Evidence of Coverage

2023 Major Medical Expense
Policy
Ambetter.SuperiorHealthPlan.com
29418TX014-2023
Notice: Premium may be increased upon the renewal date.
CELTIC INSURANCE COMPANY FOR AMBETTER FROM

SUPERIOR HEALTHPLAN
Major Medical Expense Policy
THIS MAJOR MEDICAL EXPENSE POLICY (CONTRACT) IS ISSUED TO YOU, WHO HAVE ENROLLED IN
CELTIC INSURANCE COMPANY FOR AMBETTER FROM SUPERIOR HEALTHPLAN
HEALTH BENEFIT PLAN. YOU AGREE TO ADHERE TO THESE PROVISIONS FOR COVERED HEALTH
SERVICES BY COMPLETING THE ENROLLMENT FORM, PAYING THE APPLICABLE PREMIUM AND
ACCEPTING THIS CONTRACT. THIS DOCUMENT DESCRIBES YOUR RIGHTS AND RESPONSIBILITIES IN
RELATION TO YOUR COVERED HEALTH SERVICES AND BENEFITS.
Celtic Insurance Company

200 East Randolph Street
Suite 3600
Chicago, IL 60601
1-877-687-1196
IMPORTANT NOTICES:
THIS IS NOT A POLICY OF WORKERS' COMPENSATION INSURANCE. THE EMPLOYER

DOES NOT BECOME A SUBSCRIBER TO THE WORKERS' COMPENSATION SYSTEM BY
PURCHASING THIS POLICY, AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE
EMPLOYER LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE
WORKERS' COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE
WORKERS' COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE
REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.
THIS POLICY IS NOT A MEDICARE SUPPLEMENT POLICY OR CERTIFICATE. If you are

eligible for Medicare, review the Guide to Health Insurance for People with Medicare
available from the company.
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Member Services: 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989)
Log on to: Ambetter.SuperiorHealthPlan.com
Have a complaint or need help?
If you have a problem with a claim or your premium, call your insurance company or HMO first. If you
can't work out the issue, the Texas Department of Insurance may be able to help.
Even if you file a complaint with the Texas Department of Insurance, you should also file a complaint or
appeal through your insurance company or HMO. If you don't, you may lose your right to appeal.
Ambetter from Superior HealthPlan
To get information or file a complaint with your insurance company or HMO:
Call: at 1-877-687-1196
Toll-free: 1-877-687-1196
Online: Ambetter.SuperiorHealthPlan.com
Mail: 5900 E. Ben White Blvd.

Austin, Texas 78741
The Texas Department of Insurance
To get help with an insurance question or file a complaint with the state:
Call with a question: 1-800-252-3439
File a complaint: www.tdi.texas.gov
Email: [email protected]
Mail: MC 111-1A, P.O. Box 149091, Austin, TX 78714-9091
¿Tiene una queja o necesita ayuda?
Si tiene un problema con una reclamación o con su prima de seguro, llame primero a su compañía de
seguros o HMO. Si no puede resolver el problema, es posible que el Departamento de Seguros de Texas
(Texas Department of Insurance, por su nombre en inglés) pueda ayudar.
Aun si usted presenta una queja ante el Departamento de Seguros de Texas, también debe presentar una
queja a través del proceso de quejas o de apelaciones de su compañía de seguros o HMO. Si no lo hace,
podría perder su derecho para apelar.
Para obtener información o para presentar una queja ante su compañía de seguros o
29418TX014-2023 3
HMO:
Llame a: al 1-877-687-1196
Teléfono gratuito: 1-877-687-1196

En línea: Ambetter.SuperiorHealthPlan.com
Dirección postal:
5900 E. Ben White Blvd.
Austin, Texas 78741
El Departamento de Seguros de Texas
Para obtener ayuda con una pregunta relacionada con los seguros o para presentar una
queja ante el estado:
Llame con sus preguntas al: 1-800-252-3439
Presente una queja en: www.tdi.texas.gov
Correo electrónico: [email protected]
Dirección postal: MC 111-1A, P.O. Box 149091, Austin, TX 78714-9091
29418TX014-2023 4
Major Medical Expense Policy
In this Major Medical Expense Policy (contract), the terms “you” or “your” will refer to the enrollee or
any dependent enrollees enrolled in this contract. The terms “we,” “our,” or “us” will refer to Celtic
Insurance Company or Ambetter from Superior HealthPlan.
AGREEMENT AND CONSIDERATION

This document along with the corresponding Schedule of Benefits is your contract and it is a legal
document. It is the agreement under which benefits will be provided and paid. In consideration of
your enrollment application and the timely payment of premiums, we will provide benefits to you, the
enrollee, for covered health care services as outlined in this contract. Benefits are subject to contract
definitions, provisions, limitations and exclusions.
GUARANTEED RENEWABLE
Annually, we must file this product, the cost share and the rates associated with it for approval.
Guaranteed renewable means that your contract will be renewed into the subsequent year’s approved
product on the anniversary date unless terminated earlier in accordance with contract terms. You
may keep this contract (or the new contract you are mapped to for the following year, whether
associated with a discontinuance or replacement) in force by timely payment of the required
premiums. In most cases you will be moved to a new contract each year, however, we may decide not
to renew the contract as of the renewal date if: (1) we decide not to renew all contracts issued on this
form, with a new contract at the same metal level with a similar type and level of benefits, to residents
of the state where you then live; (2) we withdraw from the service area; or (3) there is fraud or an
intentional material misrepresentation made by or with the knowledge of an enrollee in filing a claim
for covered services.
Annually, we may change the rate table used for this policy form. Each premium will be based on the
rate table in effect on that premium's due date. The policy plan, and age of enrollees, type and level of
benefits, and place of residence on the premium due date are some of the factors used in determining
your premium rates. We have the right to change premiums however, all premium rates charged will
be guaranteed for a calendar year.
In addition to the above, this guarantee for continuity of coverage shall not prevent us from cancelling
or non-renewing this contract in the following events: (1) non-payment of premium; (2) an enrollee
fails to pay premiums or contributions in accordance with the terms of this contract, including any
timeliness requirements; (3) an enrollee has performed an act or practice that constitutes fraud or has
made an intentional misrepresentation of material fact relating to this contract; or (4) a change in
federal or state law, no longer permits the continued offering of such coverage, such as CMS guidance
related to individuals who are Medicare eligible.
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This contract contains prior authorization requirements. Failure to comply with the prior
authorization requirements may result in denial of payment. Please refer to the Summary of
Benefits and Coverage (SBC) and the Prior Authorization Section.
Kevin J. Counihan, President
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TABLE OF CONTENTS
DEFINITIONS.......................................................................................................................................................................................... 13
DEPENDENT ENROLLEE COVERAGE........................................................................................................................................... 33
ONGOING ELIGIBILITY ....................................................................................................................................................................... 35
PREMIUMS .............................................................................................................................................................................................. 39
COST SHARING FEATURES............................................................................................................................................................... 41
MANAGING YOUR HEALTH CARE ................................................................................................................................................. 45
Continuity of Care ............................................................................................................................................................................ 45
Non-Emergency Services.............................................................................................................................................................. 45
Emergency Services Outside of Service Area ....................................................................................................................... 45
New Technology............................................................................................................................................................................... 45
Preferred Partnership ................................................................................................................................................................... 45
Primary Care Physician (PCP) .................................................................................................................................................... 46
Prior Authorization......................................................................................................................................................................... 47
Hospital Based Providers ............................................................................................................................................................. 48
COVERED HEALTH CARE SERVICES AND SUPPLIES ............................................................................................................ 49
Acquired Brain Injury Services .................................................................................................................................................. 49
Ambulance Services ........................................................................................................................................................................ 50
Air Ambulance Service Benefits ................................................................................................................................................ 50
Autism Spectrum Disorder Benefits ........................................................................................................................................ 51
Mental Health and Substance Use Disorder Benefits ....................................................................................................... 52
Chiropractic Services ..................................................................................................................................................................... 53
Dialysis Services ............................................................................................................................................................................... 53
Radiology, Imaging and Other Diagnostic Testing ............................................................................................................. 54
Emergency Room Services and Treatment of Accidental Injury ................................................................................. 54
Habilitation, Rehabilitation, and Extended Care Facility Expense Benefits ............................................................ 55
Home Health Care Service Expense Benefits ....................................................................................................................... 55
Hospice Care Benefits .................................................................................................................................................................... 56
Hospital Benefits .............................................................................................................................................................................. 57
Infertility ............................................................................................................................................................................................. 58
Lymphedema ..................................................................................................................................................................................... 58
Medical and Surgical Benefits..................................................................................................................................................... 58
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Diabetic Care...................................................................................................................................................................................... 60
Durable Medical Equipment, Prosthetics, and Orthotic Devices ................................................................................. 61
Orthotic and Prosthetic Devices ................................................................................................................................................ 63
Maternity Care .................................................................................................................................................................................. 65
Other Dental Services .................................................................................................................................................................... 66
Second Medical Opinion................................................................................................................................................................ 67
Clinical Trial Coverage................................................................................................................................................................... 67
Prescription Drug Benefits .......................................................................................................................................................... 69
Medical Foods ................................................................................................................................................................................... 75
Preventive Care Services .............................................................................................................................................................. 76
Medical Vision Services ................................................................................................................................................................. 80
Sleep Studies ...................................................................................................................................................................................... 81
Transplant Benefits ........................................................................................................................................................................ 81
Urgent Care ........................................................................................................................................................................................ 84
Pediatric Vision Expense Benefits ............................................................................................................................................ 84
Pediatric Services will extend through the end of the plan year in which they turn 19 years of age. ......... 85
Wellness and Other Program Benefits .................................................................................................................................... 85
Care Management Programs....................................................................................................................................................... 86
GENERAL NON-COVERED SERVICES AND EXCLUSIONS..................................................................................................... 87
TERMINATION....................................................................................................................................................................................... 91
Termination Of Contract ............................................................................................................................................................... 91
Discontinuance ................................................................................................................................................................................. 91
Portability Of Coverage ................................................................................................................................................................. 91
Notification Requirements........................................................................................................................................................... 92
Reinstatement ................................................................................................................................................................................... 92
THIRD PARTY LIABILITY AND COORDINATION OF BENEFITS ....................................................................................... 93
ENROLLEE CLAIM REIMBURSEMENT...................................................................................................................................... 101
COMPLAINT AND APPEAL PROCEDURES............................................................................................................................... 104
Complaint Process ........................................................................................................................................................................ 104
Complaint Appeals ....................................................................................................................................................................... 104
Appeal of Adverse Determination ......................................................................................................................................... 105
External Review ............................................................................................................................................................................ 106
Simultaneous Expedited Appeal and Expedited Internal Review ............................................................................ 106
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Filing Complaints with the Texas Department of Insurance ...................................................................................... 106
Retaliation Prohibited ................................................................................................................................................................ 107
ENROLLEE RIGHTS AND RESPONSIBILITIES........................................................................................................................ 109
GENERAL PROVISIONS ................................................................................................................................................................... 112
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INTRODUCTION
Welcome to Ambetter from Superior HealthPlan! We have prepared this contract to help explain your
coverage. Please refer to this contract whenever you require medical services. It describes:
o How to access medical care.
o The health care services we cover.
o The portion of your health care costs you will be required to pay.
This contract, with the enrollment application, the Schedule of Benefits, and any amendments or riders
attached, shall constitute the entire contract under which covered services and supplies are provided or
paid for by us.
This contract should be read in its entirety. Because many of the provisions of this contract are
interrelated, you should read this entire contract to gain a full understanding of your coverage. Many
words used in this contract have special meanings when used in a health care setting: these words are
italicized and are defined in the Definitions section. This contract also contains exclusions, so please be
sure to read this entire contract carefully.
Throughout this contract, you will also see references for Celtic Insurance Company and Ambetter from
Superior HealthPlan. Both references are correct, as Ambetter from Superior HealthPlan operates under its
legal entity, Celtic Insurance Company.
How To Contact Us:

Austin, Texas 78741
Normal Business Hours of Operation – 8:00 a.m. to 8:00 p.m. CST, Monday through Friday
Member Services 1-877-687-1196
Relay Texas/TTY 1-800-735-2989
Fax 1-877-941-8077
Emergency 911
24/7 Nurse Advice Line 1-877-687-1196
Website: Ambetter.SuperiorHealthPlan.com
Interpreter Services
Ambetter from Superior HealthPlan has a free service to help our enrollees who speak languages other than
English. These services ensure that you and your provider can talk about your medical or behavioral health
concerns in a way that is most comfortable for you.
Our interpreter services are provided at no cost to you. We have representatives that speak Spanish and
have medical interpreters to assist with languages other than English. Enrollees who are blind or visually
impaired and need help with interpretation can call Member Services for an oral interpretation. To
29418TX014-2023 10
arrange for interpretation services, please call Member Services at 1-877-687-1196 or for hard of hearing
(Relay Texas/TTY 1-800-735-2989).
Your Provider Directory

A listing of network providers is available online at Ambetter.SuperiorHealthPlan.com. We have network
providers and hospitals who have agreed to provide you with your health care services. You may find any of
our network providers on our website. There you will have the ability to narrow your search by provider
specialty, zip code, gender, languages spoken and whether or not they are currently accepting new
patients. Your search will produce a list of providers based on your search criteria and will give you other
information such as name, address, phone number, office hours, specialty and board certifications.
At any time, you can contact Member Services to request a Provider Directory, or for assistance in finding a
provider.
Your Enrollee Identification Card

We will mail you an enrollee identification card after we receive your completed enrollment materials,
which includes receipt of your initial premium payment. This card is proof that you are enrolled in
Ambetter. You need to keep this card with you at all times and present it to your providers. The enrollee
identification card shows your name, enrollee identification number, helpful phone numbers, and
copayment amounts you will have to pay at the time of service. If you lose your card, please call Member
Services. We will send you another enrollee identification card. A temporary enrollee identification card
can be downloaded from our secure member portal at Ambetter.SuperiorHealthPlan.com.
Our Website
Our website can answer many of your frequently asked questions and has resources and features that
make it easy to get quality care. Our website can be accessed at Ambetter.SuperiorHealthPlan.com. It also
gives you information on your benefits and services such as:
1. Finding a network provider, including hospitals and pharmacies.
2. Our programs and services, including programs to help you get and stay healthy.
3. A secure portal for you to check the status of your claims, make payments and obtain a copy of your
enrollee identification card.
4. Enrollee’s Rights and Responsibilities.
5. Notice of Privacy.
6. Current events and news.
7. Our formulary or Preferred Drug List.
8. Deductible and copayment accumulators.
9. Selecting a PCP (also accessible through the use of mobile devices).
Quality Improvement
We are committed to providing quality health care for you and your family. Our primary goal is to improve
your health and help you with any illness or disability. Our program is consistent with National Committee
on Quality Assurance (NCQA) standards. To help promote safe, reliable, and quality health care, our
programs include:
1. Conducting a thorough check on providers when they become part of the provider network.
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2. Monitoring enrollee access to all types of health care services.
3. Providing programs and educational items about general health care and specific diseases.
4. Sending reminders to enrollees to get annual tests such as a physical examination, cervical cancer
screening, breast cancer screening, and immunizations.
5. Monitoring the quality of care and developing action plans to improve the health care you are
receiving.
6. A Quality Improvement Committee which includes network providers to help us develop and
monitor our program activities.
7. Investigating any enrollee concerns regarding care received.
Ten-Day Right to Examine this Contract

You shall be permitted to return this contract within ten days of receiving it and to have any premium you
paid refunded if, after examination of the contract, you are not satisfied with it for any reason. If you
return the contract to us, the contract will be considered void from the beginning and the parties are in the
same position as if no contract had been issued. If any services were rendered or claims paid by us during
the ten days, you are responsible for repaying us for such services or claims.
Protection from Balance Billing

Under Federal law, effective January 1, 2022, non-network providers or facilities are prohibited from
balance billing health plan enrollees for:
1. Emergency Services provided to an enrollee, regardless of plan participation; or
2. Non-emergency health care services provided to an enrollee at a network hospital or at a network
health care facility if the enrollee did not give informed consent or prior authorization to be seen by
the non-network provider pursuant to the federal No Surprises Act.
Please review the Access to Care and Covered Healthcare Services and Supplies sections of this contract for
detailed information.
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SERVICE AREA MAP
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DEFINITIONS
In this contract, italicized words are defined. Words not italicized will be given their ordinary meaning.
Wherever used in this contract:
Acute rehabilitation is rehabilitation for patients who will benefit from an intensive, multidisciplinary
rehabilitation program. Patients normally receive a combination of therapies such as physical, occupational
and speech therapy as needed and are medically managed by specially trained physicians. Rehabilitation
services must be performed for three or more hours per day, five to seven days per week, by one or more
rehabilitation licensed practitioners while the enrollee is confined as an inpatient in a hospital, rehabilitation
facility, or extended care facility.
Acquired brain injury means a neurological insult to the brain, which is not hereditary, congenital, or
degenerative. The injury to the brain has occurred after birth and results in a change in neuronal activity,
which results in an impairment of physical functioning, sensory processing, cognition, or psychosocial
behavior.
Advance premium tax credit means the tax credit provided by the Affordable Care Act to help you afford
health coverage purchased through the Health Insurance Marketplace. Advance premium tax credits can be
used right away to lower your monthly premium costs. If you qualify, you may choose how much advance
premium tax credit to apply to your premiums each month, up to the maximum amount. If the amount of
advance premium tax credits you receive for the year is less than the total premium tax credit you are due,
you will get the difference as refundable credit when you file your federal income tax return. If the amount
of advance premium tax credits for the year are more than the total tax credit that you are due, you must
repay the excess advance premium tax credit with your tax return.
Adverse determination means any decision by us which results in:

1. A denial of a request for service.
2. A denial, reduction or failure to provide or make payment in whole or in part for a covered service.
3. A determination that an admission, continued stay, or other health care service does not meet our
requirements for medical necessity, appropriateness, health care setting, or level of care or
effectiveness.
4. A determination that a service is experimental, investigational, cosmetic treatment, not medically
necessary or inappropriate.
5. Our decision to deny coverage based upon an eligibility determination.
6. A rescission of coverage determination as described in the General Provisions section of this
contract.
7. A prospective review or retrospective review determination that denies, reduces or fails to provide
or make payment, in whole or in part, for a covered service.
Refer to the Complaint and Appeals Procedures section of this contract for information on your right to
appeal an adverse determination.
29418TX014-2023 14
Allowed amount (also see eligible service expense) is the maximum amount we will pay a provider for a
covered service when a covered service is received from a network provider, the allowed amount is the
amount the provider agreed to accept from us as payment for that particular service. In all cases, the
allowed amount will be subject to cost sharing (e.g., deductible, coinsurance and copayment) per the
enrollee’s benefits. This amount excludes agreed to amounts between the provider and us as a result of
Federal or State Arbitration.
Please note, if you receive services from a non-network provider, you may be responsible for the difference
between the amount the provider charges for the service (billed amount) and the allowed amount that we
pay. However, you will not be responsible for balance billing for unanticipated non-network care that is
otherwise covered under your contract and that is provided by a non-network provider at a network facility,
unless you gave informed consent before receiving the services. You also will not be responsible for
balance billing by a non-network provider or non-network facility for emergency services or air ambulance
services. See balance billing and non-network provider definitions for additional information. If you are
balance billed in these situations, please contact Member Services immediately at the number listed on the
back of your enrollee identification card.
Ambetter Telehealth means the preferred vendor who we have contracted with to provide telehealth
services to enrollees. Our preferred vendor contracts with providers to render telehealth services to
enrollees. These services can be accessed via https://ambetter.superiorhealthplan.com/benefits-
services/telehealth-services.html.
Appeal is our Utilization Review Agent’s formal process by which an enrollee, or an individual acting on
behalf of an enrollee, or an enrollee’s provider of record may request reconsideration of an adverse
determination. Appeal means a grievance requesting the insurer to reconsider, reverse, or otherwise
modify an adverse benefit determination, service or claim.
Applied behavior analysis (ABA) is the application of behavioral principles to everyday situations,
intended to increase or decrease targeted behaviors. ABA has been used to improve areas such as language,
self-help, and play skills, as well as decrease behaviors such as aggression, self-stimulatory behaviors, and
self-injury.
Authorization or authorized means our decision to approve the medical necessity or the appropriateness
of care for an enrollee by the enrollee’s PCP or provider prior to the enrollee receiving services.
Autism spectrum disorder is a neurological and developmental disorder that begins early in childhood
and lasts throughout a person's life. It is a condition related to brain development that impacts how a
person perceives and socializes with others, causing problems in social interaction and communication. It
may include intellectual impairment but not always. The disorder may include problems with the ability to
recognize or share interests or emotional experiences, problems expressing or understanding verbal or
non-verbal communication, and/or developing or maintaining relationships. Repetitive patterns of
behavior or an inability to tolerate change is often seen.
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Balance billing means a non-network provider billing you for the difference between the provider’s charge
for a service and the eligible expense. Network providers may not balance bill you for covered service
expenses beyond your applicable cost sharing amounts.
If you are ever balance billed contact Member Services immediately at the number listed on the back of
your enrollee identification card.
Behavioral health means both mental health and substance use disorders, encompassing a continuum of
prevention, intervention, treatment and recovery support services.
Bereavement counseling means counseling of enrollees of a deceased person's immediate family that is
designed to aid them in adjusting to the person's death.
Billed charges are the charges for medical care or health care services included on a claim submitted by a
physician or provider.
Care management means a program in which a registered nurse or licensed mental health professional,
known as a care manager, assists an enrollee through a collaborative process that assesses, plans,
implements, coordinates, monitors and evaluates options and health care benefits available to an enrollee.
Care management is instituted when mutually agreed to by us, the enrollee and the enrollee’s physician.
Center of Excellence means a hospital that:

