatal special care unit for newborns; and for transport between hospitals or to a higher level of care when authorized by Us.
Prior authorization is NOT required for emergency ambulance transportation; required for non-emergency transport.
Non-emergency ground or water ambulance requires prior authorization. Members should not be balance billed for covered ground or water ambulance services when balance billing protections apply.
Exclusions include services covered by local government, transport for member comfort/convenience, and non-ambulance non-emergency transport (e.g., taxis or ride-share).
Autism Spectrum Disorder
Coverage, service components, utilization management, and limitations for autism spectrum disorder (ASD).
ALL of the following
Evaluation and assessment services for autism spectrum disorder are covered when prescribed by a physician or behavioral health practitioner.
Applied Behavior Analysis (ABA) therapy, behavior training/management, and habilitation services for members diagnosed with ASD are covered; no numeric limits exist for ABA when medically necessary, but services are subject to prior authorization to establish medical necessity.
Speech, occupational, and physical therapy services related to ASD are covered when medically necessary.
Psychiatric care, counseling, and medications or nutritional supplements used to address ASD symptoms are covered when prescribed by an appropriate provider.
If multiple providers deliver services on the same day, separate cost share may apply to each provider as reflected in the Schedule of Benefits.
DME, Orthotics, Prosthetics
Durable medical equipment (DME), orthotics, and prosthetics covered items, repair/replacement rules, quantity limits, prior authorization and exclusions.
ALL of the following
DME is covered when prescribed by a physician and is durable, primarily for home use, and medically necessary. Rental or purchase will be determined by cost-effectiveness; rental will not exceed purchase price.
Covered DME examples include standard hospital bed, standard walker, standard non-motorized wheelchair, glucometer, infusion pumps, cardiac monitors, neonatal and sleep apnea monitors, and one CPM machine post joint surgery as specified. Medically necessary corrective footwear and one pair of foot orthotics per year are covered.
Repair, adjustment, and replacement of purchased equipment may be covered when the item is covered, medically necessary, and repair is not reasonable. Reimbursement for luxury or nonstandard features is limited to the standard equivalent; member pays excess cost.
Orthotic devices: initial purchase and repair of custom rigid or semi-rigid supportive devices are covered (casting, molding, fittings included). Examples: AFOs, corsets, splints, trusses, slings, wristlets, custom shoe inserts, orthopedic shoes, standard elastic stockings. Replacements allowed once per year when medically necessary; additional replacements if medically justified or irreparable damage.
Clinical Trial Coverage
Clinical trial routine patient care coverage, scope, and eligibility requirements.
ALL of the following
Routine patient care costs incurred as a result of participation in an approved Phase I–IV clinical trial for cancer or other life‑threatening conditions are covered when the clinical trial and trial site meet specified criteria and the member is enrolled in the trial.
Covered routine costs include FDA‑approved drugs or devices used in the trial (if otherwise covered), reasonable medically necessary services to administer the investigational drug/device, and items/services otherwise generally available to qualified individuals in the trial, excluding the investigational item itself and items provided solely for data collection or provided free by the sponsor.
Phase I/II trials must be sanctioned by NIH/NCI and conducted at appropriate academic or NCI centers; Phase III/IV trials must be approved/funded by eligible federal agencies, cooperative groups, IRBs, or qualified non‑governmental research entities as specified in the policy.
Facility and personnel must have appropriate expertise and volume. Participation requires informed consent and is subject to prior authorization as outlined in the contract; providers must obtain authorization and enroll members appropriately prior to services when required.
Colorectal Cancer Screening
Colorectal cancer screening coverage aligned with USPSTF guidance and age/risk criteria.
ALL of the following
Preventive colorectal cancer screening tests are covered for asymptomatic members in accordance with current USPSTF recommendations; routine coverage generally begins at age 45 or earlier for members at high risk as clinically indicated.
Coverage includes appropriate laboratory tests and procedures specified by USPSTF; preventive care cost‑sharing and high‑value network provider incentives apply per Schedule of Benefits and federal law. Reasonable medical management techniques may be applied to encourage use of high‑value preventive services from network providers.
Dental Benefits and Exclusions
Dental services coverage for adults and exclusions/limits.
ALL of the following
For adults age 19 and older, dental coverage includes diagnostic and preventive (Class I), basic restorative and endodontic/periodontic/removable prosthodontic services (Class II), and major services including crowns, bridges, and dentures (Class III) as described in the Schedule of Benefits.
Diagnostic/preventive services: routine cleanings, oral exams, and X‑rays; Basic services: fillings, root canals, periodontal scaling/maintenance, relines/repairs of removable prosthodontics, and oral surgery extractions; Major services: fixed and removable prosthodontics and complex oral surgery.
Refer to Schedule of Benefits for cost sharing, annual maximums, and service limitations; provider network information is available online or via Member Services.
Dental exclusions: cosmetic procedures, hospitalization/facility charges, prescription drugs dispensed in dental office (unless covered), services prior to effective date, anesthesiologist services, appliances to alter/maintain occlusion, TMJ appliances and related therapies, implant services and related surgical implant removal, sinus augmentation, temporary procedures, adjunctive services (oral hygiene instruction, tobacco/nutrition counseling), orthodontics, orthognathic surgery, athletic mouth guards, space maintainers, and other items listed in the non‑covered list.
Family Planning & Contraception
Family planning, contraception, and related preventive services rules and scope.
ALL of the following
Family planning and contraceptive services are covered under preventive care without cost sharing when provided by a network provider and when legal under applicable law.
Covered items include the full range of FDA‑identified contraceptives and methods (sterilization surgery for women, implantable rods, copper and progestin IUDs, injectables, oral contraceptives, patches, rings, diaphragms, sponges, cervical caps, condoms, spermicides, emergency contraception including levonorgestrel and ulipristal acetate, and any additional FDA‑approved contraceptives determined medically appropriate).
Contraceptive care also includes screening, education, counseling, provision, follow‑up, management, removal/continuation/discontinuation, and procedures integral to furnishing the listed preventive services (e.g., anesthesia for sterilization surgery).
Fertility Preservation
Fertility preservation coverage when cancer treatment may cause iatrogenic infertility.
ALL of the following
Medically necessary standard fertility preservation services and supplies are covered when cancer treatment may directly or indirectly cause iatrogenic infertility (infertility caused by medical intervention, including prescribed drugs or procedures).
Prior authorization may be required; coverage is limited to preservation services deemed medically necessary in the context of cancer treatment as described in the contract.
Habilitation, Rehabilitation & Extended Care
Habilitation and rehabilitation services, coverage settings, goals, and discontinuation criteria.
ALL of the following
Covered habilitation and rehabilitation services include inpatient facility charges (room/board/nursing), diagnostic testing, prescribed drugs, and outpatient professional services by licensed rehabilitation practitioners (physical, occupational, speech, respiratory, cardiac therapies).
Outpatient therapy and services are subject to prior authorization as outlined in the contract and to limits in the Schedule of Benefits.
Coverage ceases when the member has reached maximum therapeutic benefit, further treatment cannot restore function beyond current level, there is no measurable progress toward documented goals, or care is primarily custodial.
Home Health Care
Home health care covered components, limitations, prior authorization, and exclusions.
ALL of the following
Home health care is covered for medically necessary network services when the physician indicates the member cannot travel to a medical office. Covered services include home health aide services as part of skilled care, private duty registered nurse services (outpatient) as applicable, licensed respiratory/physical/occupational/speech therapy fees, IV medications and pain medications, hemodialysis (when appropriate), necessary medical supplies, and rental of medically necessary DME at plan discretion.
The plan may authorize purchase instead of rental when purchase is projected to be more cost‑effective and must authorize prior to purchase. Home health services are subject to prior authorization and Schedule of Benefits limits. Respite care, custodial care, and educational care are excluded under Home Health Care benefits.