1. Specializes in a specific type or types of medically necessary transplants or other services such as
cancer, bariatric or infertility; and
2. Has agreed with us or an entity designated by us to meet quality of care criteria on a cost efficient
basis. The fact that a hospital is a network provider does not mean it is a Center of Excellence.
Chiropractic care means the involvement of neuromuscular treatment in the form of manipulation and
adjustment of the tissues of the body, particularly of the spinal column and may include physical medicine
modalities or use of durable medical equipment.
Cognitive communication therapy are services designed to address modalities of comprehension and
expression, including understanding, reading, writing, and verbal expression of information.
Cognitive rehabilitation therapy are services designed to address therapeutic cognitive activities, based
on an assessment and understanding of the enrollee’s brain-behavioral deficits.
Coinsurance amount means the percentage of covered services that you may be required to pay when you
receive a covered service. Coinsurance amounts are listed in the Schedule of Benefits. Not all covered services
have coinsurance.
Community reintegration services are services that facilitate the continuum of care as an affected enrollee
transitions into the community.
29418TX014-2023 16
Complaint means any dissatisfaction expressed orally or in writing by a complainant to a health
maintenance organization regarding any aspect of the health maintenance organization’s operation. The
term includes dissatisfaction relating to plan administration, procedures related to review or appeal of an
adverse determination under Section 1301.055, 4201.204, and 4201.351, the denial, reduction, or
termination of a service for reasons not related to medical necessity, the manner in which a service is
provided, and a disenrollment decision. The term does not include:
1. A misunderstanding or a problem of misinformation that is resolved promptly by clearing up the
misunderstanding or supplying the appropriate information to the satisfaction of the enrollee; or
2. A provider's or enrollee's oral or written expression of dissatisfaction or disagreement with an
adverse determination.
Complications of pregnancy means:

1. Conditions, requiring hospital confinement (when the pregnancy is not terminated), whose
diagnoses are distinct from pregnancy but are adversely affected by pregnancy or are caused by
pregnancy, such as acute nephritis, nephrosis, cardiac decompensation, missed abortion, and
similar medical and surgical conditions of comparable severity, but shall not include false labor,
occasional spotting, provider prescribed rest during the period of pregnancy, morning sickness,
hyperemesis gravidarum, pre-eclampsia, and similar conditions associated with the management
of a difficult pregnancy not constituting a nosologically distinct complications of pregnancy; and
2. Non-elective cesarean section, termination of ectopic pregnancy, and spontaneous termination of
pregnancy, occurring during a period of gestation in which a viable birth is not possible.
Continuing care patient means an individual who, with respect to a provider or facility, is (i) undergoing a
treatment for a serious and complex condition from that provider or facility; (ii) is undergoing a course of
institutional or inpatient care from that provider or facility; (iii) is scheduled to undergo non-elective
surgery from that provider, including postoperative care; (iv) is pregnant and undergoing a course of
treatment for the pregnancy; or (v) is determined to be terminally ill and is receiving treatment for such
illness.
Contract means this contract, as issued and delivered to you. It includes the attached pages, the enrollment
application, the Schedule of Benefits, and any amendments or riders.
Copayment, copay, or copayment amount means the specific dollar amount that you may be required to
pay when you receive covered services. Copayment amounts are shown in the Schedule of Benefits. Not all
covered services have a copayment amount.
Cosmetic treatment means treatments, procedures, or services that change or improve appearance
without significantly improving physiological function and without regard to any asserted improvement to
the psychological consequences or socially avoidant behavior resulting from an injury, illness, or congenital
anomaly.
Cost sharing means the deductible amount, copayment amount and coinsurance that you pay for covered
services. The cost sharing amount that you are required to pay for each type of covered services is limited in
the Schedule of Benefits. When you receive covered services from a non-network provider in a network
29418TX014-2023 17
facility, or when you receive covered emergency services or air ambulance services from non-network
providers, cost sharing may be based on an amount different from the allowed amount.
Cost sharing reductions lowers the amount you have to pay in deductibles, copayments and coinsurance.
To qualify for cost sharing reductions, an eligible individual must enroll in a silver level plan through the
Health Insurance Marketplace. Members of a federally recognized American Indian tribe and/or an
Alaskan Native may qualify for additional cost sharing reductions.
Covered service or covered service expenses means health care services, supplies or treatment as
described in this contract which are performed, prescribed, directed or authorized by a provider. To be a
covered service the service, supply or treatment must be:
1. Provided or incurred while the enrollee's coverage is in force under this contract;
2. Covered by a specific benefit provision of this contract; and
3. Not excluded anywhere in this contract.
Custodial care are services designed to assist an enrollee with activities of daily living, often provided in a
long term care environment where full recovery is not expected and can be provided by a layperson.
Custodial care includes (but is not limited to) the following:

1. Personal care such as assistance in walking, getting in and out of bed, dressing, bathing, feeding and
use of toilet;
2. Preparation and administration of special diets;
3. Supervision of the administration of medication by a caregiver;
4. Supervision of self-administration of medication; or
5. Programs and therapies involving or described as, but not limited to, convalescent care, rest care,
educational care or recreational care.
Deductible amount or deductible means the amount that you must pay in a calendar year for covered
expenses before we will pay benefits. For family coverage, there is a family deductible amount which is two
times the individual deductible amount. Both the individual and the family deductible amounts are shown in
the Schedule of Benefits.
If you are a covered enrollee in a family of two or more enrollees, you will satisfy your deductible amount
when:
1. You satisfy your individual deductible amount; or
2. Your family satisfies the family deductible amount for the calendar year.
If you satisfy your individual deductible amount, each of the other enrollees in your family are still
responsible for their deductible until the family deductible amount is satisfied for the calendar year.
Dental services means surgery or services provided to diagnose, prevent, or correct any ailments or
defects of the teeth and supporting tissue and any related supplies or oral appliances. Expenses for such
treatment are considered dental services regardless of the reason for the services.
29418TX014-2023 18
Dependent enrollee means the primary subscriber’s lawful spouse, domestic partner and/or an eligible
child. Each dependent enrollee must either be named in the enrollment application or we must agree in
writing to add them as a dependent enrollee.
Diabetes self-management training means instruction enabling an enrollee and/or his or her caretaker to
understand the care and management of diabetes, including nutritional counseling and proper use of
diabetes equipment and supplies.
Diagnostic imaging means an imaging examination using mammography, ultrasound imaging, or

magnetic resonance imaging that is designed to evaluate:
1. A subjective or objective abnormality detected by a physician or patient in a breast;
2. An abnormality seen by a physician on a screening mammogram;
3. An abnormality previously identified by a physician as probably benign in a breast for which
follow-up imaging is recommended by a physician; or
4. An individual with a personal history of breast cancer or dense breast tissue.
Durable medical equipment means items that are used to serve a specific diagnostic or therapeutic
purpose in the treatment of an illness or injury, can withstand repeated use, are generally not useful to a
person in the absence of illness or injury, and are appropriate for use in the patient's home.
Effective date means the date an enrollee becomes covered under this contract for covered services.
Eligible child means the child of an primary subscriber, if that child is less than 26 years of age. As used in
this definition, “child” means:
1. A natural child;
2. A stepchild;
3. A legally adopted child and child for which the primary enrollee must provide medical support
under an order issued under Section 14.061, Family Code, or another order enforceable by a court
in Texas;
4. A child placed with you for adoption or for whom you are a party in a suit in which the adoption of
the child is sought;
5. A foster child placed in your custody;
6. A child for whom legal guardianship has been awarded to you, your spouse, or domestic partner;
7. A child of an on-exchange enrollee who is a resident of United States or a full-time student at an
accredited higher education institution;
8. A child of an on-exchange enrollee who is not eligible for coverage under Medicare;
9. Any children of the on-exchange enrollee’s children, if those children are dependents of the enrollee
for federal income tax purposes at the time of enrollment application; or
10. A child whose coverage is required by a medical support order.
It is your responsibility to notify the entity with which you enrolled (either the Health Insurance
Marketplace or us) if your child ceases to be an eligible child. You must reimburse us for any benefits that
we provide or pay for a child at a time when the child did not qualify as an eligible child.
29418TX014-2023 19
Eligible expense means a covered service expense as determined below.
1. For network providers: When a covered service is received from a network provider, the eligible
expense is the contracted fee with that provider.
2. For non-network providers, unless otherwise required by Federal or State law, the eligible expense is
as follows:
a. When a covered emergency service is received from a non-network provider within Texas,
the eligible expense is the lesser of: (1) the negotiated fee, if any, that has been mutually
agreed upon by us and the provider as payment in full, or (2) the usual and customary rate
for such service. You cannot be billed for the amount above the usual and customary rate. If
you have received emergency services provided by a non-network provider and received a
balance bill, notify the Texas Department of Insurance (TDI) or notify Ambetter from
Superior HealthPlan by visiting our website and Ambetter will notify TDI. You must see a
network provider for any post stabilization care and for all follow-up care.
b. When a covered emergency service is received from a non-network provider outside of
Texas, the eligible expense is the negotiated fee, if any, that has been mutually agreed upon
by us and the provider as payment in full. If the provider has not agreed to accept a
negotiated fee with us as payment in full, unless otherwise required by applicable law, the
eligible service expense is reimbursement as determined by us and as required by
applicable law. Enrollee cost share will be calculated from the recognized amount based
upon federal law. You should not be balance billed for the difference between the amount
we pay and the provider’s charges, but you may be subject to cost-sharing obligations. If
you are balance billed in these situations, please contact Member Services immediately at
the number listed on the back of your enrollee identification card.
c. When a covered service is received from a non-network professional provider who renders
non-emergency services at a network facility, including but not limited to diagnostic imaging
or laboratory testing services, the eligible expense is the negotiated fee, if any, that has been
mutually agreed upon by us and the provider as payment in full. If the provider has not
agreed to accept a negotiated fee with us as payment in full, unless otherwise required by
applicable law, the eligible expense is reimbursement as determined by us and as required
by applicable law. Unless you receive and sign the necessary written notice and consent
document under federal law before the services are provided, you should not be balance
billed for the difference between the amount we pay and the provider’s charges, but you
may be subject to cost sharing obligations. Enrollee cost share will be calculated from the
recognized amount based upon applicable law. If you are balance billed in these situations,
notify Ambetter from Superior HealthPlan by visiting our website. Ambetter will notify TDI
as appropriate.
d. When a covered air ambulance service is received from a non -network provider, the
eligible service expense is the negotiated fee, if any, that has been mutually agreed upon by
us and the provider as payment in full. If the provider has not agreed to accept a negotiated
fee with us as payment in full, unless otherwise required by applicable law, the eligible
service expense is reimbursement as determined by us and as required by applicable law.
Member cost share will be calculated from the recognized amount based upon applicable
law. You should not be balance billed for the difference between the amount we pay and the
provider’s charges, but you may be subject to cost sharing obligations. If you are balance
billed in these situations, please contact Member Services immediately at the number listed
on the back of your member identification card.
29418TX014-2023 20
e. When a covered service is not the result of an emergency, received from a non-network
provider and a notice and disclosure statement was signed, you may be balance billed for
the amount above the usual and customary rate. If you have received care provided by a
non-network provider and signed a notice and disclosure statement ten days prior to
receiving care, you are responsible for the balance billed amount.
f. For all other covered services received from a non-network provider for which any needed
authorization is received from us, the eligible expense is the negotiated fee, if any, that has
been mutually agreed upon by us and the provider as payment in full (you will not be billed
for the difference between the negotiated fee and the provider’s charge). If there is no
negotiated fee agreed to by the provider with us, the eligible expense is the greatest of the
following: (i) the amount that would be paid under Medicare; (ii) the amount for the
covered service calculated using the same method we generally use to determine payments
for non-network providers; or (iii) the contracted amount paid to network providers for the
covered service (if there is more than one contracted amount with network providers for the
covered service, the amount is the median of these amounts). In addition to applicable cost
sharing, you may be balance billed for these services.
As used in this section, “usual and customary rate” is calculated based on usual, reasonable, or customary
charges paid to and accepted by providers, and is based on generally accepted industry standards and
practices for determining the customary charges for a service.
Emergency services (medical and behavioral health) means health care services provided in a hospital
emergency facility, freestanding emergency medical care facility, or comparable emergency facility to
evaluate and stabilize a medical condition (including emergency labor and delivery) manifesting itself by
acute symptoms of sufficient severity (including severe pain, or psychiatric disturbances) such that a
prudent layperson with an average knowledge of medicine and health, could reasonably expect the
absence of immediate medical attention to result in one of the following:
1. placing the recipient’s (or, with respect to a pregnant woman, the health of the woman or her
unborn child) health in serious jeopardy;
2. serious impairment to bodily functions; or
3. serious dysfunction or disfigurement of any bodily organ or part.
Services you receive from a non-network provider or non-network facility after the point your emergency
medical/behavioral health condition is stabilized continue to meet the definition of emergency services until
(1) you are discharged from the facility, or (2) both of the following circumstances are met, as well as any
other criteria required by federal or state law: (a) the provider or facility determines you are able to travel
using nonmedical transportation or nonemergency medical transportation, and (b) your provider obtains
informed consent to provide the additional services.
Enhanced Direct Enrollment (EDE) means an Ambetter tool that allows you to apply for coverage, renew
and report life changes entirely on our website without being redirected to the Health Insurance
Marketplace (Healthcare.gov). If you have utilized enroll.ambetterhealth.com to apply or renew, a
consumer dashboard has been created for you. You can log into your consumer dashboard at
enroll.ambetterhealth.com.
29418TX014-2023 21
Enrollee means you, your lawful spouse and each eligible child:
1. Named in the enrollment application; or
2. Whom we agree in writing to add as an enrollee.
Exclusive provider (network provider) is a health care provider or an organization of health care
providers who contract or subcontract to provide health care services to covered enrollees under your
exclusive provider benefit plan.
Exclusive provider benefit plan (EPO) is a type of health care plan offered by an issuer that arranges for
or provides benefits to covered enrollees through a network of exclusive providers, and that limits or
excludes benefits for services provided by out of network providers, except in cases of emergency or
approved referral. Ambetter is an EPO.
Experimental or investigational is a health care treatment, service, or device for which there is early,
developing scientific or clinical evidence demonstrating the potential efficacy of the treatment, service, or
device, but that is not yet broadly accepted as the prevailing standard of care.
Extended care facility means an institution, or a distinct part of an institution, that:

1. Is licensed as a skilled nursing facility or rehabilitation facility by the state in which it operates;
2. Is regularly engaged in providing 24-hour skilled nursing care under the regular supervision of a
provider and the direct supervision of a registered nurse;
3. Maintains a daily record on each patient;
4. Has an effective utilization review plan;
5. Provides each patient with a planned program of observation prescribed by a provider; and
6. Provides each patient with active treatment of an illness or injury, in accordance with existing
generally accepted standards of medical practice for that condition.
Extended care facility does not include a facility primarily for rest, the aged, treatment of substance use
disorder, custodial care, nursing care, or for care of mental disorders or the mentally disabled.
Facility means a hospital, rehabilitation facility, emergency clinic, outpatient clinic, birthing center,
ambulatory surgical center, skilled nursing facility, or other health care facility providing health care
services.
Generally accepted standards of medical practice means standards that are based on credible scientific
evidence published in peer-reviewed medical literature generally recognized by the relevant medical
community, relying primarily on controlled clinical trials.
If no credible scientific evidence is available, then standards that are based on provider specialty society
recommendations or professional standards of care may be considered. We reserve the right to consult
medical professionals in determining whether a health care service, supply, or drug is medically necessary
and is a covered service under the contract. The decision to apply provider specialty society
recommendations, the choice of medical professional, and the determination of when to use any such
opinion, will be determined by us.
29418TX014-2023 22
Habilitation or habilitation services means health care services that help you keep, learn, or improve
skills and functioning for daily living. These services may be performed in an inpatient or outpatient
setting and include: physical therapy, occupational therapy, and speech therapy.
Health management means a program designed specially to assist you in managing a specific or chronic
health condition.
Home health aide services means those services provided by a home health aide employed by a home
health care agency and supervised by a registered nurse, which are directed toward the personal care of an
enrollee.
Home health services means care or treatment of an illness or injury at the enrollee's home that is:
1. Provided by a home health care agency; and
2. Prescribed and supervised by a provider.
Home health care agency means a business that:

1. provides home health services; and
2. is licensed by Texas Health and Human Services under Chapter 142 of the Health and Safety Code.
Home infusion therapy means the administration of fluids, nutrition, or medication (including all
additives and chemotherapy) by intravenous or gastrointestinal (enteral) infusion or by intravenous
injection in the home setting.
Hospice means services designed for, elected by, and provided to enrollees who are terminally ill, as
certified by a network physician. We work with certified hospice programs licensed by the state to minimize
patient discomfort and address the special physical, psychological, and social needs of a terminally ill
enrollee and those of his or her immediate family.
Hospital is a licensed institution and operated pursuant to law that:

1. Is primarily engaged in providing or operating (either on its premises or in facilities available to the
hospital on a contractual prearranged basis and under the supervision of a staff of one or more duly
licensed providers), medical, diagnostic, and major surgery facilities for the medical care and
treatment of sick or injured persons on an inpatient basis for which a charge is made;
2. Provide 24-hour nursing service by or under the supervision of a registered graduate professional
nurse (R.N.);
3. Is an institution which maintains and operates a minimum of five beds;
4. Has x-ray and laboratory facilities either on the premises or available on a contractual prearranged
basis; and
5. Maintain permanent medical history records.
While confined in a separate identifiable hospital unit, section, or ward used primarily as a nursing, rest,
custodial care or convalescent home, rehabilitation facility, extended care facility, or residential treatment
facility, halfway house, or transitional facility, or a patient is moved from the emergency room in a short
29418TX014-2023 23
term observation status, an enrollee will be deemed not to be confined in a hospital for purposes of this
contract.
Hospital Services means those medically necessary covered services that are generally and customarily
provided by acute general hospitals; and prescribed, directed or authorized by your PCP. When an enrollee
is admitted to an inpatient facility, a physician other than the enrollee’s PCP may direct and oversee the
enrollee’s care.
Illness means a sickness, disease, or disorder of an enrollee. All illnesses that exist at the same time and that
are due to the same or related causes are deemed to be one illness. Further, if an illness is due to causes that
are the same as, or related to, the causes of a prior illness, the illness will be deemed a continuation or
recurrence of the prior illness and not a separate illness.
Immediate family means the parents, spouse, domestic partner, eligible child, or siblings of an enrollee,
residing with an enrollee.
Injury means accidental bodily damage sustained by an enrollee and inflicted on the body by an external
force. All injuries due to the same accident are deemed to be one injury.
Inpatient means that services, supplies, or treatment, for medical or behavioral health, are received by a
person who is an overnight resident patient of a hospital or other facility, using and being charged for room
and board.
Intensive care unit means a unit or area of a hospital that meets the required standards of the Joint
Commission on Accreditation of Hospitals for special care units.
Intensive day rehabilitation means two or more different types of therapy provided by one or more
rehabilitation licensed practitioners and performed for three or more hours per day, five to seven days per
week.
Managed drug limitations means limits in coverage based upon time period, amount or dose of a drug, or
other specified predetermined criteria.
Maximum out-of-pocket amount means the sum of the deductible amount, prescription drug deductible
amount (if applicable), copayment amount and coinsurance of covered services, as shown in the Schedule of
Benefits.
Maximum therapeutic benefit means the point in the course of treatment where no further improvement
in an enrollee's medical condition can be expected, even though there may be fluctuations in levels of pain
and function.
Mediation means a process in which an impartial mediator facilitates and promotes agreement between
the insurer offering an exclusive provider benefit plan or the administrator and a facility-based provider or
emergency services provider or the provider's representative to settle a health benefit claim of an enrollee.
29418TX014-2023 24
Medically necessary means health care services, items or supplies needed to prevent, diagnose, or treat an
illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.
Medically stabilized for non-emergency services means that the person is no longer experiencing further
deterioration as a result of a prior injury or illness and there are no acute changes in physical findings,
laboratory results, or radiologic results that necessitate acute medical care. Acute medical care does not
include acute rehabilitation. Stabilize, with respect to an emergency medical condition, means to provide
medical treatment of the condition as necessary to assure, within reasonable medical probability, that no
material deterioration of the condition is likely to result from or occur during the transfer* to a network
facility or discharge of the individual from a facility. See Ambulance Service Benefits provision under the
Covered Health Care Services and Supplies section.
Mental health disorder means a condition that causes disturbance in behavior, emotion and cognition.
These disorders can vary in impact, ranging from no impairment to mild, moderate or severe impairment.
Depending on the severity, they may be accompanied by significant distress that affects an individual’s
work, school and social relationships. Mental health disorder benefits are defined as benefits for items or
services for mental health conditions listed in ICD-10 Chapter 5 (F), except for subchapter 1 (F01-09) and
subchapter 8 (F70-79).
Minimum essential coverage means any health insurance plan that meets the Affordable Care Act (ACA)
requirement(s) for health insurance coverage. Examples include, job-based plans, Health Insurance
Marketplace (“Marketplace”) plans, most individual plans sold outside of the Marketplace, Medicare,
Medicaid, Children Health Insurance Program (CHIP), TRICARE, COBRA and plans sold through the Small
Business Health Insurance Program (SHOP) Marketplace.
Necessary medical supplies means medical supplies that are:

1. Necessary to the care or treatment of an injury or illness;
2. Not reusable or durable medical equipment; and
3. Not able to be used by others.
Necessary medical supplies do not include first aid supplies, cotton balls, rubbing alcohol, or like items
routinely found in the home.
Network means a group of providers or facilities (including, but not limited to hospitals, inpatient mental
health care facilities, medical clinics, behavioral health clinics, acupuncturists, chiropractors, massage
therapists, nurse practitioners, addiction medicine practitioners, etc.) who have contracts with us, or our
contractor or subcontractor, and have agreed to provide health care services to our enrollees for an agreed
upon fee. Enrollees will receive most, if not all, of their health care services by accessing the network.
Network eligible expense means the eligible expense for services or supplies that are provided by a
network provider. For facility services, this is the eligible expense that is provided at and billed by a network
facility for the services of either a network or non-network provider. Network eligible expense includes
benefits for emergency health services even if provided by a non-network provider.
29418TX014-2023 25
Network provider means any licensed person or entity that has entered into a contract with Ambetter
from Superior HealthPlan to provide covered services to enrollees under this contract, including but not
limited to, hospitals, specialty hospitals, urgent care facilities, physicians, pharmacies, laboratories and
other health professionals within our service area.
Neurobehavioral testing is an evaluation of the history of neurological and psychiatric difficulty, current
symptoms, current mental status, and premorbid history, including the identification of problematic
behavior and the relationship between behavior and the variables that control behavior. This may include
interviews of the enrollee, family, or others.
Neurobehavioral treatment is interventions that focus on behavior and the variables that control
behavior.
Neurocognitive rehabilitation are services designed to assist cognitively impaired enrollees to

compensate for deficits in cognitive functioning by rebuilding cognitive skills and/or developing
compensatory strategies and techniques.
Neurocognitive therapy are services designed to address neurological deficits in informational processing
and to facilitate the development of higher level cognitive abilities.
Neurofeedback therapy are services that utilize operant conditioning learning procedure based on
electroencephalography (EEG) parameters, and which are designed to result in improved mental
performance and behavior, and stabilized mood.
Neurophysiological testing is an evaluation of the functions of the nervous system.
Neurophysiological treatment means interventions that focus on the functions of the nervous system.
Neuropsychological testing is the administering of a comprehensive battery of tests to evaluate

neurocognitive, behavioral, and emotional strengths and weaknesses and their relationship to normal and
abnormal central nervous system functioning.
Neuropsychological treatment means interventions designed to improve or minimize deficits in

behavioral and cognitive processes.
Non-network provider means a medical practitioner, provider facility, or other provider that does not
have a contract with us to provide medical care or health care to the enrollee through this contract.
Services received from a non-network provider are “out-of-network” and are not covered except for:
1. Emergency services, as described in the Covered Services section of this contract;
2. Non-emergency health care services received at a network facility, as described in the Managing
Your Health Care section of this contract; or
3. Situation otherwise specifically described in this contract.
29418TX014-2023 26
Orthotic device means a medically necessary device used to support, align, prevent or correct deformities,
protect a body function, improve the function and movable body part or assist with dysfunctional joints.
Orthotics must be used for the therapeutic support, protection, restoration or function of an impaired body
part for treatment of an illness or injury.
Other plan means any plan or policy that provides insurance, reimbursement, or service benefits for
hospital, surgical, or medical expenses. This includes payment under group or individual insurance
policies, automobile no-fault or medical pay, homeowner insurance medical pay, premises medical pay,
nonprofit health service plans, health maintenance organization member contracts, self-insured group
plans, prepayment plans, and Medicare when the enrollee is enrolled in Medicare. Other plan will not
include Medicaid.
Other practitioner as used in your Schedule of Benefits and related to Mental Health/Substance Use
Disorder services, refers to a mental health or substance use disorder provider licensed/certified by the
state in which care is being rendered and performing services within the scope of that license/certification.
Outpatient day treatment services means structured services provided to address deficits in
physiological, behavioral and/or cognitive functions.
Outpatient services means facility, ancillary and professional charges when given as an outpatient at
a hospital, alternative care facility, Retail Health Clinic, or other provider as determined by us. These
facilities may include a non-hospital site providing diagnostic and therapy services, surgery, or
rehabilitation, or other provider facility as determined by us. Professional charges only include services
billed by a physician or other professional.
Outpatient surgical facility means any facility with a medical staff of providers that operates pursuant to
law for the purpose of performing surgical procedures, and that does not provide accommodations for
patients to stay overnight. This does not include facilities such as: acute-care clinics, urgent care centers,
ambulatory-care clinics, free-standing emergency facilities, and provider offices.
Physician means a licensed medical practitioner who is practicing within the scope of his or her licensed
authority in treating a bodily injury or illness and is required to be covered by state law. A physician does
NOT include someone who is related to a covered person by blood, marriage, or adoption or who is
normally a member of the covered person's household.
Post-acute transition services are services that facilitate the continuum of care beyond the initial
neurological consult through rehabilitation and community reintegration.
Pregnancy means the physical condition of being pregnant, but does not include complications of
pregnancy.
Prescription drug means any FDA approved medicinal substance whose label is required to bear the
legend "RX only".
29418TX014-2023 27
Prescription order means the request for each separate drug or medication by a provider or each authorized
refill or such requests.
Primary care physician or PCP means a provider who gives or directs health care services for you. PCPs
include internists, family practitioners, general practitioners, Advanced Practice Registered Nurses
(APRN), Physician Assistants (PA), pediatricians and obstetrician/gynecologist (OB/GYN) or any other
practice allowed by us. A PCP supervises, directs and gives initial care and basic medical services to you
and is in charge of your ongoing care.
Prior authorization means a determination by us that the health care services proposed to be provided to
an enrollee are medically necessary and appropriate. Prior Authorization process will conducted in
accordance with Texas Insurance Code, Chapter 1301 and 4201, or in accordance with the law in the state
of Texas.
Proof of loss means information required by us to decide if a claim is payable and the amount that is
payable. It may include, but is not limited to, claim forms, medical bills, or records, other plan information,
payment of claim, network re-pricing information, bank statements, and police reports. Proof of loss must
include a copy of all Explanation of Benefit forms from any other carrier, including Medicare.
Prosthetic device means a medically necessary device used to replace, correct or support a missing portion
of the body, to prevent or correct a physical deformity or malfunction, or to support a weak or deformed
portion of the body.
Provider facility means a hospital, rehabilitation facility, skilled nursing facility, or other health care
facility.
Qualified health plan or QHP means a health plan that has in effect a certification that it meets the
standards described in subpart C of part 156 issued or recognized by each Health Insurance Marketplace
through which such plan is offered in accordance with the process described in subpart K of part 155.
Qualified individual means, with respect to a Health Insurance Marketplace, an individual who has been
determined eligible to enroll through the Health Insurance Marketplace in a qualified health plan in the
individual market.
Reconstructive surgery means surgery performed on an abnormal body structure caused by congenital
defects, developmental abnormalities, trauma, infection, tumors, or disease in order to improve function or
to improve the patient's appearance, to the extent possible. This includes craniofacial abnormalities.
Rehabilitation means care for restoration (including by education or training) of one's prior ability to
function at a level of maximum therapeutic benefit. This includes acute rehabilitation, sub-acute
rehabilitation, or intensive day rehabilitation, and it includes rehabilitation therapy, cardiac rehabilitation
therapy, and pain management programs. An inpatient hospitalization will be deemed to be for
rehabilitation at the time the enrollee has been medically stabilized and begins to receive rehabilitation
therapy or treatment under a pain management program.
29418TX014-2023 28
Rehabilitation facility means an institution or a separate identifiable hospital unit, section, or ward that:
1. Is licensed by the state as a rehabilitation facility; and
2. Operates primarily to provide 24-hour primary care or rehabilitation of sick or injured persons as
inpatients.
Rehabilitation facility does not include a facility primarily for rest, the aged, long term care, assisted living,
custodial care, nursing care, or for care of the mentally disabled.
Rehabilitation licensed practitioner means, but is not limited to, a provider, physical therapist, speech
therapist, occupational therapist, or respiratory therapist. A rehabilitation licensed practitioner must be
licensed or certified by the state in which care is rendered and performing services within the scope of that
license or certification.
Rehabilitation therapy means therapy to help a person regain abilities that have been lost or impaired as
a result of disease, injury or treatment. It is provided to optimize functioning and reduce disability in
individuals. Types of rehabilitation therapy include: physical therapy, occupational therapy, speech
therapy, cardiac therapy, respiratory therapy. It may occur in either an outpatient or inpatient setting.
Rescission of a contract means a determination by an insurer to withdraw the coverage back to the initial
date of coverage.
Residence means the physical location where you live. If you live in more than one location, and you file a
United States income tax return, the physical address (not a P.O. Box) shown on your United States income
tax return as your residence will be deemed to be your place of residence. If you do not file a United States
income tax return, the residence where you spend the greatest amount of time will be deemed to be your
place of residence.
Residential treatment facility means a facility that provides (with or without charge) sleeping
accommodations, and:
1. Is not a hospital, extended care facility, or rehabilitation facility; or
2. Is a unit whose beds are not licensed at a level equal to or more acute than skilled nursing.
Respite care means home health care services provided temporarily to an enrollee in order to provide
relief to the enrollee's immediate family or other caregiver.
Routine patient care costs means the costs of any medically necessary health care service for which
benefits are provided under a health benefit plan, without regard to whether the enrollee is participating in
a clinical trial. Routine patient care costs do not include:
1. the cost of an investigational new drug or device that is not approved for any indication by the
United States Food and Drug Administration, including a drug or device that is the subject of the
clinical trial;
2. the cost of a service that is not a health care service, regardless of whether the service is required
in connection with participation in a clinical trial;
29418TX014-2023 29
3. the cost of a service that is clearly inconsistent with widely accepted and established standards of
care for a particular diagnosis;
4. a cost associated with managing a clinical trial; or
5. the cost of a health care service that is specifically excluded from coverage under a health benefit
plan.
Schedule of Benefits means a summary of the deductible, copayment amount, coinsurance amount,
maximum out-of-pocket amount, and other limits that apply when you receive covered services and
supplies.
Self-injectable drugs means prescription drugs that are delivered into a muscle or under the skin with a
syringe and needle. Although medical supervision or instruction may be needed in the beginning, the
patient or caregiver can administer self-injectable drugs safely and effectively.
Serious and complex condition means, in the case of an acute illness, a condition that is serious enough to
require specialized medical treatment to avoid the reasonable possibility of death or permanent harm; or,
in the case of a chronic illness or condition, a condition that is life-threatening, degenerative, potentially
disabling, or congenital; and requires specialized medical care over a prolonged period of time.
Service area means a geographical area, made up of counties, where we have been authorized by the State
of Texas to sell and market our health plans. Those counties are: Andrews, Aransas, Armstrong, Atascosa,
Austin, Bandera, Bastrop, Bell, Bexar, Blanco, Bosque, Brazoria, Brazos, Brewster, Brooks, Brown, Burleson,
Burnet, Caldwell, Calhoun, Cameron, Camp, Carson, Castro, Chambers, Cherokee, Coke, Coleman, Collin,
Collingsworth, Colorado, Comal, Comanche, Concho, Cooke, Dallam, Dallas, Deaf Smith, Delta, Denton,
DeWitt, Donley, Ector, Edwards, El Paso, Ellis, Falls, Fannin, Fayette, Fisher, Fort Bend, Freestone, Frio,
Galveston, Gillespie, Goliad, Gonzales, Gray Grayson, Gregg, Grimes, Guadalupe, Hamilton, Hardin, Harris,
Hartley, Hays, Henderson, Hidalgo, Hill, Hood, Houston, Hunt, Irion, Jack, Jackson, Jefferson, Johnson,
Kendall, Kerr, Kimble, Kinney, Lampasas, Lavaca, Lee, Leon, Liberty, Limestone, Llano, Madison, Mason,
Matagorda, Maverick. McCulloch, McLennan, Medina, Menard, Milam, Mills, Mitchell, Montague,
Montgomery, Nacogdoches, Navarro, Nueces, Oldham, Orange, Palo Pinto, Panola, Parker, Parmer, Potter,
Rains, Randall, Real, Refugio, Robertson, Rockwall, Runnels, Rusk, San Jacinto, San Saba, Schleicher, Scurry,
Sherman, Smith, Somervell, Starr, Sterling, Stonewall, Sutton, Tarrant, Tom Green, Travis, Trinity, Tyler, Val
Verde, Van Zandt, Victoria, Walker, Waller, Webb, Wharton, Wheeler, Willacy, Williamson, Wise, Wood, and
Zapata. You can receive precise service area boundaries from our website or Member Services.
Specialist is a physician who focuses on a specific area of medicine and has additional expertise to help
treat specific disorders or illnesses. Specialists may be needed to diagnose, manage, prevent or treat certain
types of symptoms and conditions related to their specific field of expertise.
Spouse means the person to whom you are lawfully married.
Sub-acute rehabilitation means one or more different types of therapy provided by one or more
rehabilitation licensed practitioners and performed for one-half hour to two hours per day, five to seven
days per week, while the enrollee is confined as an inpatient in a hospital, rehabilitation facility, or extended
care facility.
29418TX014-2023 30
Subscriber means the primary individual who applied for this insurance policy.
Substance use disorder means a disorder that affects a person’s brain and behavior, leading to an inability
to control his/her use of substances (e.g., alcohol, medications and legal or illegal drugs). Symptoms can
range from moderate to severe, with addiction being the most severe form of a substance use disorder.
Substance use disorder benefits are defined as benefits for items or services for substance use disorder
conditions listed in ICD 10 Chapter 5 (F), except for subchapter 1 (F01-09) and subchapter 8 (F70-79).
Surgery or surgical procedure means:

1. An invasive diagnostic procedure; or
2. The treatment of an enrollee's illness or injury by manual or instrumental operations, performed by
a provider while the enrollee is under general or local anesthesia.
Surrogacy arrangement means an understanding in which a woman (the Surrogate) agrees to become
pregnant and carry a child (or children) for another person (or persons) who intend to raise the child (or
children), whether or not the Surrogate receives payment for acting as a Surrogate.
Surrogate means an individual carrier who, as part of a Surrogacy Arrangement, (a) uses her own egg that
is fertilized by a donor or (b) is a gestational carrier who has a fertilized egg placed in her body but the egg
is not her own.
Telehealth service means a health service, other than a telemedicine medical service, or a teledentistry
dental service, delivered by a health professional licensed, certified, or otherwise entitled to practice in this
state and acting within the scope of the health professional's license, certification, or entitlement to a
patient at a different physical location than the health professional using telecommunications or
information technology to facilitate the diagnosis, consultation, treatment, education, care management,
and self-management of a patient's health care.
Telemedicine medical service o means a health care service delivered by a physician licensed in this state,
or a health professional acting under the delegation and supervision of a physician licensed in this state,
and acting within the scope of the physician's or health professional's license to a patient at a different
physical location than the physician or health professional using telecommunications or information
technology to facilitate the diagnosis, consultation, treatment, education, care management, and self-
management of a patient's health care.
Teledentistry dental services means a health care service delivered by a dentist, or a health care
professional acting under the delegation and supervision of a dentist, acting within the scope of the
dentist’s or health professional’s license or certification to a patient at a different physical location than the
dentist or health professional using telecommunications or information technology.
Terminal illness counseling means counseling of the immediate family of a terminally ill person for the
purpose of teaching the immediate family to care for and adjust to the illness and impending death of the
terminally ill person.
29418TX014-2023 31
Terminally ill means a provider has given a prognosis that an enrollee has an advanced stage of disease
with an unfavorable prognosis that, without life-sustaining procedures, will soon result in death or a state
of permanent unconsciousness from which recovery is unlikely.
Third party means a person or other entity that is or may be obligated or liable to the enrollee for payment
of any of the enrollee's expenses for illness or injury. The term “third party” includes, but is not limited to, an
individual person; a for-profit or non-profit business entity or organization; a government agency or
program; and an insurance company. However, the term “third party” will not include any insurance
company with a policy under which the enrollee is entitled to benefits as a named enrollee or an insured
dependent enrollee of a named enrollee except in those jurisdictions where statutes or common law does
not specifically prohibit our right to recover from these sources.
Tobacco or nicotine use or use of tobacco or nicotine means use of tobacco or nicotine by individuals who
may legally use tobacco or nicotine under federal and state law on average four or more times per week
and within no longer than the six months immediately preceding the date enrollment application for this
contract was completed by the enrollee, including all tobacco and nicotine products, e-cigarettes or vaping
devices, but excluding religious and ceremonial uses of tobacco.
Transcranial magnetic stimulation (TMS) means a non-invasive procedure in which a changing magnetic
field is used to cause electric current to flow in a small targeted region of the brain via electromagnetic
induction.
Unproven service(s) means services, including medications, which are determined not to be effective for
treatment of the medical condition, and/or not to have a beneficial effect on health outcomes, due to
insufficient and inadequate clinical evidence from well-conducted randomized controlled trials or well-
conducted cohort studies in the prevailing published peer-reviewed medical literature.
1. “Well-conducted randomized controlled trials” means that two or more treatments are compared to
each other, and the patient is not allowed to choose which treatment is received.
2. “Well-conducted cohort studies” means patients who receive study treatment are compared to a
group of patients who receive standard therapy. The comparison group must be nearly identical to
the study treatment group.
Urgent care center means a facility, not including a hospital emergency room or a provider's office, that
provides treatment or services that are required:
1. To prevent serious deterioration of an enrollee's health; and
2. As a result of an unforeseen illness, injury, or the onset of acute or severe symptoms.
Utilization review means a process used to monitor the use of, or evaluate the clinical necessity,
appropriateness, efficacy, or efficiency of, health care services, procedures, or settings. Areas of review may
include ambulatory review, prior authorization, prospective review, second opinion, certification,
concurrent review, care management, discharge planning, or retrospective review.
29418TX014-2023 32
DEPENDENT ENROLLEE COVERAGE
Dependent Enrollee Eligibility
Your dependent enrollees become eligible for coverage under this contract on the latter of:
1. The date you became covered under this contract;
2. The date of marriage to add a spouse;
3. The date of an eligible newborn’s birth;
4. The date that an adopted child is placed with the enrollee for the purposes of adoption or the
enrollee assumes total or partial financial support of the child;
5. The date of termination that the Health Insurance Marketplace provides us upon your request of
cancellation to the Health Insurance Marketplace, or if you enrolled directly with us, the last day of
the month we receive a request from you to terminate this contract, or any later date stated in your
request will be effective the last day of the requested month but no further than 60 days in
advance;
6. The date a foster child is placed in your custody; or
7. The date a domestic partnership is established, pursuant to state law.
Effective Date for Initial Dependent Enrollees

Dependent enrollees included in the initial enrollment application for this contract will be covered on your
effective date.
Coverage for a Newborn Child

An eligible child born to you or a covered family member will be covered from the time of birth until the
31st day after its birth, unless we have received notice from the entity that you have enrolled (either the
Health Insurance Marketplace or us). Each type of covered service incurred by the newborn child will be
subject to the cost sharing amount listed in the Schedule of Benefits.
Additional premium will be required to continue coverage beyond the 31 st day after the date of birth. The
required premium will be calculated from the child's date of birth. If notice of the newborn is given to us by
the Health Insurance Marketplace within the 31 days from birth, an additional premium for coverage of the
newborn child will be charged for not less than 31 days after the birth of the child. If notice is not given
with the 31 days from birth, we will charge an additional premium from the date of birth. If notice is given
by the Health Insurance Marketplace within 60 days of the birth of the child, we may not deny coverage of
the child due to failure to notify us of the birth of the child or to pre-enroll the child. Coverage of the child
will terminate on the 31st day after its birth, unless we have received notice from the entity in which you
have enrolled (either the Health Insurance Marketplace or us).
Coverage for an Adopted Child

An eligible child legally placed for adoption with you or your spouse will be covered from the date of
placement until the 31st day after placement, unless the placement is disrupted prior to legal adoption and
the child is removed from your or your spouse's custody.
The child will be covered for loss due to injury and illness, including medically necessary care and treatment
of conditions existing prior to the date of placement.
29418TX014-2023 33
Additional premium will be required to continue coverage beyond the 31 st day following placement of the
child and we have received notification from the Health Insurance Marketplace. The required premium will
be calculated from the date of placement for adoption. Coverage of the child will terminate on the 31st day
following placement, unless we have received both: (A) Notification of the addition of the child from the
Health Insurance Marketplace within 60 days of the birth or placement; and (B) any additional premium
required for the addition of the child within 90 days of the date of placement.
As used in this provision, “placement” means the earlier of:
1. The date that you or your spouse assume physical custody of the child for the purpose of adoption;
or
2. The date of entry of an order granting you or your spouse custody of the child for the purpose of
adoption and any child for whom you are a party in a suit in which the adoption of the child is
sought.
Adding Other Dependent Enrollees

If you are enrolled in an off-exchange policy and apply in writing, or directly at enroll.ambetterhealth.com,
to add a dependent enrollee and you pay the required premiums, we will send you written confirmation of
the added dependent enrollee’s effective date of coverage and enrollee identification card for the added
dependent enrollee.
29418TX014-2023 34
ONGOING ELIGIBILITY
For All Enrollees
An enrollee's eligibility for coverage under this contract will cease on the earlier of:
1. The date that an enrollee has failed to pay premiums or contributions in accordance with the terms
of this contract or the date that we have not received timely premium payments in accordance with
the terms of this contract;
2. The primary enrollee residing outside the service area or moving permanently outside the service
area of this contract;
3. The date the enrollee has performed an act or practice that constitutes fraud or made an intentional
misrepresentation of a material fact;
4. The date of termination that the Health Insurance Marketplace provides us upon your request of
cancellation to the Health Insurance Marketplace, or if you enrolled directly with us, the date we
receive a request from you to terminate this contract, or any later date stated in your request;
5. The date we decline to renew this contract, as stated in the Discontinuance provision; or
6. The date of an enrollee’s death.
If you have material modifications (examples include a change in life event such as marriage, death or
other change in family status), or questions related to your health insurance coverage, contact the Health
Insurance Marketplace (Marketplace) at www.healthcare.gov or 1-800-318-2596. If you enrolled through
Ambetter, please contact 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989).
Prior Coverage
If an enrollee is confined as an inpatient in a hospital on the effective date of this contract, and prior
coverage terminating immediately before the effective date of this contract furnishes benefits for the
hospitalization after the termination of prior coverage, then services and benefits will not be covered
under this contract for that enrollee until the enrollee is discharged from the hospital or benefits under the
prior coverage are exhausted, whichever is earlier. “Discharge” means a formal release of an enrollee from
an inpatient hospital stay when the need for continued care at an inpatient hospital has concluded.
Transfers from one inpatient hospital to another shall not be considered a discharge.
If there is no prior coverage or no continuation of Inpatient coverage after the Effective Date, your
Ambetter coverage will apply for covered services related to the Inpatient coverage after your Effective
Date. Ambetter coverage requires you notify Ambetter within two days of your Effective Date so we can
review and Authorize Medically Necessary services. If services are at a non-contracted Hospital, claims will
be paid at the Ambetter allowable and you may be billed for any balance of costs above the Ambetter
allowable.
Open Enrollment
There will be an open enrollment period for coverage on the Health Insurance Marketplace. The open
enrollment period begins November 1, 2022 and extends through January 15, 2023. Qualified individuals
who enroll on or before December 15, 2022 will have an effective date of coverage on January 1, 2023.
29418TX014-2023 35
The Health Insurance Marketplace may provide a coverage effective date for a qualified individual earlier
than specified in the paragraphs above, provided that either:
1. The qualified individual has not been determined eligible for advance premium tax credit or cost
sharing reductions; or
2. The qualified individual pays the entire premium for the first partial month of coverage as well as
all cost sharing, thereby waiving the benefit of advance premium tax credit and cost sharing
reduction payments until the first of the next month. We will send written annual open enrollment
notification to each enrollee no earlier than September 1st, and no later than September 30th.
Special Enrollment
In general, a qualified individual has 60 days to report certain life changes, known as “qualifying
events” to the Health Insurance Marketplace or by using Ambetter’s Enhanced Direct Enrollment
tool. Qualified Individuals may be granted a Special Enrollment Period where they may enroll in
or change to a different Health Insurance Marketplace plan during the current plan year if they
have a qualifying event. Qualifying events include:
1. A qualified individual or dependent experiences a loss of minimum essential coverage, non-calendar
year group or individual health insurance coverage, pregnancy-related coverage, access to health
care services through coverage provided to a pregnant enrollee’s unborn child, or medically needed
coverage;
2. A qualified individual gains a dependent or becomes a dependent through marriage, birth, adoption,
placement for adoption, placement in foster care, or a child support order or other court order. In
the case of marriage, at least one spouse must demonstrate having minimum essential coverage as
described in 26 CFR 1.5000A-1(b) for one or more days during the 60 days preceding the date of
marriage;
3. A qualified individual or dependent, who was not previously a citizen, national, or lawfully present
individual gains such status; or who is no longer incarcerated or whose incarceration is pending
the disposition of charges;
4. A qualified individual’s enrollment or non-enrollment in a plan is unintentional, inadvertent, or
erroneous and is the result of the error, misrepresentation, or inaction of an officer, employee, or
its instrumentalities as evaluated and are determined by the Health Insurance Marketplace;
5. An enrollee or dependent adequately demonstrates to the Health Insurance Marketplace that the
plan in which he or she is enrolled substantially violated a material provision of its contract in
relation to the enrollee;
6. A qualified individual, enrollee, or dependent, adequately demonstrates to the Health Insurance
Marketplace that a material error related to plan benefits, service area, or premium influenced the
qualified individual’s or enrollee’s decision to purchase the QHP;
7. An enrollee or dependent enrolled in the same plan is determined newly eligible or newly ineligible
for advance premium tax credits or has a change in eligibility for cost sharing reductions;
8. A qualified individual or dependent who is enrolled in an eligible employer-sponsored plan is
determined newly eligible for advance premium tax credits based in part on a finding that such
individual is ineligible for qualifying coverage in an eligible-employer sponsored plan in
accordance with 26 CFR §1.36B-2(c)(3);
29418TX014-2023 36
9. A qualified individual, enrollee, or dependent gains access to new QHPs as a result of a permanent
move, and had minimum essential coverage as described in 26 CFR 1.5000A–1(b) for one or more
days during the 60 days preceding the date of the permanent move;
10. A qualified individual or dependent who gains or maintains status as an Indian, as defined by
section 4 of the Indian Health Care Improvement Act, may enroll in a plan or change from
one plan to another one time per month;
11. A qualified individual or enrollee demonstrates to the Health Insurance Marketplace, in
accordance with guidelines issued by Health and Human Services (HHS), that the individual
meets other exceptional circumstances as the Health Insurance Marketplace may provide;
12. A qualified individual, enrollee, or dependent is a victim of domestic abuse or spousal
abandonment as defined by 26 CFR 1.36B–2, and would like to enroll in coverage separate
from the perpetrator of the abuse or abandonment;
13. A qualified individual or dependent is determined to be potentially eligible for Medicaid or
Children’s Health Insurance Program (CHIP), but is subsequently determined to be
ineligible after the open enrollment period has ended or more than 60 days after the
qualifying event; or applies for coverage at the State Medicaid or CHIP agency during the
annual open enrollment period, and is determined ineligible for Medicaid or CHIP after
open enrollment has ended;
14. A qualified individual newly gains access to an employer sponsored Individual Coverage
Health Reimbursement Arrangement (ICHRA) (as defined in 45 CFR 146.123(b)) or a
Qualified Small Employer Health Reimbursement Arrangement (QSHRA) (as defined in
section 9831(d)(2) of the Internal Revenue Code);
15. At the option of the Health Insurance Marketplace, a qualified individual provides
satisfactory documentary evidence to verify his or her eligibility for an insurance
affordability program or enrollment in a plan through the Health Insurance Marketplace
following termination of enrollment due to a failure to verify such status within the time
period specified in 45 C.F.R. § 155.315 or is under 100 percent of the federal poverty level
and did not enroll in coverage while waiting for HHS to verify his or her citizenship, status
as a national, or lawful presence; or
16. A qualified individual or dependent is enrolled in COBRA continuation coverage for which an
employer is paying all or part of the premiums, or for which a government entity is providing
subsidies, and the employer completely ceases its contributions or government subsidies
completely cease.
17. Subject to the availability of enhanced tax subsidies, a qualified individual or enrollee, or their
dependent who is eligible for advance payments of the premium tax credit, and whose household
income is expected to be no greater than 150 percent of the Federal poverty level.
To determine if you are eligible and apply for a Special Enrollment Period, please visit
Healthcare.gov and search for “special enrollment period.” The Health Insurance Marketplace is
responsible for all health care eligibility and enrollment decisions for enrollees who enrolled via the
Marketplace.
If you are currently enrolled in Ambetter from Superior HealthPlan, please contact Member
Services at 1-877-687-1196 with any questions related to your health insurance coverage
29418TX014-2023 37
Coverage Effective Dates for Special Enrollment Periods
Regular effective dates. Except as specified below, coverage will be effective on the first of the
month following plan selection.
Special effective dates. In the case of birth, adoption, placement for adoption, or placement in
foster care, coverage is effective for a qualified individual or enrollee on the date of birth, adoption,
placement for adoption, or placement in foster care. In the case of marriage, or in the case where a
qualified individual loses minimum essential coverage, coverage is effective on the first day of the
following month.
In the case of erroneous enrollment, contract violation, or exceptional circumstances, coverage is

effective on an appropriate date based on the circumstances of the special enrollment period, in
accordance with guidelines issued by the Department of Health and Human Services. Such date
must be either (i) the date of the event that triggered the special enrollment period or (ii) in
accordance with the regular effective dates.
If a qualified individual, enrollee, or dependent loses coverage, gains access to a new QHP, becomes
newly eligible for enrollment in a QHP, becomes newly eligible for advance payments of the
premium tax credit in conjunction with a permanent move, or is enrolled in COBRA continuation
coverage and employer contributions to or government subsidies completely cease, and if the plan
selection is made on or before the day of the triggering event the Health Insurance Marketplace
must ensure that the coverage effective date is the first day of the month following the date of the
triggering event. If the plan selection is made after the date of the triggering event, coverage is
effective on the first day of the following month.
If a qualified individual, enrollee, or dependent newly gains access to an ICHRA or is newly provided
a QSEHRA, and if the plan selection is made before the day of the triggering event, coverage is
effective on the first day of the month following the date of the triggering event or, if the triggering
event is on the first day of a month, on the date of the triggering event. If the plan selection is made
on or after the day of the triggering event, coverage is effective on the first day of the month
following plan selection.
1. If a qualified individual, enrollee, or dependent did not receive timely notice of an event that triggers
eligibility for a special enrollment period, and otherwise was reasonably unaware that a qualifying
event occurred, the Health Insurance Marketplace must allow the qualified individual, enrollee, or
dependent to select a new plan within 60 days of the date that he or she knew, or reasonably should
have known, of the occurrence of the triggering event. And at the option of a qualified individual,
enrollee or dependent, the Health Insurance Marketplace must provide the earliest effective that
would have been available, based on the applicable qualifying event.
29418TX014-2023 38
PREMIUMS
Premium Payment
Each premium is to be paid on or before its due date. The initial premium must be paid prior to the
coverage effective date, although an extension may be provided during the annual Open Enrollment period.
Grace Period
When an enrollee is receiving a premium subsidy:
Grace Period: A grace period of 90 days will be granted for the payment of each premium due after
the first premium. During the grace period, the contract continues in force.
If full payment of premium is not received within the grace period, coverage will be terminated as
of the last day of the first month during the grace period, if advance premium tax credits are
received.
We will continue to pay all appropriate claims for covered services rendered to the enrollee during
the first and second month of the grace period, and may pend claims for covered services rendered
to the enrollee in the third month of the grace period. We will notify Health and Human Services
(HHS) of the non-payment of premiums, the enrollee, as well as providers of the possibility of
denied claims when the enrollee is in the third month of the grace period. We will continue to
collect advance premium tax credits on behalf of the enrollee from the Department of the Treasury,
and will return the advance premium tax credits on behalf of the enrollee for the second and third
month of the grace period if the enrollee exhausts their grace period as described above. An
enrollee is not eligible to re-enroll once terminated, unless an enrollee has a special enrollment
circumstance, such as a marriage or birth in the family or during annual open enrollment periods.
When an enrollee is not receiving a premium subsidy:
Grace Period: A grace period of 60 days will be granted for the payment of each premium due after
the first premium. During the grace period, the contract continues in force.
Premium payments are due in advance, on a calendar month basis. Monthly payments are due on
or before the first day of each month for coverage effective during such month. This provision
means that if any required premium is not paid on or before the date it is due, it may be paid during
the grace period. During the grace period, the contract will stay in force; however, claims may
pend for covered services rendered to the enrollee during the grace period. We will notify the
enrollee, as well as providers, of the possibility of denied claims when the enrollee is in the grace
period.
Third Party Payment of Premium or Cost Sharing

We require each enrollee to pay his or her premiums and this is communicated on your monthly billing
statements. Our payment policies were developed based on guidance from the Centers for Medicare and
29418TX014-2023 39
Medicaid Services (CMS) recommendations against accepting third party premiums. Consistent with CMS
guidance, the following are the ONLY acceptable third parties who may pay premiums on your behalf:
1. Ryan White HIV/AIDS Program under title XXVI of the Public Health Service Act;
2. Indian tribes, tribal organizations or urban Indian organizations;
3. State and Federal Government programs;
4. Family members;
5. An employer for an employee under an Individual Coverage Health Reimbursement Account
(ICHRA) or Qualified Small Employer Health Reimbursement Account (QSEHRA) plan; or
6. Private, not-for-profit foundations which have no incentive for financial gain, no financial
relationship, or affiliation with providers of covered services and supplies on behalf of enrollees,
where eligibility is determined based on defined criteria without regard to health status and where
payments are made in advance for a coverage period from the effective date of eligibility through
the remainder of the calendar year.
Upon discovery that premiums were paid by a person or entity other than those listed above, we will reject
the payment and inform the enrollee that the payment was not accepted and that the premium remains
due.
Misstatement of Age
If an enrollee's age has been misstated, the enrollee’s premium may be adjusted to what it should have been
based on the enrollee’s actual age, we have the right to rerate the contract back to the original effective date.
Change or Misstatement of Residence

If you change your residence, you must notify the Health Insurance Marketplace of your new residence
within 60 days of the change. As a result your premium may change and you may be eligible for a Special
Enrollment Period. See the Special Enrollment Periods provision for more information.
Misstatement of Tobacco or Nicotine Use

The answer to the tobacco or nicotine question on the enrollment application is material to our correct
underwriting. If an enrollee's use of tobacco or nicotine has been misstated on the enrollee's enrollment
application for coverage under this contract, we have the right to rerate the contract back to the original
effective date.
29418TX014-2023 40
COST SHARING FEATURES
Cost Sharing Features
We will pay benefits for covered services as described in the Schedule of Benefits and the covered services
sections of this contract. All benefits we pay will be subject to all conditions, limitations, and cost sharing
features of this contract. Cost sharing means that you participate or share in the cost of your health care
services by paying deductible amounts, copayments and coinsurance for some covered services. For example,
you may need to pay a deductible, copayment or coinsurance amount when you visit your physician or are
admitted into the hospital. The copayment or coinsurance required for each type of service as well as your
deductible is listed in your Schedule of Benefits.
When you, or a covered dependent, receive health care services from a provider, there may be multiple
claims for that episode of care. An episode of care means the services provided by a health care facility or
provider to treat a condition or an illness. Each claim that we receive for services covered under this
contract are adjudicated or processed as we receive them. Coverage is only provided for eligible expenses.
Each claim received will be processed separately according to the cost share as outlined in the contract and
in your Schedule of Benefits.
Deductibles
The benefits of this contract will be available after satisfaction of the applicable deductibles as shown on
your Schedule of Benefits. The deductibles are explained as follows:
Calendar Year Deductible: The individual deductible amount shown under “Deductibles” on your
Schedule of Benefits must be satisfied by each enrollee under your coverage each calendar year.
This deductible, unless otherwise indicated, will be applied to all categories of eligible expenses before
benefits are available under the contract.
The following are exceptions to the deductibles described above:

1. If you have several covered dependents, all charges used to apply toward an “individual” deductible
amount will be applied toward the “family” deductible amount shown in your Schedule of Benefits.
2. When that family deductible amount is reached, no further individual deductibles will have to be
satisfied for the remainder of that calendar year. No enrollee will contribute more than the
individual deductible amounts to the “family” deductible amount.
The deductible amount does not include any copayment amount.
Copayments
A copayment is typically a fixed dollar amount due at the time of service. Enrollees may be required to pay
copayments to a provider each time services are performed that require a copayment. Copayments, as
shown in the Schedule of Benefits, are due at the time of service. Payment of a copayment does not exclude
the possibility of a provider billing you for any non-covered services. Copayments do not count or apply
toward the deductible amount, but do apply toward your maximum out-of-pocket amount.
Coinsurance Stop-Loss Amount

Most of your eligible expense payment obligations, including copayment amounts, are considered
coinsurance amounts and are applied to the coinsurance stop-loss amount maximum.
Your coinsurance stop-loss amount will not include:
1. Services, supplies, or charges limited or excluded by the contract;
29418TX014-2023 41
2. Expenses not covered because a benefit maximum has been reached;
3. Any eligible expenses paid by the primary plan when Ambetter from Superior HealthPlan is the
secondary plan for purposes of coordination of benefits;
4. Any deductibles;
5. Penalties applied for failure to receive authorization;
6. Any copayment amounts paid under the Pharmacy Benefits; or
7. Any remaining unpaid Medical/ Surgical Expense in excess of the benefits provided for covered
drugs.
Individual Coinsurance Stop-Loss Amount

When the coinsurance amount for the network or non-network benefits level for an enrollee in a calendar
year equals the “individual” “coinsurance stop-loss amount” shown on your Schedule of Benefits for that
level, the benefit percentages automatically increase to 100 percent for purposes of determining the
benefits available for additional eligible expenses incurred by that enrollee for the remainder of that
calendar year for that level.
Family Coinsurance Stop-Loss Amount

When the coinsurance amount for the network or non-network benefits level for all enrollees under your
coverage in a calendar year equals the “family” “coinsurance stop-loss amount” shown on your Schedule of
Benefits for that level, the benefit percentages automatically increase to 100 percent for purposes of
determining the benefits available for additional eligible expenses incurred by all family enrollees for the
remainder of that calendar year for that level. No enrollee will be required to contribute more than the
individual coinsurance amount to the family coinsurance stop-loss amount.
Coinsurance Percentage
We will pay the applicable coinsurance in excess of the applicable deductible amount(s) and copayment
amount(s) for a service or supply that:
1. Qualifies as a covered service expense under one or more benefit provisions; and
2. Is received while the enrollee's insurance is in force under the contract if the charge for the service
or supply qualifies as an eligible expense.
When the annual maximum out-of-pocket amount has been met, additional covered service expenses will be
provided or payable at 100 percent of the allowable expense.
The amount provided or payable will be subject to:

1. Any specific benefit limits stated in the contract;
2. A determination of eligible expenses;
3. Any reduction for expenses incurred at a non-network provider.
Please refer to the applicable deductible amount(s), coinsurance amounts, and copayment amounts on your
Schedule of Benefits.
Non-Network Liability and Balance Billing

If you receive services from a non-network provider, you may have to pay more for services you receive.
Non-network providers may be permitted to bill you for the difference between what we agreed to pay and
the full amount charged for a service. This is known as balance billing. This amount is likely more than
network costs for the same service and might not count toward your annual maximum out-of-pocket
amount limit.
29418TX014-2023 42
When receiving care at a network facility, it is possible that some hospital-based providers (for example,
assistant surgeons, hospitalists, and intensivists) may not be under contract with us as network providers.
We encourage you to inquire about the providers who will be treating you before you begin your
treatment, so that you can understand their network participation status with us.
As an enrollee, non-network providers should not bill you for covered services for any amount greater than
your applicable network cost sharing responsibilities when:
1. You receive a covered emergency service or air ambulance service from a non-network provider.
This includes services you may get after you are in stable condition, unless the non-network
provider obtains your written consent.
2. You receive non-emergency ancillary services (emergency medicine, anesthesiology, pathology,
radiology, and neonatology, as well as diagnostic services (including radiology and laboratory
services)) from a non-network provider at a network hospital or network ambulatory surgical
facility.
3. You receive other non-emergency services from a non-network provider at a network hospital or
network ambulatory surgical facility, unless the non-network provider obtains your written consent.
Changing the Deductible

You may increase the deductible to an amount currently available only if enrolled through a special
enrollment period. A request for an increase in the deductible between the first and 15th day of the month
will become effective on the first day of the following month. Requests between the 16 th and last day of the
month will become effective on the first day of the second following month. Your premium will then be
adjusted to reflect this change.
Coverage Under Other Contract Provisions

Charges for services and supplies that qualify as covered service expenses under one benefit provision will
not qualify as covered service expenses under any other benefit provision of this contract.
Health Savings Account (HSA )

A Health Savings Account (HSA) is a special tax-exempt custodial account or trust owned by a member
where contributions to the account may be used to pay for current and future qualified medical expenses.
Please refer to your Schedule of Benefits to see if the plan you are enrolled in has a HSA. For members
enrolled in an HSA compatible plan, the following terms apply.
Individual members must satisfy federal HSA eligibility criteria in order to open and contribute to an HSA.
This contract is administered by and underwritten by Celtic Insurance Company for Ambetter from
Superior Health Plan. Neither entity is an HSA trustee, HSA custodian or a designated administrator for
HSAs. Celtic Insurance Company its designee and its affiliates, including Celtic Insurance Company for
Ambetter from Superior Health Plan., do not provide tax, investment or legal advice to members.
MEMBERS ARE SOLELY RESPONSIBLE FOR ADHERING TO ALL FEDERAL REGULATIONS AND
GUIDELINES CONCERING HSA MAXIMUM ALLOWABLE AMOUNT, CONTRIBUTIONS AND QUALIFIED
WITHDRAWALS. IN ADDITION, EACH MEMBER WITH AN HSA IS RESPONSIBLE FOR NOTIFYING HIS/HER
HSA CUSTODIAN OR TRUSTEE IF ENROLLMENT UNDER THEIR HSA PLAN HAS BEEN CANCELED OR
TERMINATED.
THE TERMS OF THIS CONTRACT ARE CONFINED TO THE BENEFITS PROVIDED HEREIN AND DO NOT
ENCOMPASS ANY INDIVIDIUAL HSA FEE ARRANGEMENTS, ACCOUNT MAINTENANCE OR CONTRIBUTION
29418TX014-2023 43
REQUIREMENTS, APPLICATION PROCEDURES, TERMS, CONDITIONS, WARRANTIES OR LIMITATIONS
THERETO, GRIEVANCES OR CIVIL DISPUTES WITH ANY HSA CUSTODIAN OR TRUSTEE.
PLEASE CONSULT A PROFESSIONAL TAX ADVISOR FOR MORE INFORMATION ABOUT THE TAX
IMPLICATIONS OF A HSA OR HSA PROGRAM.
29418TX014-2023 44
MANAGING YOUR HEALTH CARE
Continuity of Care
Under the No Surprises Act, if an enrollee is receiving a covered service with respect to an network provider
or facility and (1) the contractual relationship with the provider or facility is terminated, such that the
provider or facility is no longer in network; or (2) benefits are terminated because of a change in the terms
of the participation of the provider or facility, as it pertains to the benefit the enrollee is receiving, then we
will (1) notify each enrollee who is a continuing care patient on a timely basis of the termination and their
right to elect continued transitional care from the provider or facility; (2) provide the individual with an
opportunity to notify us of the individual’s need for transitional care; and (3) permit the individual to elect
to continue to have their benefits for the course of treatment relating to the individual’s status as a
continuing care patient during the period beginning on the date on which the above notice is provided and
ending on the earlier of (i) the 90-day period beginning on such date; or the (ii) date on which such
individual is no longer a continuing care patient with respect to their provider or facility.
Non-Emergency Services
If you are traveling outside of the Texas service area you may be able to access providers in another state if
there is an Ambetter plan located in that state. You can locate Ambetter providers outside of Texas by
searching the relevant state in our provider directory at https://guide.ambetterhealth.com. Not all states
have Ambetter plans. If you intend to seek care from an Ambetter provider outside of the service area, you
may be required to obtain prior authorization from the originating Ambetter state for non-emergency
services. Contact Member Services at the phone number on your enrollee identification card for further
information.
Emergency Services Outside of Service Area