Hospice Care
Hospice benefits scope, covered services, limits, and prior authorization.
ALL of the following
Hospice care benefits apply to terminally ill members receiving medically necessary hospice services in a hospice program or home setting. Covered services include inpatient hospice room/board (up to the hospice's usual semi‑private rate), occupational and speech‑language therapy, rental of medical equipment during hospice care, medical/palliative/supportive care for symptom management, member counseling, family terminal illness counseling, and bereavement counseling.
Respite care is covered for temporary relief for caregivers; respite days applied toward deductible are benefits and count toward any applicable maximums. Hospice inpatient, home and outpatient care benefits are available for a member's lifetime but subject to medical necessity and prior authorization per contract.
Exclusions/limitations in the contract remain applicable where noted; medical necessity determinations apply to hospice services and supplies provided as part of hospice care.
Hospital & Emergency Services
Hospital and emergency services, covered items, emergency protections, and LTACH/transitions.
ALL of the following
Hospital benefits cover daily room and board up to the semi‑private rate, private room when medically necessary for isolation, ICU room and board, outpatient operating/treatment/recovery room use, and routine inpatient services/supplies including drugs and medicines.
Emergency services (medical and behavioral) are covered 24/7 both in and out of service area; benefits provided without prior authorization for emergency services. Members must notify Us of inpatient admissions within 48 hours or as soon as reasonably possible to avoid potential financial responsibility for non‑medically necessary inpatient care.
Balance billing protections apply for emergency services and certain non‑network services per federal law; members should not be balance billed for covered emergency services subject to these protections.
Long‑term acute care hospital (LTACH) services and transfers are covered when medically necessary and prior authorization is required; LTACH criteria include clinical complexity, need for extended hospital‑level care, ventilator support, complex wound care, infectious disease management, or medical complexity requiring continued acute monitoring.
Infertility Services
Infertility diagnostic and medically necessary treatment coverage and exclusions.
ALL of the following
Covered infertility services are limited to medically necessary diagnostic tests to determine infertility and treatment of underlying medical conditions that cause infertility (e.g., endometriosis, obstructed fallopian tubes, hormone deficiencies).
Excluded services: artificial insemination, in vitro fertilization (IVF), embryo transfer, GIFT, ZIFT, and other assisted reproductive technologies that are specifically listed as excluded under the contract, unless otherwise stated in Schedule of Benefits.
Lymphedema Benefit
Lymphedema treatment scope and covered supplies.
ALL of the following
Treatment of lymphedema is covered when rendered or prescribed by a licensed physician or received in an authorized facility. Coverage includes multilayer compression bandaging systems and custom or standard‑fit gradient compression garments when medically necessary.
Mammography
Mammography screening and diagnostic coverage aligned to USPSTF and applicable laws.
ALL of the following
Mammography screenings and diagnostic mammograms are covered consistent with USPSTF A and B recommendations and applicable laws. Covered modalities include screening mammography, diagnostic mammography, digital breast tomosynthesis, breast MRI, ultrasound, and pathology evaluations when medically necessary or prescribed by a licensed practitioner.
Coverage is available to all members as clinically indicated; refer to the Preventive Care Guide and Schedule of Benefits for details and any age‑specific provisions.
Maternity & Newborn
Maternity and newborn inpatient stay rules, covered prenatal/postpartum services, and newborn coverage.
ALL of the following
Maternity inpatient stay: a minimum of 48 hours after vaginal delivery and 96 hours after cesarean are covered; providers are not required to obtain prior authorization for stays up to these lengths. Discharge earlier than these periods may occur at provider discretion after consultation with the mother.
Covered prenatal, pre/postpartum services, prenatal diagnostic testing, physician home visits, breastfeeding education, nutritional counseling, risk assessment, childbirth classes, and care for complications of pregnancy are included; some services may require prior authorization per Schedule of Benefits.
Newborns are covered from time of birth through the 31st calendar day; each newborn's services are subject to their own cost sharing. Additional premium required to continue coverage beyond 31 days; refer to Dependent Member Coverage rules for enrollment timelines.