We cover emergency services when you are outside of our service area. If you are temporarily out of the
service area and have medical or behavioral health emergency, call 911 or go to the nearest emergency
room. Be sure to call us and report your emergency within one business day. You do not need prior
authorization for emergency services.
New Technology
Health technology is always changing. If we think a new medical advancement can benefit our enrollees, we
evaluate it for coverage. These advancements include:
 New technology
 New medical procedures
 New drugs
 New devices
 New application of existing technology
Sometimes, our medical director and/or medical management staff will identify technological advances
that could benefit our enrollees. The Clinical Policy Committee (CPC) reviews requests for coverage and
decides whether we should change any of our benefits to include the new technology.
If the CPC does not review a request for coverage of new technology, our Medical Director will review the
request and make a one-time determination. The CPC may then review the new technology request at a
future meeting.
Preferred Partnership
As innovative technologies and solutions are established in market under expedited research and
development, we may elect to offer, at our discretion, new services or preferred partnerships designed to
29418TX014-2023 45
improve access to care and enhance care management. Ambetter will provide access to third party
services at preferred or discounted rate. The preferred or discounted rates to these services may be
communicated to all enrollees by email, mail or phone promotions. The preferred partnerships are optional
benefits to all enrollees.
Primary Care Physician (PCP)

You may, but are not required to, select any network PCP who is accepting new patients from any of the
following provider types:
1. Family practitioners
2. General practitioners
3. Internal medicine
4. Nurse practitioners*
5. Physician assistants
6. Obstetricians/gynecologists
7. Pediatricians (for children)
*If you choose a nurse practitioner as your PCP, your benefit coverage and copayment amounts are the
same as they would be for services from other network providers. See your Schedule of Benefits for more
information.
You may obtain a list of network PCPs at our website by using the “Find a Provider” function or by
contacting our Member Services department. You should get to know your PCP and establish a healthy
relationship with them. Your PCP will:
1. Provide preventive care and screenings
2. Conduct regular physical examinations as needed
3. Conduct regular immunizations as needed
4. Deliver timely service
5. Work with other doctors when you receive care somewhere else
6. Coordinate specialty care with network specialists
7. Provide any ongoing care you need
8. Update your medical record, which includes keeping track of all the care that you get from all of
your providers
9. Treat all patients the same way with dignity and respect
10. Make sure you can contact him/her or another provider at all times
11. Discuss what advance directive are and file directives appropriately in your medical record
Your network PCP will be responsible for coordinating all covered health services with other network
providers.
Contacting Your Primary Care Physician (PCP)

To make an appointment with your PCP, call his/her office during business hours and set up a date and
time. If you need to cancel or change your appointment, call 24 hours in advance. At every appointment,
make sure you bring your enrollee identification card and photo identification.
Should you need care outside of your PCP's office hours, you should call your PCP's office for information
on receiving after hours care in your area. If you have an urgent medical problem or question or cannot
reach your PCP during normal office hours, call our 24/7 nurse advice line at 1-877-687-1196 (Relay
Texas/TTY 1-800-735-2989). A licensed nurse is always available and ready to answer your health
questions. In an emergency, call 911 or head straight to the nearest emergency room.
29418TX014-2023 46
Your network PCP will assist you in coordinating all covered health services with other network providers,
if necessary. Should medically necessary covered health care services not be available through network
providers, upon the request of a network PCP, within the time appropriate to the circumstances relating to
the delivery of the health care services and your condition, but in no event to exceed five business days
after receipt of reasonably requested documentation, we shall allow a referral to a non-network provider
and shall fully reimburse the non-network provider at the usual and customary rate or agreed rate.
Changing Your Primary Care Physician (PCP)

You may change your network PCP for any reason, but not more frequently than once a month, by
submitting a written request, online at our website at ambetter.superiorhealthplan.com, or by contacting
Member Services at the number shown on your enrollee identification card. The change to your network
PCP of record will be effective no later than 30 days from the date we receive your request.
Prior Authorization
Ambetter reviews services to ensure the care you receive is the best way to help improve your health
condition. Utilization review includes:
 Pre-service or prior authorization review – occurs when a medical service has been pre-approved
by Ambetter
 Concurrent review – occurs when a medical service is reviewed as they happen (e.g., inpatient stay
or hospital admission)
 Retrospective review – occurs after a service has already been provided.
Some medical, pharmaceutical and behavioral health covered services require prior authorization. In
general, network providers do not need to obtain authorization from us prior to providing a service or
supply to an enrollee. However, there are some covered services for which you must obtain the prior
authorization.
For services or supplies that require prior authorization, as shown on the Schedule of Benefits, you must
obtain authorization from us before you or your dependent enrollee:
1. Receives a service or supply from a non-network provider;
2. Are admitted into a network facility by a non-network provider; or
3. Receives a service or supply from a network provider to which you or your dependent enrollee were
referred by a non-network provider.
We suggest that prior authorization (medical, pharmaceutical and behavioral health) requests are
submitted to us by Provider Portal/efax/phone call as follows:
1. At least five days prior to an elective admission as an inpatient in a hospital, extended care or
rehabilitation facility, hospice facility, or residential treatment facility.
2. At least 30 days prior to the initial evaluation for organ transplant services.
3. At least 30 days prior to receiving clinical trial services.
4. Within 24 hours of any inpatient admission, including emergent inpatient admissions.
5. At least five days prior to the scheduled start of home health services, except those enrollees needing
home health services after hospital discharge.
After prior authorization has been requested and all required or applicable documentation has been
submitted, we will notify you and your provider if the request has been approved as follows:
1. For services that require prior authorization, within three calendar days of receipt.
2. For concurrent review, within 24 hours of receipt of the request.
3. For post-stabilization treatment or life-threatening condition, within the timeframe appropriate to
the circumstances and condition of the enrollee, but not to exceed one hour of receipt of the
request.
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4. For post-service requests, within 30 calendar days of receipt of the request.
Prior Authorization Renewal Process

Medical Management will process requests for prior authorization renewals at least 60 days before the
date the preauthorization expires. As reference in House Bill 3041, 86th Texas Legislature. If the issuer
receives a renewal request before the existing preauthorization expires, the issuer must, if practicable,
review and issue a determination before the existing preauthorization expires.
How to Obtain Prior Authorization

To obtain prior authorization or to confirm that a network provider has obtained prior authorization,
contact us by telephone at the telephone number listed on your enrollee identification card before the
service or supply is provided to the enrollee.
Failure to Obtain Prior Authorization

Failure to comply with the prior authorization requirements will result in benefits being reduced or not
covered.
Network providers cannot bill you for services for which they fail to obtain prior authorization as required.
In cases of emergency, benefits will not be reduced for failure to comply with prior authorization
requirements. However, you must contact us as soon as reasonably possible after the emergency occurs.
Prior Authorization Does Not Guarantee Benefits

Our authorization does not guarantee either payment of benefits or the amount of benefits and is only a
statement that proposed services are medically necessary and appropriate. If a provider materially
misrepresents the proposed medical or health care services, or has substantially failed to perform the
proposed medical or health care services, we may deny or reduce payment to the provider. Eligibility for
and payment of benefits are subject to all terms and conditions of the contract.
Prior Authorization Denials

Refer to the Complaint and Appeals Procedures section of this contract for information on your rights to
appeal a denied authorization.
Hospital Based Providers

When receiving care at a network hospital or other facility, it is possible that some hospital based providers
(for example, assistant surgeons, hospitalists, and intensivists) may not be under contract with us as
network providers. If appropriate notice is provided to and acknowledged by you before rendering services,
you may be responsible for payment of all or part of the fees for those professional services that are not
paid or covered by us – this is known as “balance billing”. We encourage you to inquire about the providers
who will be treating you before you begin your treatment, so you can understand their network status with
us. Any amount you are obligated to pay to the non-network provider in excess of the eligible expense will
not apply to your deductible amount or maximum out-of-pocket .
You may not be balance billed for non-emergency ancillary services (emergency medicine, anesthesiology,
pathology, radiology, and neonatology, as well as diagnostic services (including radiology and laboratory
services)) received from a non-network provider at a network hospital or network ambulatory facility.
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COVERED HEALTH CARE SERVICES AND SUPPLIES
We provide coverage for health care services for you and your covered dependents when received from
network providers. Some services require prior authorization.
Essential health benefits are defined by federal and state law and refer to benefits in at least the following
categories: ambulatory patient services, emergency services, hospitalization, maternity and newborn care,
mental health and substance use disorder services, including behavioral health treatment, prescription
drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness
services and chronic disease management and pediatric services, including oral and vision care. Essential
health benefits provided within this contract are not subject to lifetime or annual dollar maximums.
Certain non-essential health benefits, however, are subject to either a lifetime or annual dollar maximum.
Copayment, deductible and coinsurance amounts must be paid to your network provider at the time you
receive services.
The benefit percentages of your total eligible health care services shown on the Schedule of Benefits in
excess of your copayment amounts, coinsurance amounts, and any applicable deductibles shown are our
obligation. The remaining unpaid Medical/ Surgical Expense in excess of the copayment amounts,
coinsurance amounts, and any deductibles is your obligation to pay.
To calculate your benefits, subtract any applicable copayment amounts and deductibles from your total
eligible Medical/ Surgical Expense and then multiply the difference by the benefit percentage shown on
your Schedule of Benefits. Most remaining unpaid health care services in excess of the copayment amounts
and deductible is your coinsurance amount.
All covered services are subject to conditions, exclusions, limitations, terms and provision of this contract.
Covered services must be medically necessary and not experimental or investigational.
Benefit Limitations
Limitations may also apply to some covered services that fall under more than one covered service category.
Please review all limits carefully. Ambetter from Superior HealthPlan will not pay benefits for any of the
services, treatments, items or supplies that exceed benefit limits.
Acquired Brain Injury Services

Benefits for eligible service expenses incurred for medically necessary treatment of an acquired brain
injury will be determined on the same basis as treatment for any other physical condition. Cognitive
rehabilitation therapy, cognitive communication therapy, neurocognitive therapy and rehabilitation;
neurobehavioral, neuropsychological, neurophysiological and psychophysiological testing and treatment;
neurofeedback therapy, remediation required for and related to treatment of an acquired brain injury,
post-acute transition services and community reintegration services, including outpatient day treatment
services, or any other post-acute treatment services are covered, if such services are necessary as a result
of and related to an acquired brain injury.
29418TX014-2023 49
Treatment for an acquired brain injury may be provided at a hospital, an acute or post-acute rehabilitation
hospital, a skilled nursing facility or any other facility at which appropriate services or therapies may be
provided. Service means the work of testing, treatment, and providing therapies to an individual with an
acquired brain injury. Therapy means the scheduled remedial treatment provided through direct
interaction with the individual to improve a pathological condition resulting from an acquired brain injury.
To ensure that appropriate post-acute care treatment is provided, this plan includes coverage for
reasonable expenses related to periodic reevaluation of the care of an individual covered who:
1. Has incurred an acquired brain injury;
2. Has been unresponsive to treatment;
3. Is medically stable; and
4. To ensure that appropriate post-acute care treatment is provided, this plan includes coverage for
reasonable expenses related to periodic reevaluation of the care of an individual covered with the
expectation that with the provision of these services and support, the person can return to a
community-based setting, rather than reside in a facility setting.
Ambulance Services
Covered service expenses will include ambulance services for ground and water transportation:
1. To the nearest hospital that can provide services appropriate to the enrollee's illness or injury, in
cases of emergency.
2. To the nearest neonatal special care unit for newborn infants for treatment of illnesses, injuries,
congenital birth defects, or complications of premature birth that require that level of care.
3. Transportation between hospitals or between a hospital and skilled nursing, rehabilitation facility,
or hospice facility when authorized by Ambetter from Superior HealthPlan.
4. When ordered by an employer, school, fire or public safety official and the enrollee is not in a
position to refuse; or
5. When an enrollee is required by us to move from a non-network provider to a network provider.
Prior authorization is not required for emergency ambulance transportation. Note: Non-emergency
ambulance transportation requires prior authorization. Unless otherwise required by Federal or State law,
if you receive services from non-network ambulance providers, you may be responsible for costs above the
allowed amount.
Exclusions:
No benefits will be paid for:
1. Expenses incurred for ambulance services covered by a local governmental or municipal body,
unless otherwise required by law.
2. Ambulance services provided for an enrollee's comfort or convenience.
3. Non-emergency transportation excluding ambulances.
Air Ambulance Service Benefits

Covered services will include ambulance services for transportation by fixed wing and rotary wing
ambulance from home, scene of accident, or medical emergency:
1. To the nearest hospital that can provide services appropriate to the enrollee's illness or injury, in
cases of emergency.
29418TX014-2023 50
2. To the nearest neonatal special care unit for newborn infants for treatment of illnesses, injuries,
congenital birth defects, or complications of premature birth that require that level of care.
3. Transportation between hospitals or between a hospital and a skilled nursing, rehabilitation facility,
and enrollee’s home when authorized by Ambetter from Superior HealthPlan.
4. When ordered by an employer, school, fire or public safety official and the enrollee is not in a
position to refuse; or
Prior authorization is not required for emergency ambulance transportation. Note: You should not be
balance billed for services from a non-network ambulance provider, beyond your cost share, for air
ambulance services.
Limitations: Coverage for air ambulance services is limited to the following scenarios:
1. Services requested by police or medical authorities at the site of an emergency.
2. Those situations in which the enrollee is in a location that cannot be reached by ground ambulance.
3. Transportation to the nearest hospital equipped and staffed for treatment of the enrollee’s
condition.
Note: Non-emergency ambulance transportation requires prior authorization.
Exclusions:
No benefits will be paid for:
1. Expenses incurred for air ambulance services covered by a local governmental or municipal body,
unless otherwise required by law.
2. Non-emergency medical transportation.
3. Air medical transportation:
a. Outside of the 50 United States and the District of Columbia;
b. From a country or territory outside of the United States to a location within the 50 United
States or the District of Columbia; or
c. From a location within the 50 United States or the District of Columbia to a country or
territory outside of the United States.
4. Air ambulance services provided for an enrollee's comfort or convenience.
5. Non-emergency transportation excluding ambulances.
Autism Spectrum Disorder Benefits

Generally recognized services prescribed in relation to autism spectrum disorder by the enrollee’s physician
or Behavioral Health Practitioner in a treatment plan recommended by that physician or Behavioral Health
Practitioner.
Individuals providing treatment prescribed under that plan must be a health care practitioner:
1. who is licensed, certified, or registered by an appropriate agency of the state of Texas;
2. whose professional credential is recognized and accepted by an appropriate agency of the United
States; or
3. who is certified as a provider under the TRICARE military health system.
29418TX014-2023 51
For purposes of this section, generally recognized services may include services such as:
1. evaluation and assessment services;
2. applied behavior analysis therapy;
3. behavior training and behavior management;
4. speech therapy;
5. occupational therapy;
6. physical therapy;
7. psychiatric care such as counseling services provided by a licensed psychiatrist, licensed
psychologist, professional counselor or clinical social worker; and
8. medications or nutritional supplements used to address symptoms of autism spectrum disorder.
No limitation exists within the benefits for applied behavior analysis services. These services are subject to
prior authorization to determine medical necessity. If multiple services are provided on the same day
by different providers, a separate copayment and/or coinsurance will apply to each provider.
Eligible expenses, as otherwise covered under this contract, will be available. All provisions of this contract
will apply, including but not limited to, defined terms, limitations and exclusions, prior authorizations and
benefit maximums.
Mental Health and Substance Use Disorder Benefits

The coverage described below is designed to comply with requirements under the Paul Wellstone-Pete
Domenici Mental Health Parity and Addiction Equity Act of 2008 as well as House Bill 10, which was
enacted by the 85th Texas legislature.
Mental health services will be provided on an inpatient and outpatient basis and include mental health
conditions. These conditions affect the enrollee’s ability to cope with the requirements of daily living. If you
need mental health and/or substance use disorder treatment, you may choose any behavioral health
network provider. Deductible amounts, copayment or coinsurance amounts and treatment limits for covered
mental health and substance use disorder benefits will be applied in the same manner as physical health
service benefits.
Covered services for mental health and substance use disorder are included on a non-discriminatory basis
for all enrollees for the diagnosis and medically necessary treatment of mental, emotional, or substance use
disorders as defined in this contract.
When making coverage determinations, our mental health and substance use Utilization Management staff
employ established level of care guidelines and medical necessity criteria that are based on currently
accepted standards of practice and take into account legal and regulatory requirements. They utilize
Change Healthcare InterQual criteria for mental health and substance use disorder determinations.
Services should always be provided in the least restrictive clinically appropriate setting. Any
determination that requested services are not medically necessary will be made by a qualified licensed
mental health professional.
Covered inpatient and outpatient mental health and/or substance use disorder services are as follows:
29418TX014-2023 52
Inpatient
1. Inpatient psychiatric hospitalization;
2. Inpatient detoxification treatment;
3. Crisis stabilization;
4. Inpatient rehabilitation;
5. Residential treatment facility for mental health and substance use disorders; and
6. Electroconvulsive Therapy (ECT).
Outpatient
1. Individual and group therapy for mental health and substance use;
2. Partial Hospitalization Program (PHP);
3. Medication Management services;
4. Psychological and neuropsychological testing and assessment;
5. Applied Behavior Analysis (ABA) for treatment of Autism spectrum disorders;
6. Telehealth services and telemedicine medical services;
7. Electroconvulsive Therapy (ECT);
8. Intensive Outpatient Program (IOP);
9. Mental health day treatment;
10. Outpatient detoxification programs;
11. Evaluation and assessment for mental health and substance use;
12. Medication Assisted Treatment – combines behavioral therapy and medications to treat substance
use disorders;
13. Transcranial Magnetic Stimulation (TMS); and
14. Assertive Community Treatment (ACT).
In addition, Integrated Care Management is available for all of your health care needs, including behavioral
health and substance use disorders. Please call 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989) to be
referred to a care manager for an assessment.
Behavioral health covered services are only for the diagnosis or treatment of mental health conditions and
the treatment of substance use/ chemical dependency.
Expenses for these services are covered, if medically necessary and may be subject to prior authorization.
Please see your Schedule of Benefits for more information regarding services that require prior
authorization and specific benefit limits, if any.
Chiropractic Services
Chiropractic services are covered when a network chiropractor finds that the services are medically
necessary to treat or diagnose neuromusculoskeletal disorders on an outpatient basis. See your Schedule of
Benefits for benefit levels or additional limits. Covered service expenses are subject to all other terms and
conditions of the contract, including the deductible amount and cost sharing provisions.
Dialysis Services
Medically necessary acute and chronic dialysis services are covered services unless other coverage is
29418TX014-2023 53
primary, such as Medicare for dialysis. There are two types of treatment provided you meet all the criteria
for treatment. You may receive hemodialysis in a network dialysis facility or peritoneal dialysis in your
home from a network provider when you qualify for home dialysis.
Covered service expenses and supplies include:

1. Services provided in an outpatient dialysis facility or when services are provided in the home by a
network provider;
2. Processing and administration of blood or blood components;
3. Dialysis services provided in a hospital;
4. Dialysis treatment of an acute or chronic kidney ailment, which may include the supportive use of
an artificial kidney machine.
After you receive appropriate training at a network dialysis facility, we will cover equipment and medical
supplies that you or your caregiver require for home hemodialysis and home peritoneal dialysis. Coverage
is limited to the standard item of equipment or supplies that adequately meets your medical needs. We will
determine if equipment is made available on a rental or purchase basis. At our option, we may authorize
the purchase of the equipment in lieu of its rental if the rental price is projected to exceed the equipment
purchase price, but only from a provider we authorize before the purchase.
Radiology, Imaging and Other Diagnostic Testing

Medically necessary radiology services, imaging and tests performed are a covered service (e.g., X-ray,
Magnetic Resonance Imaging (MRI), Computerized Tomography (CT) scan, Positron Emission Tomography
(PET)/Single Photon Emission Computerized Tomography (SPECT), mammogram, ultrasound). Prior
authorization may be required, see your Schedule of Benefits for details. Note: Depending on the service
performed, two bills may be incurred – both subject to any applicable cost sharing – one for the technical
component (the procedure itself) and another for the professional component (the reading/interpretation
of the results by a physician or other qualified practitioner).
Emergency Room Services and Treatment of Accidental Injury

In an emergency situation (anything that could endanger your life (or your unborn child’s life), you should
call 911 or head straight to the nearest emergency room. We cover emergency medical and behavioral
health services both in and out of our service area. We cover these services 24 hours a day, seven days a
week. Examples of medical emergencies are unusual or excessive bleeding, broken bones, acute abdominal
or chest pain, unconsciousness, convulsions, difficult breathing, suspected heart attack, sudden persistent
pain, severe or multiple injuries or burns, and poisonings.
If reasonably possible, contact your network provider or behavioral health practitioner before going to the
hospital emergency room/treatment room. They can help you determine if you need emergency services or
treatment of an accidental injury and recommend that care. If not reasonably possible, go to the nearest
emergency facility, whether or not the facility is in the network.
Whether you require hospitalization or not, you should notify your network provider or behavioral health
practitioner within 48 hours, or as soon as reasonably possible, of any emergency medical treatment so he
or she can recommend the continuation of any necessary medical services.
29418TX014-2023 54
All treatment received from a non-network provider for an emergency medical condition prior to
stabilization, and including services originating in an emergency facility following treatment or
stabilization of an emergency medical condition, will be treated as covered services received from a
network provider.
Please note some providers that treat you within the emergency room may not be contracted with us. If
that is that case, they may not balance bill you for the difference between our allowed amount and their
billed amount.
Treatment provided by non-network providers after stabilization of the emergency medical condition, and
not originating in the emergency facility, requires prior authorization. We will facilitate transfer to a
network facility for necessary inpatient care following stabilization of an emergency medical condition
treated at a non-network facility. Please notify us as soon as reasonably possible upon receiving treatment
for an emergency medical condition. Unless authorized by us, services received from a non-network
provider following stabilization of an emergency medical condition are not covered services.
Habilitation, Rehabilitation, and Extended Care Facility Expense Benefits