Newborn and mother protections under federal law (Newborns' and Mothers' Health Protection Act) are preserved; no authorization required for stays not exceeding 48/96 hours as applicable.
Medical & Surgical Benefits
Scope of medical and surgical benefits, covered services, testing, implants, and therapy.
ALL of the following
Medical and surgical services include surgical procedures (office, inpatient, outpatient), pre/post‑surgical testing and procedures for the same illness or injury, clinical lab tests, bone density studies, GI procedures, pulmonary function tests, genetic and molecular cancer testing, biomarker testing, and other indicated diagnostic services when medically necessary.
Covered medical services include office and facility professional services by licensed practitioners, chemotherapy (including oral), inhalation/infusion/radiation therapies, durable medical equipment/prosthetics/orthotics following procedures, hemodialysis, anesthesia, oxygen, drugs/biologicals, and medically necessary reconstructive surgeries (including post‑mastectomy reconstruction and related prosthetics and lymphedema treatment).
Medically necessary dental surgery related to accidental injury or functional defects caused by congenital/acquired disease is covered (with limitations); dental anesthesia in hospital/ambulatory settings may be covered for complex cases or certain medical conditions — prior authorization may be required.
Medical and surgical covered services
Specific covered medical and surgical services list and operational notes (supplement to Medical & Surgical Benefits).
ALL of the following
Medically necessary implants and procedures covered include corneal transplants, vascular grafts, heart valve grafts, prosthetic tissue replacements (joint replacements), implantable prosthetic lenses for cataracts, skin grafts, and medically necessary reconstructive craniofacial surgery.
Genetic and molecular testing (including tumor mutation testing, next‑generation sequencing, germline testing, pharmacogenomics, whole exome/genome sequencing) are covered when medically necessary and consistent with labeling, national/local coverage determinations, or recognized clinical guidelines.
Medically necessary telehealth services are covered and subject to the same cost sharing as in‑person services (except where Virtual 24/7 care has separate terms). Use of general anesthesia for dental procedures in hospital/ambulatory settings is subject to prior authorization.
Medical foods and metabolic-disease dietary products
Medical foods and metabolic dietary products coverage and exclusions.
ALL of the following
Medical foods and formulas are covered for outpatient total parenteral nutrition, outpatient elemental formulas for malabsorption, and dietary formulas medically necessary for treatment of PKU and certain inborn errors of metabolism.
Pasteurized donor human milk is covered when prescribed by a pediatrician or licensed pediatric provider for infants medically unable to receive maternal milk or when the mother cannot produce sufficient milk.
Low‑protein food products for certain inherited metabolic diseases (e.g., PKU, MSUD, MMA, IVA, propionic acidemia, glutaric acidemia, urea cycle defects, tyrosinemia) are covered when used under physician direction. Exclusions: other dietary formulas, oral nutritional supplements, special diets, prepared meals, and formulas for access problems unless specifically stated.
Pediatric routine vision coverage
Pediatric routine vision benefits for members under 19, covered materials, and exclusions.
ALL of the following
For children under 19, routine ophthalmological exams (including refraction and dilation), prescription lenses (single, bifocal, trifocal, lenticular), standard frames, additional lens options (progressive, intermediate, blended segment, hi‑index, photosensitive, photochromic, sunglasses lenses, tints, coatings, anti‑reflective coatings), polycarbonate lenses, and contact lenses (in lieu of glasses) are covered.
Coverage includes low vision evaluations/aids. Refer to Schedule of Benefits for cost sharing, annual maximums, and limitations. Exclusions: deluxe frame upgrades, visual therapy (medical coverage may apply separately), two pairs of glasses as substitute for bifocals, and LASIK surgery.
Behavioral health and substance use disorder coverage
Behavioral health and substance use disorder coverage, parity, levels of care, and authorization notes.
ALL of the following
Behavioral health includes mental health and substance use disorder services on an inpatient and outpatient basis, subject to parity requirements. Deductibles, copays, coinsurance, and limits apply no more restrictively than for physical health benefits.
Covered inpatient services include psychiatric hospitalization, inpatient detoxification, crisis stabilization, inpatient rehabilitation, residential treatment, and ECT. Outpatient services include PHP, IOP, medication management, outpatient detox, psychological testing, evaluation/assessment, applied behavior analysis, telehealth therapy, individual/group therapy, medication‑assisted treatment, mental health day treatment, ECT and TMS where medically necessary.
Utilization management follows InterQual for mental health and ASAM for substance use disorder determinations. Prior authorization may be required for non‑emergent services; emergent inpatient withdrawal management or emergent inpatient treatment will not require prior authorization.
Prescription drug and formulary coverage
Prescription drug coverage, formulary rules, self‑injectable drugs, day‑supply limits, and exclusions.
ALL of the following
Prescription drug benefits cover drugs dispensed by licensed network pharmacies per the formulary. Coverage includes prescription drugs, self‑injectables, and certain off‑label drugs when supported by standard reference compendia or peer‑reviewed literature as specified.
Formulary (prescription drug list) categorizes generics and preferred brands; generic options are preferred. The formulary is periodically updated; plan or tier design may limit coverage for certain products regardless of formulary listing. Specialty drugs and certain categories may be limited to 30‑day retail supplies; extended day supply (up to 90 days) is available for select maintenance medications via participating pharmacies.
Non‑covered prescription items include erectile dysfunction drugs (unless on formulary), weight‑loss drugs (unless on formulary), medications while inpatient at institutional facilities that dispense pharmaceuticals, refills dispensed >12 months from physician order, drugs labeled investigational, therapeutic duplications identified by DUR, certain foreign medications, infertility drugs unless listed, drugs deemed unsafe or ineffective by the Pharmacy & Therapeutics committee, and other exclusions listed in the contract. Compound drugs require at least one FDA‑approved ingredient to be covered.
Coverage exclusions, limits and processes
Common coverage exclusions, numerical limits, and processes for applying limits or exclusions.
ALL of the following
General non‑covered services include items not identified as covered, services provided without cost absent insurance, services by immediate family members, charges in excess of eligible expenses, and services where another plan is primary until that plan pays as required.
Specific exclusions include weight modification/bariatric procedures (except where specifically covered), reversal of sterilization, elective abortions except to save life/health as permitted, many dental services (except as provided under medical benefits), cosmetic procedures (except reconstructive following covered injury or birth defect), most experimental/investigational services, surrogacy‑related services, and a list of miscellaneous exclusions (e.g., in vitro fertilization, domiciliary care, most home test kits, routine elective care outside service area).
When preventive services or high‑value network services are available, reasonable medical management techniques may be used to encourage use of network providers; cost sharing may apply if a member chooses a non‑high‑value option as permitted by law.
Service coverage and administrative criteria
Operational service coverage and administrative criteria: prior authorization timing, concurrent/retrospective review, prior auth response timeframes, and non‑network service rules.
note":"Prior authorization does not guarantee payment; medical necessity and contract terms apply."},{"text":"Services from non‑network providers are generally not covered unless prior authorized because no network provider is reasonably available; balance billing protections apply where required by law and members should not be balance billed for protected services."}]}
Non-covered services, administrative provisions, subrogation, and COB
Non‑covered services, administrative rules, subrogation, and coordination of benefits highlights.
ALL of the following
Non‑covered services are listed in the General Non‑Covered Services section and include many items described elsewhere (see exclusions). Administrative provisions include requirements to obtain covered services from network providers unless authorized otherwise, and the plan's right of reimbursement and subrogation applies when third parties are responsible for injuries/illnesses.
Coordination of benefits and subrogation: when this plan is secondary, benefits paid will be reduced so combined payments do not exceed Ambetter Health's allowable; repayment or recovery actions (including claims against settlements) may be pursued under the contract's right of reimbursement/subrogation provisions.
Secondary plan benefit reductions
When this plan is secondary, how benefits are reduced and determination of allowable expenses.
ALL of the following
If Ambetter Health is secondary, benefits will be reduced so that total payments from primary and secondary plans do not exceed Ambetter Health's maximum allowable benefit for each covered service. Ambetter Health will not pay more than it would if it were primary; claims are adjudicated as submitted during the claim determination period and reductions may reflect Medicare allowable rules when applicable.
Claims and documentation requirements
Claims submission timing, notice/proof of loss requirements, and documentation expectations.
ALL of the following
Members or providers must give notice of claim within 30 days of loss or as soon as reasonably possible. Proof of loss (written) must be provided within 90 days or as soon as reasonably possible; late proofs beyond one year may be rejected unless the member lacked legal capacity.
Providers usually submit claims on member's behalf; members can request reimbursement with detailed provider claims and completed member reimbursement forms. Claims for emergency services outside the U.S. must be submitted within 180 days with clinical documentation in English or with translation and proof of travel dates.
Cooperation provision and claim consequences
Cooperation requirements for claim determinations and consequences for failure to cooperate.
ALL of the following
Members or their agents must cooperate by signing authorizations, furnishing medical/other information, answering questions under oath, and providing other assistance requested to determine rights and obligations under the contract.
Failure to provide requested information or to cooperate may result in claim closure, denial, or delay until requested items are received; persistent failure may lead to claim denial as described in Claims and Cooperation provisions.
Custodial parent claim handling
Custodial parent rights and claim handling when custody orders exist.
ALL of the following
When parents are divorced or legally separated and a custodial parent is specified by court order, upon request the custodial parent will receive information about the contract's terms, may submit claim forms and requests for claim payment, and may receive claim payments directly. The plan will accept assignments to pay providers with approval and documentation.
Legal actions, assignment, and examinations
Time limits for legal actions, assignment/non‑assignment rules, and requirements for examinations and providing proof.
ALL of the following
No lawsuit may be brought sooner than 60 days after required proof of loss is submitted and no later than three years after the date proof of loss is required. Coverage rights and benefits are not assignable except for specific written authorizations to pay providers directly, which the plan will honor.
Members must cooperate with examinations and provide requested documentation; failure to comply may affect claim adjudication and legal remedies available to the plan for fraud or misrepresentation, including rescission in limited circumstances.
Appeals, grievances, external review, and contract provisions
Appeals, grievances, external review rights, timelines, and how to contact Appeals & Grievances.
ALL of the following
Members may appeal adverse benefit determinations within 180 calendar days of the determination. Appeals may be submitted in writing or orally; representatives may be designated. The plan will acknowledge appeals within five business days and decide standard appeals within 30 calendar days (extensions and expedited processes apply as described).
Expedited appeals are available when delay would seriously jeopardize life, health, or ability to regain maximum function and are resolved as quickly as the member's condition requires but no later than 48 hours after receipt. External review by an IRO is available after final internal adverse benefit determination; IRO decisions are binding and members incur no cost for IRO services.
Standard grievance timelines: filing within 180 days, acknowledgement within 5 business days, resolution within 20 business days (extension up to 10 business days). Detailed timelines for pre/post service appeals, expedited appeals, and external reviews are provided in the Appeals & Grievances section.
Administrative coverage-impacting criteria
Administrative rules and operational notes that affect coverage (prior auth enforcement, continuity of care, continuity protections, and non‑waiver).
ALL of the following
Continuity of care transitional coverage is provided when a network provider's contractual relationship terminates and the member is a continuing care patient; members will be notified and allowed to elect transitional care for specified durations (up to 90 days or until no longer a continuing care patient).
Prior authorization requirements, failure to obtain prior authorization consequences, provider network adequacy rules, and balance billing protections are enforced per contract and applicable federal law. Failure by the plan or member to enforce contract terms does not constitute a waiver of rights (Non‑Waiver provision).