Covered service expenses include services provided or expenses incurred for habilitation or rehabilitation
services or confinement in an extended care facility, subject to the following limitations:
1. Covered service expenses available to an enrollee while confined primarily to receive habilitation or
rehabilitation are limited to those specified in this provision.
2. Rehabilitation services or confinement in a rehabilitation facility or extended care facility must be
determined medically necessary.
3. Covered service expenses for provider facility services are limited to charges made by a hospital,
rehabilitation facility, or extended care facility for:
a. Daily room and board and nursing services.
b. Diagnostic testing.
c. Drugs and medicines that are prescribed by a provider, filled by a licensed pharmacist, and
approved by the United States Food and Drug Administration.
4. Covered service expenses for non-provider facility services are limited to charges incurred for the
professional services of rehabilitation licensed practitioners.
5. Outpatient physical therapy, occupational therapy, and speech therapy.
See your Schedule of Benefits for benefit levels or additional limits.
Care ceases to be rehabilitation upon our determination of any of the following:

1. The enrollee has reached maximum therapeutic benefit.
2. Further treatment cannot restore bodily function beyond the level the enrollee already possesses.
3. There is no measurable progress toward documented goals.
4. Care is primarily custodial care.
Home Health Care Service Expense Benefits

Covered service expenses and supplies for home health care are covered when your physician provides an
order indicating you are not able to travel for appointments to a medical office. Coverage is provided for
medically necessary network care provided at the enrollee’s home and are limited to the following charges:
29418TX014-2023 55
1. Home health aide services, only if provided in conjunction with skilled registered nurse or licensed
practical nursing services.
2. Professional fees of a licensed respiratory, physical, occupational, or speech therapist required for
home health care.
3. Home infusion therapy.
4. Hemodialysis, and for the processing and administration of blood or blood components.
5. Skilled services of a registered nurse or licensed practical nurse rendered on an outpatient basis.
6. Necessary medical supplies.
7. Rental of medically necessary durable medical equipment.
Charges under (3) are covered service expenses to the extent they would have been covered service expenses
during an inpatient hospital stay.
At our option, we may authorize the purchase of the equipment in lieu of its rental if the rental price is
projected to exceed the equipment purchase price, but only from a provider we authorize before the
purchase.
Please refer to the Schedule of Benefits for cost sharing, and any limitations associated with this benefit.
Exclusion:
No benefits will be payable for charges related to respite care, custodial care, personal attendant services or
educational care.
Hospice Care Benefits

This provision only applies to a terminally ill enrollee receiving medically necessary care under a hospice
care program or in a home setting. Respite care is only for services related to hospice care in home and
inpatient locations, and is subject to all forms of cost sharing. Respite care allows temporary relief to family
members from the duties of caring for an enrollee who is undergoing hospice care. Respite days that are
applied toward the enrollee’s cost share obligations are considered benefits provided and shall apply
against any maximum benefit limit for these services.
Covered service expenses include:

1. Room and board in a hospice while the enrollee is an inpatient.
2. Occupational therapy.
3. Speech-language therapy.
4. Respiratory therapy.
5. The rental of medical equipment while the terminally ill enrollee is in a hospice care program to the
extent that these items would have been covered under the contract if the enrollee had been
confined in a hospital.
6. Medical, palliative, and supportive care, and the procedures necessary for pain control and acute
and chronic symptom management.
7. In home dialysis (except when End State Renal Disease (ESRD) is the terminal condition.)
8. Counseling the enrollee regarding his or her terminal illness.
9. Terminal illness counseling of the enrollee's immediate family.
10. Bereavement counseling.
Exclusions and Limitations:
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Hospice care benefits do not include the following:
1. Services received from a provider who is related to an enrollee or dependent enrollees by blood,
marriage or adoption or who is normally a member of the enrollee’s or dependent enrollee’s
household;
2. Services or procedures to cure or prolong life;
3. Services for which any other benefits are payable under this contract;
4. Services or supplies that are used primarily to aid the enrollee or dependent enrollee in daily living;
5. Services for custodial care; and
6. Nutritional supplements, non-prescription drugs or substances, medical supplies, vitamins or
minerals.
Hospital Benefits
Covered service expenses and supplies are limited to charges made by a hospital for:
1. Daily room and board and nursing services, not to exceed the hospital's most common semi-private
room rate.
2. A private hospital room when needed for isolation.
3. Daily room and board and nursing services while confined in an intensive care unit.
4. Inpatient use of an operating, treatment, or recovery room.
5. Outpatient use of an operating, treatment, or recovery room for surgery.
6. Services and supplies, including drugs and medicines, which are routinely provided by the hospital
to persons for use only while they are inpatient.
7. Emergency treatment of an injury or illness, even if confinement is not required. See your Schedule
of Benefits for limitations.
Long Term Acute Care

Long-term acute care hospitals (LTACHs) furnish extended medical and rehabilitative care to individuals
with clinically complex problems, such as multiple acute or chronic conditions, that need hospital-level
care for relatively extended periods.
Common conditions/services that may be considered medically necessary for LTACH level of care
included, but are not limited to:
• Complex wound care:
o Daily physician monitoring of wound
o Wound requiring frequent complicated dressing changes, and possible repeated debridement of
necrotic tissue
o Large wound with possible delayed closure, draining, and/or tunneling or high output fistulas
o Lower extremity wound with severe ischemia
o Skin flaps and grafts requiring frequent monitoring
• Infectious disease:
o Parenteral anti-infective agent(s) with adjustments in dose
o Intensive sepsis management
o Common conditions include osteomyelitis, cellulitis, bacteremia, endocarditis, peritonitis,
meningitis/encephalitis, abscess and wound infections
• Medical complexity:
o Primary condition and at least two other actively treated co-morbid conditions that require
monitoring and treatment
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o Common conditions include metabolic disorders, stroke, heart failure, renal insufficiency,
necrotizing pancreatitis, emphysema (COPD), peripheral vascular disease, and
malignant/end-stage disease
• Rehabilitation:
o Care needs cannot be met in a rehabilitation or skilled nursing facility
o Patient has a comorbidity requiring acute care
o Patient is able to participate in a goal-oriented rehabilitation plan of care
o Common conditions include CNS conditions with functional limitations, debilitation,
amputation, cardiac disease, orthopedic surgery
o Mechanical ventilator support:
o Failed weaning attempts at an acute care facility
o Patient has received mechanical ventilation for 21 consecutive days for 6 hours or
more/day
o Ventilator management required at least every 4 hours as well as appropriate diagnostic
services and assessments
o Patient exhibits weaning potential, without untreatable and/or progressive lung and/or
neurological conditions
o Patient is hemodynamically stable and not dependent on vasopressors
o Respiratory status is stable with maximum PEEP requirement 10 cm H2O, and FiO2 60% or
less with O2 saturation at least 90%
o Common conditions include complications of acute lung injury, disorders of the central
nervous and neuromuscular systems, and cardiovascular, respiratory, and pleural/chest
wall disorders
Patient continues to meet the criteria above and does not meet the criteria to be transitioned to alternate
level of care.
Infertility
Infertility treatment is a covered service expense when medical services are provided to the enrollee which
are medically necessary for the diagnosis of infertility such as diagnostic laparoscopy, endometrial biopsy
and semen analysis. Benefits are included to treat the underlying medical conditions that cause infertility
(such as endometriosis, obstructed fallopian tubes and hormone deficiency). This does not cover treatment
or surgical procedures for infertility including artificial insemination, in vitro fertilization, and other types
of artificial or surgical means of contraception including drugs administered in connection with these
procedures.
Lymphedema
Treatment of lymphedema is covered when rendered or prescribed by a licensed physician or received in a
hospital or other public or private facility authorized to provide lymphedema treatment. Coverage includes
multilayer compression bandaging systems and custom or standard-fit gradient compression garments.
Medical and Surgical Benefits

1. Surgery in a provider's office or at an outpatient surgical facility, including services and supplies.
2. Physician professional services, including surgery.
3. Assistant surgeon.
4. Professional services of a non-physician medical practitioner, including surgery.
5. Medical supplies that are medically necessary, including dressings, crutches, orthopedic splints,
braces, casts, or other necessary medical supplies.
6. Diagnostic testing using radiologic, ultrasonographic, or laboratory services.
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7. Chemotherapy, radiation therapy or treatment (inpatient or outpatient), and inhalation therapy.
8. Hemodialysis, and the charges by a hospital for processing and administration of blood or blood
components.
9. Anesthetic cost and administration.
10. Oxygen and its administration.
11. Cosmetic or plastic surgery for the correction of congenital deformities or for conditions resulting
from accidental injuries, scars, tumors or diseases will be the same as for treatment of any other
illness as shown on your Schedule of Benefits.
12. Reconstructive surgery - The following eligible expenses described below for reconstructive surgery
will be the same as for treatment of any other illness as shown on your Schedule of Benefits:
a. Treatment provided for the correction of defects incurred in an accidental injury sustained
by the enrollee;
b. Treatment provided for reconstructive surgery following cancer surgery;
c. Surgery performed for the treatment or correction of a congenital defect;
d. For the treatment or correction of a congenital defect other than conditions of the breast; or
e. Reconstructive breast surgery charges as a result of a partial or total mastectomy. Coverage
includes surgery and reconstruction of the diseased and non-diseased breast and prosthetic
devices necessary to restore a symmetrical appearance and treatment in connection with
other physical complications resulting from the mastectomy including lymphedemas, are
covered at all stages of mastectomy.
13. Mastectomy or Lymph Node Dissection
Minimum inpatient stay: If due to treatment of breast cancer, any person covered by this contract
has either a mastectomy or a lymph node dissection, this contract will provide coverage for
inpatient care for a minimum of:
a. 48 hours following a mastectomy, and
b. 24 hours following a lymph node dissection.
The minimum number of inpatient hours is not required if the covered enrollee receiving the
treatment and the attending provider determine that a shorter period of inpatient care is
appropriate.
14. Diabetic equipment and supplies that are medically necessary and prescribed by a provider.
15. Tissue transplants.
16. Artificial eyes or larynx, breast prosthesis, or basic artificial limbs (but not the replacement thereof,
unless required by a physical change in the enrollee and the item cannot be modified). If more than
one prosthetic device can meet an enrollee's functional needs, only the charge for the most cost
effective prosthetic device will be considered a covered expense.
17. Genetic blood tests that are medically necessary.
18. Immunizations to prevent Respiratory Syncytial Virus (RSV) that are medically necessary.
19. Rental of Continuous Passive Motion (CPM) machine; one per enrollee following a covered joint
surgery.
20. One pair of eyeglasses or contact lenses per enrollee following a covered cataract surgery.
21. Benefits for speech and hearing services are available for the services of a physician or other
professional provider to restore loss of or correct an impaired speech or hearing function, including
coverage of hearing aids for enrollees and dependent enrollees. See your Schedule of Benefits for
benefit levels or additional limits.
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22. Coverage for medically necessary bone mass measurement and for diagnosis and treatment of
osteoporosis.
23. Medically necessary telehealth services subject to the same clinical and utilization review criteria,
plan requirements and limitations as the same health care services when delivered to an enrollee in
person. Telehealth Services provided by Ambetter Telehealth Vendors are subject to $0 copay.
Telehealth Services not provided by Ambetter Telehealth Vendors would be subject to the same cost
sharing as the same health care services when delivered to an insured in-person. Pursuant to
federal regulation, the $0 cost share does not apply to enrollees enrolled in an HSA-eligible plan.
Please review your Schedule of Benefits to determine if your contract is HSA-eligible.
24. For respiratory and pulmonary therapy.
25. Family planning for certain professional provider contraceptive services and supplies, including
but not limited to vasectomy, tubal ligation and insertion or extraction of FDA-approved
contraceptive devices.
26. Testing of pregnant women and other enrollees for lead poisoning.
27. For pulse oximetry screening on a newborn.
28. Allergy testing, injections and serum.
29. For children’s early intervention therapy for expenses arising from the services of licensed and
credentialed occupational therapists, physical therapists, speech-language pathologists, and clinical
social workers working with children from birth to 36 months of age with an identified
developmental disability and/or delay;
30. Medically necessary routine footcare; prior authorization may be required.
31. Medically necessary nutritional counseling; prior authorization may be required.
Diabetic Care
Benefits are available for medically necessary services and supplies used in the treatment of persons with
gestational, type I or type II diabetes.
Coverage for diabetic care includes the following:

1. Diabetes self-management training;
2. Blood glucose monitors, including noninvasive glucose monitors designed to be used by or adapted
for the legally blind;
3. Test strips specified for use with a corresponding glucose monitor;
4. Lancets and lancet devices;
5. Visual reading strips and urine testing strips and tablets which test for glucose, ketones and
protein;
6. Insulin and insulin analog preparations;
7. Injection aids, including devices used to assist with insulin injection and needleless systems;
8. Insulin syringes;
9. Biohazard disposal containers;
10. Insulin pumps, both external and implantable, and associated appurtenances, which include insulin
infusion devices, batteries, skin preparation items, adhesive supplies, infusion sets, insulin
cartridges, durable and disposable devices to assist in the injection of insulin; and other required
disposable supplies;
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11. Repairs and necessary maintenance of insulin pumps not otherwise provided for under a
manufacturer's warranty or purchase agreement, and rental fees for pumps during the repair and
necessary maintenance of insulin pumps, neither of which shall exceed the purchase price of a
similar replacement pump;
12. Prescription medications and medications available without a prescription for controlling the
blood sugar level;
13. Podiatric appliances, including up to two pairs of therapeutic footwear per calendar year, for the
prevention of complications associated with diabetes;
14. Routine foot care such as trimming of nails and corns;
15. Glucagon emergency kits;
16. On approval of the United States Food and Drug Administration, any new or improved diabetes
equipment or supplies if medically necessary and appropriate as determined by a provider or other
health care practitioner;
17. Eye examination and one retinopathy examination screening per year;
18. Glucometers; and
19. Nutritional counseling.
Durable Medical Equipment, Prosthetics, and Orthotic Devices

The supplies, equipment and appliances described below are covered services under this benefit. If the
supplies, equipment and appliances include comfort, luxury, or convenience items or features which
exceed what is medically necessary in your situation or needed to treat your condition, reimbursement will
be based on the maximum allowed amount for a standard item that is a covered service, serves the same
purpose, and is medically necessary. Any expense that exceeds the maximum allowed amount for the
standard item which is a covered service is your responsibility. For example, the reimbursement for a
motorized wheelchair will be limited to the reimbursement for a standard wheelchair, when a standard
wheelchair adequately accommodates your condition. Repair, adjustment and replacement of purchased
equipment, supplies or appliances as set forth below may be covered, as approved by us. The repair,
adjustment or replacement of the purchased equipment, supply or appliance is covered if:
1. The equipment, supply or appliance is a covered service;
2. The continued use of the item is medically necessary; and
3. There is reasonable justification for the repair, adjustment, or replacement (warranty expiration is
not reasonable justification).
In addition, replacement of purchased equipment, supplies or appliance may be covered if:

1. The equipment, supply or appliance is worn out or no longer functions.
2. Repair is not possible or would equal or exceed the cost of replacement. An assessment by our
habilitation equipment specialist or vendor should be done to estimate the cost of repair.
3. Individual’s needs have changed and the current equipment is no longer usable due to weight gain,
rapid growth, or deterioration of function, etc.
4. The equipment, supply or appliance is damaged and cannot be repaired.
Benefits for repairs and replacement do not include the following:

1. Repair and replacement due to misuse, malicious breakage or gross neglect.
2. Replacement of lost or stolen items.
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We may establish reasonable quantity limits for certain supplies, equipment or appliance described below.
Durable Medical Equipment

The rental (or, at our option, the purchase) of durable medical equipment prescribed by a physician or other
provider. Durable medical equipment is equipment which can withstand repeated use; i.e., could normally
be rented, and used by successive patients; is primarily and customarily used to serve a medical purpose;
is not useful to a person in the absence of illness or injury; and is appropriate for use in a patient’s home.
Examples include but are not limited to wheelchairs, crutches, hospital beds, and oxygen equipment. Rental
costs must not be more than the purchase price. We will not pay for rental for a longer period of time than
it would cost to purchase equipment. The cost for delivering and installing the equipment are covered
services. Payment for related supplies is a covered service only when the equipment is a rental, and
medically fitting supplies are included in the rental; or the equipment is owned by the enrollee; medically
fitting supplies may be paid separately. Equipment should be purchased when it costs more to rent it than
to buy it. Repair of medical equipment is covered.
Covered services and supplies may include, but are not limited to:
1. Hemodialysis equipment.
2. Crutches and replacement of pads and tips.
3. Pressure machines.
4. Infusion pump for IV fluids and medicine.
5. Glucometer.
6. Tracheotomy tube.
7. Cardiac, neonatal and sleep apnea monitors.
8. Augmentive communication devices are covered when we approve based on the enrollee’s
condition.
9. Home INR testing machines.
Exclusions:
Non-covered services and supplies may include, but are not limited to:
1. Air conditioners.
2. Ice bags/coldpack pump.
3. Raised toilet seats.
4. Rental of equipment if the enrollee is in a facility that is expected to provide such equipment.
5. Translift chairs.
6. Treadmill exerciser.
7. Tub chair used in shower.
Medical and Surgical Supplies

Coverage for non-durable medical supplies and equipment for management of disease and treatment of
medical and surgical conditions.
1. Allergy serum extracts.
2. Chem strips, Glucometer, Lancets.
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3. Clinitest.
4. Needles/syringes.
5. Ostomy bags and supplies except charges such as those made by a Pharmacy for purposes of a
fitting are not covered services.
6. Disposable medical supplies, which have a primary medical purpose, are covered and are subject to
reasonable quantity limits as determined by us. Examples include, but are not limited to: bandages
& wraps, gloves, suction catheters, surgical sponges, hypodermic needles, syringes, and applicators.
The supplies are subject to the enrollee’s deductible, copayment, and/or coinsurance amounts.
Exclusions:
1. Adhesive tape, band aids, cotton tipped applicators.
2. Arch supports.
3. Doughnut cushions.
4. Hot packs, ice bags.
5. Vitamins (except as provided for under Preventive Care Expense Benefits provision).
6. Med-injectors.
7. Items usually stocked in the home for general use like Band-Aids, thermometers, and petroleum
jelly.
Orthotic and Prosthetic Devices

We will cover the most appropriate model of orthotic and prosthetic devices that are determined medically
necessary by your treating physician, podiatrist, prosthetist, or orthotist.
Prosthetics
Artificial substitutes for body parts and tissues and materials inserted into tissue for functional or
therapeutic purposes. Covered services include purchase, fitting, needed adjustment, repairs, and
replacements of prosthetic devices and supplies that:
1. Replace all or part of a missing body part and its adjoining tissues; or
2. Replace all or part of the function of a permanently useless or malfunctioning body part.
Prosthetic devices should be purchased not rented, and must be medically necessary. Applicable taxes,
shipping and handling are also covered.
1. Aids and supports for defective parts of the body including but not limited to internal heart valves,
mitral valve, internal pacemaker, pacemaker power sources, synthetic or homograft vascular
replacements, fracture fixation devices internal to the body surface, replacements for injured or
diseased bone and joint substances, mandibular reconstruction appliances, bone screws, plates,
and vitallium heads for joint reconstruction.
2. Left Ventricular Assist Devices (LVAD).
3. Breast prosthesis whether internal or external, following a mastectomy, and four surgical bras per
benefit period, as required by the Women’s Health and Cancer Rights Act. Maximums for prosthetic
devices, if any, do not apply.
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4. Replacements for all or part of absent parts of the body or extremities, such as artificial limbs,
artificial eyes, etc.
5. Intraocular lens implantation for the treatment of cataract or aphakia. Contact lenses or glasses are
often prescribed following lens implantation and are covered services. (If cataract extraction is
performed, intraocular lenses are usually inserted during the same operative session). Eyeglasses
(for example bifocals) including frames or contact lenses are covered when they replace the
function of the human lens for conditions caused by cataract surgery or injury; the first pair of
contact lenses or eyeglasses are covered. The donor lens inserted at the time of surgery are not
considered contact lenses, and are not considered the first lens following surgery. If the injury is to
one eye or if cataracts are removed from only one eye and the enrollee selects eyeglasses and
frames, then reimbursement for both lenses and frames will be covered.
6. Cochlear implant.
7. Colostomy and other ostomy (surgical construction of an artificial opening) supplies directly
related to ostomy care.
8. Restoration prosthesis (composite facial prosthesis).
9. Wigs (not to exceed one per benefit period), when purchased through a network provider. This
coverage is only provided for enrollees who suffer from hair loss as a result of an underlying
medical condition, treatment or injury. Coverage shall be subject to a written recommendation by
the treating physician stating that the wig is medically necessary.
Exclusions:
Non-covered prosthetic appliances may include, but are not limited to:
1. Dentures, replacing teeth or structures directly supporting teeth.
2. Dental appliances (oral appliances, oral sprints, oral orthotics, devices or prosthetics).
3. Devices that prevent or correct defects to the teeth and supporting tissues.
4. Such non-rigid appliances as elastic stockings, garter belts, arch supports and corsets.
5. Wigs (except as described above).
Orthotic Devices
Covered services are the initial purchase, fitting, and repair of a custom made rigid or semi-rigid supportive
device used to support, align, prevent, or correct deformities or to improve the function of movable parts
of the body, or which limits or stops motion of a weak or diseased body part. The cost of casting, molding,
fittings, and adjustments are included. Applicable tax, shipping, postage and handling charges are also
covered. The casting is covered when an orthotic appliance is billed with it, but not if billed separately. We
cover medically necessary corrective footwear. Prior authorization may be required.
Covered orthotic devices may include, but are not limited to, the following:
1. Cervical collars.
2. Ankle foot orthosis.
3. Corsets (back and special surgical).
4. Splints (extremity).
5. Trusses and supports.
6. Slings.
7. Wristlets.
8. Built-up shoe.
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9. Custom made shoe inserts.
Orthotic appliances may be replaced or repaired, unless the repair or replacement is due to misuse or loss
by the enrollee.
Exclusions:
1. Foot support devices, such as arch supports, unless they are an integral part of a leg brace.
2. Standard elastic stockings, garter belts, and other supplies not specially made and fitted (except as
specified under the Medical Supplies provision above).
3. Garter belts or similar devices.
4. Any non-surgical (dental restorations, orthodontics, or physical therapy) or non-diagnostic
services or supplies provided for the treatment of the temporomandibular joint and all adjacent or
related muscles and nerves.
Maternity Care
An inpatient stay is covered for the mother and newborn for at least 48 hours following an uncomplicated
vaginal delivery, and for at least 96 hours following an uncomplicated cesarean delivery. We do not require
that a physician or other health care provider obtain prior authorization for the delivery. However, an
inpatient stay longer than 48 hours for a vaginal delivery or 96 hours for a cesarean delivery will require
notification to us.
Other maternity benefits which may require prior authorization include:

1. Outpatient and inpatient pre- and post-partum care including examinations, prenatal diagnosis of
genetic disorder, laboratory and radiology diagnostic testing, health education, nutritional
counseling, risk assessment, and childbirth classes.
2. Physician home visits and office services.
3. Parent education, assistance, and training in breast or bottle feeding and the performance of any
necessary and appropriate clinical tests.
4. Complications of pregnancy.
5. Hospital stays for other medically necessary reasons associated with maternity care.
6. Medical services or supplies for maternity deliveries at home, required for medical professional or
medically necessary treatment.
Note: This provision does not amend the contract to restrict any terms, limits, or conditions that may
otherwise apply to covered service expenses for childbirth. This provision also does not require an enrollee
to:
1. give birth to a child in a hospital or other health care facility; or
2. remain under inpatient care in a hospital or other health care facility for any fixed term following
the birth of a child.
Duty to Cooperate. We do not cover services or supplies related to enrollees pregnancy when an enrollee is
acting as a surrogate and has entered into a surrogacy arrangement. For more information on excluded
services, please see the General Non Covered Services and Exclusions section. Enrollees who are a
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surrogate at the time of enrollment or enrollees who agree to a surrogacy arrangement during the plan year
must, within 30 days of enrollment or agreement to participate in a Surrogacy Arrangement, send us
written notice of the Surrogacy Arrangement to Superior Health Plan at Member Services, 5900 E. Ben
White Blvd., Austin, Texas 78741. In the event that an enrollee fails to comply with this provision, we
reserve our right to enforce this contract on the bases of fraud, misrepresentation or false information, up
to and including recoupment of all benefits that we paid on behalf of the surrogate during the time that the
surrogate was insured under our contract, plus interest, attorneys' fees, costs and all other remedies
available to us.
Note: This provision does not amend the contract to restrict any terms, limits, or conditions that may
otherwise apply to Surrogates and children born from Surrogates. Please see General Non-Covered
Services and Exclusions section, as limitations may exist.
In the event we cancel or do not renew this contract, there will be an extension of pregnancy benefits for a
pregnancy commencing while the contract is in force and for which benefits would have been payable had
the contract remained in force.
Newborn Charges
Medically necessary services, including hospital services, are provided for a covered newborn child
immediately after birth. Each type of covered service incurred by the newborn child will be subject to
his/her own cost sharing (copayment, coinsurance, deductible and maximum out-of-pocket amount), as
listed in the Schedule of Benefits. Please refer to the Dependent Enrollee Coverage section of this document
for details regarding Coverage for a Newborn Child/Coverage for an Adopted Child.
Newborns’ and Mothers’ Health Protection Act Statement of Rights

Health Insurance Issuers generally may not, under federal law, restrict benefits for any hospital length of
stay in connection with childbirth for the mother or newborn child to less than 48 hours following a
vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does
not prohibit the mother's or newborn's attending provider, after consulting with the mother, from
discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case,
plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or
the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
Other Dental Services

Anesthesia and hospital charges for dental care, for an enrollee less than 19 years of age or an enrollee who
is physically or mentally disabled, are covered if the enrollee requires dental treatment to be given in a
hospital or outpatient ambulatory surgical facility. The indications for general anesthesia, as published in
the reference manual of the American Academy of Pediatric Dentistry, should be used to determine
whether performing dental procedures is necessary to treat the enrollee’s condition under general
anesthesia.
Coverage is also provided for:

1. For medically necessary oral surgery, including the following:
a. Treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia;
b. Orthognathic surgery for a physical abnormality that prevents normal function of the upper and/or
lower jaw bone and is medically necessary to attain functional capacity of the affected part.
29418TX014-2023 66
c. Oral/surgical correction of accidental injuries.
d. Treatment for Temporomandibular Joint Disorder (TMJ), including removable appliances for TMJ
repositioning and related surgery, medical care, and diagnostic services.
e. Treatment of non-dental lesions, such as removal of tumors and biopsies.
f. Incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses.
g. Surgical procedures that are medically necessary to correct disorders caused by (or resulting in) a
specific medical condition such as degenerative arthritis, jaw fractures or jaw dislocations.
h. Reconstructive surgery to correct significant deformities caused by congenital or developmental
abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance.
2. Dental anesthesia charges include coverage for the administration of general anesthesia and hospital
or office charges for dental care, rendered by a dentist, regardless of whether the services are provided
in a participating hospital, surgical center or office, provided to the following enrollees:
a. An enrollee under the age of 19;
b. a person who is severely disabled; or
c. a person who has a medical or behavioral condition which requires hospitalization or general
anesthesia when dental care is provided.
3. For dental service expenses when an enrollee suffers an injury, that results in:
a. Damage to his or her natural teeth;
b. Expenses are incurred within six months of the accident or as part of a treatment plan that was
prescribed by a health care professional and began within 12 months of the accident to be
considered as a covered service; and
c. Injury to the natural teeth will not include any injury as a result of chewing.
4. For surgery, excluding tooth extraction, to treat craniomandibular disorders, or malocclusions.
Second Medical Opinion

Enrollees are entitled to a second medical opinion under the following conditions:
1. Whenever a minor surgical procedure is recommended to confirm the need for the procedure;
2. Whenever a serious injury or illness exists; or
3. Whenever you find that you are not responding to the current treatment plan in a satisfactory
manner.
If requested, the second opinion consultation is to be provided by a physician of the enrollee’s choice. The
enrollee may select a network provider listed in the Provider Directory. If an enrollee chooses a network
provider, he or she will only be responsible for the applicable copayment amount for the consultation. Any
lab tests and/or diagnostic and therapeutic services are subject to the additional cost sharing. If a second
medical opinion is obtained by a non-network provider, prior authorization must be obtained before
services are considered an eligible expense. If prior authorization is not obtained for a second medical
opinion from a non-network provider, you will be responsible for the related expenses.
Clinical Trial Coverage

Clinical Trial Coverage includes routine patient care costs incurred as the result of an approved phase I, II,
III or phase IV clinical trial and the clinical trial is undertaken for the purposes of prevention, early
detection, or treatment of cancer or other life-threatening disease or condition. Coverage will include
routine patient care costs incurred for (1) drugs and devices that have been approved for sale by the United
States Food and Drug Administration (FDA), regardless of whether approved by the FDA for use in treating
the patient’s particular condition, (2) reasonable and medically necessary services needed to administer the
drug or use the device under evaluation in the clinical trial and (3) all items and services that are
otherwise generally available to a qualified individual that are provided in the clinical trial except:
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1. The investigational item or service itself;
2. Items and services provided solely to satisfy data collection and analysis needs and that are not used
in the direct clinical management of the patient; and
3. Items and services customarily provided by the research sponsors free of charge for any enrollee in
the trial.
Phase I and II clinical trials must meet the following requirements:

1. Phase I and II of a clinical trial is approved or funded by one or more of the following:
a. The National Institutes of Health;
b. The Centers for Disease Control and Prevention;
c. The Agency for Health Care Research and Quality;
d. The Centers for Medicare & Medicaid Services;
e. Cooperative group or center of any of the entities described in clauses (a) through (d) or the
Department of Defense or the Department of Veterans Affairs;
f. A qualified non-governmental research entity identified in the guidelines issued by the
National Institutes of Health for center support grants;
g. The study or investigation is conducted under an investigational new drug application
reviewed by the United States Food and Drug Administration;
h. The study or investigation is a drug trial that is exempt from having such an investigational
new drug application; and
2. The enrollee is enrolled in the clinical trial. This section shall not apply to enrollees who are only
following the protocol of phase I or II of a clinical trial, but not actually enrolled.
Phase III and IV clinical trials must be approved or funded by one of the following entities:
1. One of the National Institutes of Health (NIH);
2. The Centers for Disease Control and Prevention;
3. The Agency for Health Care Research and Quality;
4. The Centers for Medicare & Medicaid Services;
5. An NIH Cooperative Group or Center;
6. The FDA in the form of an investigational new drug application;
7. The federal Departments of Veterans’ Affairs, Defense, or Energy;
8. An institutional review board in this state that has an appropriate assurance approved by the
Department of Health and Human Services assuring compliance with and implementation of
regulations for the protection of human subjects; or
9. A qualified non-governmental research entity that meets the criteria for NIH Center support grant
eligibility.
In a clinical trial, the treating facility and personnel must have the expertise and training to provide the
treatment and treat a sufficient volume of patients. There must be equal to or superior, non-investigational
treatment alternatives and the available clinical or preclinical data must provide a reasonable expectation
that the treatment will be superior to the non-investigational alternatives.
Providers participating in clinical trials shall obtain a patient’s informed consent for participation in the
clinical trial in a manner that is consistent with current legal and ethical standards. Such documents shall
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be made available to us upon request.
Prescription Drug Benefits

Covered service expenses and supplies in this benefit subsection are limited to charges from a licensed
pharmacy for:
1. A prescription drug.
2. Any drug that, under the applicable state law, may be dispensed only upon the written prescription
of a medical practitioner.
3. For any other use of a drug approved by the FDA when the drug has not been approved by the FDA
for the treatment of the particular indication for which the drug has been prescribed, provided
such drug is recognized for treatment of such indication in one of the standard reference
compendia or in the medical literature as recommended by current American Medical Association
(AMA) policies. Any coverage of a drug required shall also include medically necessary services
associated with the administration of the drug. This benefit shall not be construed to require:
a. Coverage for any drug if the FDA has determined its use to be contraindicated for the
treatment of the particular indication for which the drug has been prescribed;
b. Coverage for experimental or investigational drugs not approved for any indication by the
FDA; and
c. Reimbursement or coverage for any drug not included on the drug formulary or list of
covered drugs specified in this policy.
4. Off-label drugs that are:
a. Recognized for treatment of the indication in at least one (1) standard reference
compendium; or
b. Recommended for a particular type of cancer and found to be safe and effective in formal
clinical studies, the results of which have been published in a peer reviewed professional
medical journal published in the United States or Great Britain.
5. Prescribed, oral anticancer medication.
Such covered service expenses shall include those for prescribed, orally administered anticancer medications.
The covered service expenses shall be no less favorable than for intravenously administered or injected
cancer medications that are covered as medical benefits under this contract.
Maximum Insulin Medication Cost Share:

Insulin medications are covered with a maximum cost share of $25 per prescription for a 30-day supply. If
your cost share per 30-day supply of insulin medications is less than $25, you will be responsible for the
lower amount. Please refer to our formulary for tier placement of insulin medications and your Schedule of
Benefits for your cost share responsibility for the associated drug tier. The total amount you will be
required to pay for a covered insulin drug will not exceed any state and/or federally mandated limits.
Emergency refills of insulin and insulin-related equipment will be covered in the same manner as non-
emergency refills.
Formulary or Preferred Drug List

The formulary or preferred drug list is a guide to available generic and brand name drugs and some over-
the-counter medications when ordered by a physician that are approved by the United States Food and
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Drug Administration (FDA) and covered through your prescription drug benefit. Generic drugs have the
same active ingredients as their brand name counterparts and should be considered the first line of
treatment. The FDA requires generics to be safe and work the same as brand name drugs. If there is no
generic available, there may be more than one brand name drug to treat a condition. Preferred brand name
drugs are listed on Tier 2 of the Drug List to help identify brand name drugs that are clinically appropriate,
safe and cost effective treatment options, if a generic medication on the formulary is not suitable for your
condition.
Please note, the formulary is not meant to be a complete list of the drugs covered under your prescription
benefit. Not all dosage forms or strengths of a drug may be covered. This list is periodically reviewed and
updated and may be subject to change. Drugs may be added or removed or additional requirements may be
added in order to approve continued usage of a specific drug.
Specific prescription benefit plan designs may not cover certain products or categories, regardless of their
appearance in the formulary. For the most current Ambetter Formulary or Preferred Drug List or for more
information about our pharmacy program, visit Ambetter.SuperiorHealthPlan.com (under “For Members”,
“Drug Coverage”) or call Member Services at 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989).
Formulary means our list of covered drugs available on our website at Ambetter.SuperiorHealthPlan.com
or by calling Member Services. The drug formulary (approved drug list) is a list of prescription drugs that
are covered by this contract. The formulary includes drugs for a variety of disease states and conditions.
Periodically, the formulary is reviewed and updated to assure that the most current and clinically
appropriate drug therapies are being used. Sometimes it is medically necessary for an enrollee to use a
drug that is not on the formulary, or has been removed from the formulary. When this occurs, the
prescribing provider may request an exception for coverage through Member Services. For a list of
covered drugs please visit Ambetter.SuperiorHealthPlan.com or contact Member Services. In addition,
some covered drugs on the formulary may require prior authorization to ensure it is clinically appropriate
for an enrollee.
The appropriate drug choice for an enrollee is a determination that is best made by the enrollee and his or
her physician.
Coverage is provided for any prescription drug that was approved or covered under our formulary for a
medical condition or mental illness, regardless of whether the drug has been removed from our drug
formulary, at the contracted benefit level until the contract renewal date.
Certain specialty and non-specialty generic medications may be covered at a higher cost share than other
generic products. Please reference the formulary and Schedule of Benefits for additional information. For
purposes of this section, the tier status as indicated by the formulary will be applicable.
You will not be required to pay more than the applicable copayment, allowable claim amount, or amount
required without insurance or discounts at the time of purchase.
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For prescription eye drops to treat a chronic eye disease or condition, refills are dispensed on or before the
last day of the prescribed dosage period, but not earlier than the following:
1. 21st day after the date a prescription for a 30-day supply of eye drops is dispensed;
2. 42nd day after the date a prescription for a 60-day supply of eye drops is dispensed; or
3. 63rd day after the date a prescription for a 90-day supply of eye drops is dispensed.
Please note: We will provide a 30-day notice prior to the discontinuance of concurrent prescription drugs
and intravenous infusions.
Over-the-Counter (OTC) Prescriptions

We cover a variety of over-the-counter (OTC) medications when ordered by a physician. You can find a list
of covered over-the-counter medications in our formulary – they will be marked as “OTC”. Your
prescription order must meet all legal requirements.
How to Fill a Prescription

Prescription orders can be filled at a network retail pharmacy or through our mail order pharmacy.
If you decide to have your prescription order filled at a network pharmacy, you can use the Provider
Directory to find a pharmacy near you. You can access the Provider Directory at
Ambetter.SuperiorHealthPlan.com on the Find a Provider page. You can also call Member Services to help
you find a pharmacy. At the pharmacy, you will need to provide the pharmacist with your prescription
order and your enrollee identification card.
We also offer a three-month (90-day) supply of maintenance medications by mail or from network retail
pharmacies for specific benefit plans. These drugs treat long-term conditions or illnesses, such as high
blood pressure, asthma and diabetes. You can find a list of covered medications on
Ambetter.SuperiorHealthPlan.com. You can also request to have a copy mailed directly to you.
Mail Order Pharmacy

If you have more than one prescription you take regularly, you may select to enroll in our mail order
delivery program. Your prescriptions will be safely delivered right to your door at no extra charge to you.
You will still be responsible for your regular copayment/coinsurance. To enroll for mail order delivery or
for any additional questions, call our mail order pharmacy at 1-888-624-1139 or 1-800-552-6694.
Alternatively, you can find instructions on how to enroll on our Ambetter website. Once on our website,
click on the section, “For Member,” “Drug Coverage.” The enrollment form will be located under “Forms.”
Self-injectable Drugs
Self-injectable drugs are delivered into a muscle or under the skin with a syringe and needle. Although
medical supervision or instruction may be needed in the beginning, the patient or caregiver can administer
self-injectable drugs safely and effectively. Self-injectable drugs are covered under the prescription drug
benefits; prescription drug cost share applies.
Step Therapy
The step-therapy does not apply to prescription drugs associated with the treatment of stage-four
advanced, metastatic cancer or associated conditions.
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Non-Formulary and Tiered Formulary Contraceptives:
Under the Affordable Care Act, you have the right to obtain contraceptives that are not listed on the
formulary (otherwise known as “non-formulary drugs”) and tiered contraceptives (those found on a
formulary tier other than “Tier 0 – no cost share”) at no cost to you on you or your medical practitioner’s
request. To exercise this right, please get in touch with your medical practitioner. Your medical
practitioner can utilize the usual prior authorization request process. See “ Prescription Drug Exception
Process” below for additional details.
Non-Formulary Prescription Drugs:

Under the Affordable Care Act, you have the right to request coverage of prescription drugs that are not
listed on our formulary (otherwise known as “non-formulary drugs”). To exercise this right, please get in
touch with your medical practitioner. Your medical practitioner can utilize the usual prior authorization
request process. See “Prior Authorization” below for additional details.
Prescription Drug Synchronization

Under Texas law, you have the right to request synchronization of your medications. Synchronization is
alignment of your fill dates so that all of your medication-refill dates are on the same day. For example, if
you fill medication A on the fifth of each month and your prescriber prescribes you a new prescription B on
the 20th of the month, you have the right to request a refill for prescription B that is shorter or longer than
30 days. This may help you adjust your fill dates for medication B and synchronize the fill dates with
medication A. We will adjust copays to reflect shorter or longer coverage. If you would like to exercise this
right, please call Member Services.
Prescription Drug Exception Process

Standard exception request
An enrollee, an enrollee’s authorized representative or an enrollee’s prescribing provider may request a
standard review of a decision that a drug is not covered by this contract. The request can be made in
writing or by telephone. Within 72 hours of the request being received, we will provide the enrollee, the
enrollee’s authorized representative or the enrollee’s prescribing provider with our coverage determination.
If we do not deny a standard exception request within 72 hours, the request is considered granted. Should
the standard exception request be granted, we will provide coverage of the non-formulary drug for the
duration of the prescription, including refills.
Expedited exception request

An enrollee, an enrollee’s authorized representative or an enrollee’s prescribing provider may request an
expedited review based on exigent circumstances. Exigent circumstances exist when an enrollee is
suffering from a health condition that may seriously jeopardize the enrollee's life, health, or ability to
regain maximum function or when an enrollee is undergoing a current course of treatment using a non-
formulary drug. Within 24 hours of the request being received, we will provide the enrollee, the enrollee’s
authorized representative or the enrollee’s prescribing provider with our coverage determination. If we do
not deny an expedited exception request within 24 hours, the request is considered granted. Should the
expedited exception request be granted, we will provide coverage of the non-formulary drug for the
duration of the exigency.
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External exception request review
If we deny a request for a standard exception or for an expedited exception, the enrollee or the enrollee’s
authorized representative may request that the denial of such request be reviewed by an external review
organization. The external review organization will make the determination on the denied exception
request and notify the enrollee or the enrollee’s authorized representative of the coverage determination no
later than 72 hours following receipt of the request, if the original request was a standard exception, and
no later than 24 hours following its receipt of the request, if the original request was an expedited
exception.
If we or the external review organization grants an exception for a standard or expedited exception
request, we will provide coverage of the non-formulary drug for the duration of the exigency.
Exception to step therapy or fail first protocol:

We will grant an exception to step therapy or fail first protocol when:
a. The drug required under the step therapy protocol:
1. Is contraindicated;
2. Will likely cause an adverse reaction in or physical or mental harm to the patient;
3. Is expected to be ineffective based on the known clinical characteristics of the patient and
the known characteristics of the prescription drug regimen;
4. The patient previously discontinued taking the drug required under the step therapy
protocol, or another prescription drug in the same pharmacologic class or with the same
mechanism of action as the required drug, while under the health benefit plan currently in
force or while covered under another health benefit plan because the drug was not effective
or had a diminished effect or because of an adverse event;
5. The drug required under the step therapy protocol is not in the best interest of the patient,
based on clinical appropriateness, because the patient's use of the drug is expected to:
1) Cause a significant barrier to the patient's adherence to or compliance with the
patient's plan of care;
2) Worsen a comorbid condition of the patient; or
3) Decrease the patient's ability to achieve or maintain reasonable functional ability
in performing daily activities.
6. The drug that is subject to the step therapy protocol was prescribed for the patient's
condition and:
1) The patient received benefits for the drug under the health benefit plan currently
in force or a previous health benefit plan;
2) The patient is stable on the drug; and
3) The change in the patient's prescription drug regimen required by the step
therapy protocol is expected to be ineffective or cause harm to the patient based
on the known clinical characteristics of the patient and the known characteristics
of the required prescription drug regimen.
For product approved under this section we will issue an approval letter outlining coverage under this
contract. For any product denied under this section, you have the right to appeal our decision. Any product
requested under this section will be reviewed within 72 hours of receipt of the request for standard
requests and within 24 hours of receipt of urgent or exigent request. If we fail to respond to a step therapy
request with 24 hours for urgent and 72 hour for standard requests, such requests will be automatically
approved.
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Non-Covered Services and Exclusions:
No benefits will be paid under this benefit provision for services provided or expenses incurred:
1. For prescription drug treatment of erectile dysfunction or any enhancement of sexual performance
unless such treatment is listed on the formulary.
2. For weight loss prescription drugs unless otherwise listed on the formulary.
3. For immunization agents otherwise not required by the Affordable Care Act.
4. For medication that is to be taken by the enrollee, in whole or in part, at the place where it is
dispensed.
5. For medication received while the enrollee is a patient at an institution that has a facility for
dispensing pharmaceuticals.
6. For a refill dispensed more than 12 months from the date of a physician's order.
7. For more than the predetermined managed drug limitations assigned to certain drugs or
classification of drugs.
8. For a prescription order that is available in over-the-counter form, or comprised of components
that are available in over-the-counter form, and is therapeutically equivalent, except for over-the-
counter products that are listed on the formulary.
9. For drugs labeled "Caution - limited by federal law to investigational use" or for investigational or
experimental drugs.
10. For any drug that we identify as therapeutic duplication through the Drug Utilization Review
program.
11. For more than a 30-day supply when dispensed in any one prescription or refill or for maintenance
drugs up to a 90-day supply when dispensed by mail order or a pharmacy that participates in
extended day supply network. Specialty drugs and other select drug categories are limited to 30-
day supply when dispensed by retail or mail order. Please note that only the 90 day supply is
subject to the discounted cost sharing. Ambetter permits pharmacies to dispense at mail order
discounted cost sharing should they request to join our mail order network and accept all terms
and conditions. Mail orders less than 90 days are subject to the standard cost sharing amount.
12. Foreign Prescription Medications, except those associated with an Emergency Medical Condition
while you are traveling outside the United States. These exceptions apply only to medications with
an equivalent FDA-approved Prescription Medication that would be covered under this document
if obtained in the United States.
13. For prevention of any diseases that are not endemic to the United States, such as malaria, and
where preventative treatment is related to enrollee’s vacation during out of country travel. This
section does not prohibit coverage of treatment for aforementioned diseases.
14. For medications used for cosmetic purposes.
15. For infertility drugs unless otherwise listed on the formulary.
16. For any controlled substance that exceeds state established maximum morphine equivalents in a
particular time period, as established by state laws and regulations.
17. For drugs or dosage amounts determined by Ambetter’s Pharmacy and Therapy committee to be
ineffective, unproven, or unsafe for the indication for which they have been prescribed, regardless
of whether such drugs or dosage amounts have been approved by any governmental regulatory
body for that use.
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18. For any drug related to dental restorative treatment or treatment of chronic periodontitis, where
drug administration occurs at dental practitioner’s office.
19. For any drug related to surrogate pregnancy.
20. For any injectable medication or biological product that is not expected to be self-administered by
the enrollee at enrollee’s place of residence unless listed on the formulary.
21. For any claim submitted by non-lock-in pharmacy while enrollee is in lock-in status. To facilitate
appropriate benefit use and prevent opioid overutilization, enrollee’s participation in lock-in status
will be determined by review of pharmacy claims.
22. For any prescription or over the counter version of vitamin(s) unless otherwise included on the
formulary.
23. Medication refills where an enrollee has more than 15 days' supply of medication on hand.
24. Compound drugs, unless there is at least one ingredient that is an FDA approved drug.
Lock-in program
To help improve enrollee safety, decrease overutilization and abuse, certain enrollees identified through
our Lock-in Program, may be locked into a specific pharmacy for the duration of their participation in the
lock-in program. Enrollees locked into a specific pharmacy will be able to obtain their medication(s) only at
specified location. Ambetter pharmacy, together with Medical Management will review enrollee profiles
and using specific criteria, will recommend enrollees for participation in lock-in program. Enrollees
identified for participation in lock-in program and associated providers will be notified of enrollee
participation in the program via mail. Such communication will include information on duration of
participation, pharmacy to which enrollee is locked-in, and any appeals rights.
Medication Balance-On-Hand
Medication refills are prohibited until an enrollee’s cumulative balance-on-hand is equal to or fewer than
15 days' supply of medication. This provision operates in addition to any applicable medication quantity
limit or refill guidelines.
Split-Fill Dispensing Program

Enrollees are limited to 15-day supplies for the first 90 days when starting new therapy using certain
medications (like oral oncology). Enrollees pay half the 30-day cost-share for a 15-day supply, and would
be responsible for the other half of the 30-day cost share for each additional 15-day supply. After 90 days,
enrollees will fill their medications for 30-day supplies.
Medical Foods
We cover medical foods and formulas when medically necessary for the treatment of Phenylketonuria
(PKU) or other heritable diseases regardless of the formula delivery method. Coverage for inherited
diseases of amino acids and organic acids shall, in addition to the enteral formula, include food products
modified to be low protein. Such coverage shall be provided when the prescribing physician has issued a
written order stating that the enteral formula or food product is medically necessary.
Exclusions: any other non-medical dietary formulas, oral nutritional supplements, special diets, prepared
foods/meals and formula for access problems.
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Preventive Care Services
Preventive care services are covered as required by the Affordable Care Act (ACA). According to the ACA,
preventive care services must include the following:
1. Evidence based items or services that have in effect a rating of A or B in the current
recommendations of the United States Preventive Services Task Force (USPSTF).
2. Immunizations for routine use in children, adolescents and adults that have in effect a
recommendation from the Advisory Committee on Immunization Practices (ACIP) of the Centers
for Disease Control and Prevention (CDC).
3. With respect to infants, children and adolescents, evidence-informed preventive care and
screenings provided for in the comprehensive guidelines supported by the Health Resources and
Services Administration (HRSA).
4. With respect to women, such additional preventive care and screenings as provided for in
comprehensive guidelines supported by the HRSA.
Preventive care benefits obtained from a network provider are covered without enrollee cost share (i.e.,
covered in full without deductible, coinsurance or copayment). For current information regarding available
preventive care benefits, please access the Federal Government's website at: www.healthcare.gov/
coverage/preventive-care-benefits/ .
Preventive care refers to services or measures taken to promote health and early detection or prevention
of diseases and injuries, rather than treating or curing them. Preventive care includes, but is not limited to,
immunizations, medications, tobacco cessation treatment, examinations and screening tests tailored to an
individual’s age, health and family history.
Certain services can be performed for preventive or diagnostic reasons (e.g., mammograms). If a service is
deemed preventive care and is appropriately reported/billed, it will be covered under the preventive care
services benefit. However, when a service is performed for diagnostic purposes and reported/billed
accordingly, it will be considered a non-preventive medical benefit and appropriate cost share will apply.
Note: If preventive and diagnostic services are performed during the same visit, applicable cost share will
be taken for the latter.
As new preventive care recommendations and guidelines are issued (by the USPSTF, CDC or HRSA), those
services will become covered preventive care benefits. According to the ACA, coverage of new
recommendations and guidelines become effective upon a plan’s start or anniversary date that is one year
after the date the recommendation or guideline is issued.
Note: In addition to providing coverage in accordance with the ACA, we also provide preventive care
benefits in accordance with applicable State law.
Notification
As required by section 2715(d)(4) of the Public Health Service Act, we will provide 60 days advance notice
to you before any material modification will become effective, including any changes to preventive benefits
covered under this contract. You may access our website or the Member Services Department at 1-877-
687-1196 to get the answers to many of your frequently asked questions regarding preventive services.
Our website has resources and features that make it easy to get quality care. Our website can be accessed
at ambetter.superiorhealthplan.com.
Covered Preventive Care Services for Children including:

1. Autism screening;
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2. Behavioral assessments for children of all ages. Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11
to 14 years, 15 to 17 years;
3. Developmental screening for children under age 3, and surveillance throughout childhood;
4. Fluoride Chemoprevention supplements for children without fluoride in their water source;
5. Lead screening for children at risk of exposure;
6. Tuberculin testing;
7. Obesity screening and counseling; and
8. Oral Health risk assessment for young children. Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years.
Covered Preventive Care Services for Women, Including Pregnant Women:

1. Anemia screening on a routine basis for pregnant women;
2. BRCA counseling about genetic testing for women at higher risk;
3. Breastfeeding comprehensive support and counseling from trained providers, as well as access to
breastfeeding supplies, for pregnant and nursing women;
4. Contraceptive care;
5. Domestic and interpersonal violence screening and counseling for all women;
6. Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of
developing gestational diabetes;
7. Gonorrhea screening for all women at higher risk;
8. Hepatitis B screening for pregnant women at their first prenatal visit;
9. Human Immunodeficiency Virus (HIV) screening and counseling for sexually active women;
10. Human Papillomavirus (HPV) DNA Test: high risk HPV DNA testing every three years for women
with normal cytology results who are 30 or older;
11. Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher
risk;
12. Sexually Transmitted Infections (STI) counseling for sexually active women;
13. Well-woman visits; and
14. Tobacco or nicotine use screening and interventions for all enrollees, and expanded counseling for
pregnant tobacco users.
Covered Preventive Services for Adults including:

1. Alcohol Misuse screening and counseling;
2. Blood Pressure screening for all adults;
3. Depression screening for adults;
4. Type 2 Diabetes screening for adults with high blood pressure;
5. HIV screening for all adults at higher risk;
6. Obesity screening and counseling for all adults;
7. Tobacco or nicotine use screening for all adults and cessation interventions for tobacco or nicotine
users;
8. Syphilis screening for all adults at higher risk; and
9. Colorectal cancer tests for any non-symptomatic covered person, in accordance with the current
American Cancer Society guidelines. Covered services include tests for covered persons, starting at
age 45 (note: screening should start before age 45 for high risk ).
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Benefits for Routine Examinations and Immunizations
Benefits for routine examinations are available for the following Preventive Care Services:
1. Well-baby care (after newborn’s initial examination and discharge from the hospital);
2. Routine annual physical examination;
3. Annual vision examination;
4. Annual hearing examinations, except for benefits as provided under Required Benefits for
Screening Tests for Hearing Impairment. Screening tests for hearing impairment from birth
through the date the child is 30 days old and necessary diagnostic follow-up care related to the
screening test from birth through the date the child is 24 months old. Charges are not subject to
the deductible amount;
5. Immunizations – Deductibles will not be applicable to immunizations of a Dependent child age
seven years of age or younger. Immunizations include diphtheria, haemophilus influenza type b,
hepatitis B, measles, mumps, pertussis, polio, rubella, tetanus, varicella and any other
immunization that is required by law for the child. Charges for immunization are not subject to
deductible, coinsurance or copayment requirements. Charges for other services rendered at the
same time as immunizations are subject to deductible, coinsurance and copayment in accordance
with regular contract provisions; and
6. Newborn coverage includes all newborn test screenings and testing screening kits.
Benefits are not available for inpatient hospital expense or Medical/ Surgical Expense for routine physical
examinations performed on an inpatient basis, except for the initial examination of a newborn child.
Injections for allergies are not considered immunizations under this benefit provision.
Benefits for Certain Tests for Detection of Human Papillomavirus, Ovarian and Cervical Cancer
Benefits are available for certain tests for the detection of Human Papillomavirus, Ovarian Cancer, and
Cervical Cancer, for each enrollee who is 18 years of age or older, for an annual medically recognized
diagnostic examination for the early detection of ovarian and cervical cancer. Coverage includes, at a
minimum, a CA 125 blood test, a conventional Pap smear screening or a screening using liquid−based
cytology methods as approved by the United States Food and Drug Administration alone or in combination
with a test approved by the United States Food and Drug Administration for the detection of the human
papillomavirus.
Benefits for Mammography Screening and Diagnostic Imaging

Benefits are available for a diagnostic or screening for the presence of occult breast cancer for an enrollee.
Benefits for mammogram screenings are limited to one test per year for enrollees 35 years of age and
older. Benefits for diagnostic imaging are allowed for enrollees regardless of age.
A mammogram is an x-ray of the breast. While screening mammograms are routinely administered to
detect breast cancer in women who have no apparent symptoms, diagnostic imaging is used after
suspicious results on a screening mammogram or after some signs of breast cancer alert the physician to
check the tissue.
Such signs may include:
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 A lump
 Breast pain
 Nipple discharge
 Thickening of skin on the breast
 Changes in the size or shape of the breast
Diagnostic imaging can help determine if these symptoms are indicative of the presence of cancer.
As compared to screening mammograms, diagnostic imaging provides a more detailed x-ray of the breast
using specialized techniques. They are also used in special circumstances, such as for patients with breast
implants.
Benefits for Detection and Prevention of Osteoporosis

If an enrollee is a qualified individual, benefits are available for medically accepted bone mass measurement
for the detection of low bone mass and to determine risk of osteoporosis and fractures associated with
osteoporosis.
Qualified Individual means:

1. A postmenopausal enrollee not receiving estrogen replacement therapy;
2. An individual with:
a. vertebral abnormalities,
b. primary hyperparathyroidism, or
c. a history of bone fractures; or
3. An individual who is:
a. receiving long−term glucocorticoid therapy, or
b. being monitored to assess the response to or efficacy of an approved osteoporosis drug
therapy.
Benefits for Certain Tests for Detection of Prostate Cancer

Covered service expenses includes an annual digital rectal examination and prostate specific antigen tests
performed to determine the level of prostate specific antigen in the blood for a covered enrollee who is at
least 50 years of age; and at least once annually for a covered enrollee who is less than 50 years of age and
who is at high risk for prostate cancer according to the most recently published guidelines of the American
Cancer Society.
Benefits for Early Detection Tests for Cardiovascular Disease

Benefits are available for one of the following noninvasive screening tests for atherosclerosis and
abnormal artery structure and function every five years when performed by a laboratory that is certified
by a recognized national organization:
1. Computed tomography (CT) scanning measuring coronary artery calcifications; or
2. Ultrasonography measuring carotid intima-media thickness and plaque.
Tests are available to each covered individual who is (1) a male older than 45 years of age and younger
than 76 years of age, or (2) a female older than 55 years of age and younger than 76 years of age. The
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individual must be a diabetic or have a risk of developing coronary heart disease, based on a score derived
using the Framingham Heart Study coronary prediction algorithm that is intermediate or higher.
Benefits for Screening Tests for Hearing Impairment

Benefits are available for eligible expenses incurred by a covered Dependent child:
1. For a screening test for hearing loss from birth through the date the child is 30 days old; and
2. Necessary diagnostic follow-up care related to the screening tests from birth through the date the
child is 24 months.
Deductibles indicated on your Schedule of Benefits will not apply to this provision.
Covered services include the cost of medically necessary hearing aid or cochlear implant and related
services and supplies:
1. Fitting and dispensing services and the provision of ear molds as necessary to maintain optimal fit
of hearing aids;
2. Any treatment related to hearing aids and cochlear implants, including coverage for habilitation
and rehabilitation as necessary for educational gain; and
3. For a cochlear implant, and external speech processor and controller with necessary components
replacement every three years.
Limitations:
1. One hearing aid in each ear every three years; and
2. One cochlear implant in each ear with internal replacement as medically or audiologically
necessary.
Contraceptive Care
All FDA-approved contraception methods (identified on www.fda.gov) are approved for enrollees without
cost sharing as required under the Affordable Care Act. Enrollees have access to the methods available and
outlined on our drug formulary or Preferred Drug List without cost share. Some contraception methods
are available through an enrollee’s medical benefit, including the insertion and removal of the
contraceptive device at no cost share to the enrollee. Emergency contraception is available to enrollees
without a prescription and at no cost share to the enrollee.
Medical Vision Services

Covered services include:
 Vision screenings to diagnose and treat a suspected disease or injury of the eye.
 Vision screenings to determine the presence of refractive error.
 Enrollees who have been diagnosed with diabetes may self-refer once each year to an eye care
specialist, for the purpose of receiving an eye examination for the detection of eye disease.
Continued, or follow-up care from the eye care specialist may require a referral through your PCP.
Vision Services under the medical portion of your health plan do not include:
 Referrals to a specialist for evaluation and diagnosis of refractive error, including presbyopia, for
enrollees over the age of 19 years.
 Eye examinations required by an employer or as a condition of employment.
 Radial keratotomy, LASIK, and other refractive eye surgery.
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 Services or materials provided as a result of any workers' compensation law or required by any
governmental agency.
 Orthoptics, vision training, or subnormal vision aids.
Sleep Studies
Sleep studies are covered when determined to be medically necessary; prior authorization may be required.
Note: A sleep study can be performed either at home or in a facility.
Transplant Benefits
Covered services for transplant service expenses:
Transplants are a covered service when an enrollee is accepted as a transplant candidate and obtain prior
authorization in accordance with this contract. Prior authorization must be obtained through the Center of
Excellence, a network facility, or in our approved non-network facility when there is no network adequacy,
before an evaluation for a transplant. We may require additional information such as testing and/or
treatment before determining medical necessity for the transplant benefit. Authorization must be obtained
prior to performing the transplant surgery. Transplant services must meet medical criteria as set by
Medical Management Policy.
Cost share benefit coverage related to transplant services is available to both the recipient and donor of a
covered transplant as follows:
1. If both the donor and recipient have coverage provided by the same insurer each will have their
benefits paid by their own coverage program.
2. If you are the recipient of the transplant, and the donor for the transplant has no coverage from any
other source, the benefits under this contract will be provided for both you and the donor. In this
case, payments made for the donor will be charged against enrollees benefits.
3. If you are the donor for the transplant and no coverage is available to you from any other source,
the benefits under this contract will be provided for you. However, no benefits will be provided for
the recipient.
4. If lapse in coverage due to non-payment of premium, no services related to transplants will be paid
as a covered service.
If we determine that an enrollee and donor are appropriate candidates for a medically necessary transplant
or live donation, covered service expenses will be provided for:
1. Pre-transplant evaluation.
2. Pre-transplant harvesting of the organ from the donor.
3. Left Ventricular Assist Devices (LVAD) (only when used as a bridge to a heart transplant).
4. Outpatient covered services related to the transplant surgery, pre- transplant laboratory testing and
treatment; such as high dose chemotherapy, peripheral stem cell collection, and other
immunosuppressive drug therapy, etc. Also included is the cost for human leukocyte antigen
testing, also referred to as histocompatibility locus antigen testing, for A, B, and DR antigens for
utilization in bone marrow transplantation. Coverage is limited to a maximum cost of $75 per
transplant.
5. Pre-transplant stabilization, meaning an inpatient stay to medically stabilize to prepare for a later
transplant, whether or not the transplant occurs.
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6. The transplant itself, including the acquisition cost for the organ or bone marrow when authorized
through the Center of Excellence, a network facility, or in our approved non-network facility when
there is no network adequacy and services are performed at a network facility.
7. Post-transplant follow-up visits and treatments.
8. Transplant benefit expenses include services related to donor search and acceptability testing of
potential live donors.
9. All costs incurred and medical expenses by the donor; shall be paid under the transplant recipient
policy, this excludes travel, lodging, food, and mileage. Please refer to the Member Transplant
Travel Reimbursement Policy for outlined details on reimbursement limitations at
https://ambetter.superiorhealthplan.com/resources/handbooks-forms.html.
These medical expenses are covered to the extent that the benefits remain and are available under the
enrollee's contract, after benefits for the enrollee's own expenses have been paid. In the event of such
coverage, the otherwise existing coverage of a live donor shall be secondary to benefits under the enrollee's
contract when donor has no coverage available to them from any other source.
Ancillary "Center Of Excellence" Service Benefits:

An enrollee may obtain services in connection with a transplant from any physician. However, if a
transplant is performed in a Center of Excellence, a network facility, or in our approved non-network facility
when there is no network adequacy:
1. We will pay for the following services when the enrollee is required to travel more than 75 miles
from the residence to the Center of Excellence:
2. We will pay a maximum of $10,000 per transplant service for the following services:
a. Transportation for the enrollee, any live donor, and the immediate family to accompany the
enrollee to and from the Center of Excellence, a network facility, or in our approved non-
network facility when there is no network adequacy, in the United States.
b. When enrollee and/or donor is utilizing their personal transportation vehicle; a mileage log
is required for reimbursement.
c. Maximum reimbursement for mileage is limited to travel to and from the enrollee’s home to
the transplant facility, and to and from the donor’s home to the transplant facility, and will
be reimbursed at the current IRS mileage standard for miles driven for medical purposes.
d. Lodging at or near the Center of Excellence, a network facility, or in our approved non-
network facility when there is no network adequacy for any live donor and the immediate
family accompanying the enrollee while the enrollee is confined in the Center of Excellence in
the United States. We will reimburse enrollees for the proof of costs directly related for
transportation, lodging and any of the following approved items listed in the member
transplant reimbursement guidelines. However, you must make the arrangements and
provide the necessary paid receipts for reimbursement within six months of the date of
service in order to be reimbursed.
e. Incurred costs related to a certified/registered service animal for the transplant enrollee
and/or donor.
f. Please refer to the member resources page for member reimbursement transplant travel
forms and information at https://ambetter.superiorhealthplan.com/resources/handbooks-
forms.html.
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Non-Covered Services and Exclusions:
No benefits will be provided or paid under these Transplant Service Expense Benefits:
1. For a prophylactic bone marrow harvest or peripheral blood stem cell collection when no
transplant occurs.
2. For animal to human transplants.
3. For procurement or transportation of the organ or tissue, unless expressly provided for in this
provision through the Center of Excellence, a network facility, or in our approved non-network
facility when there is no network adequacy.
4. To keep a donor alive for the transplant operation, except when authorized through the Center of
Excellence, a network facility, or in our approved non-network facility when there is no network
adequacy.
5. For a live donor where the live donor is receiving a transplanted organ to replace the donated
organ.
6. Related to transplants unauthorized through the Center of Excellence, a network facility, or in our
approved non-network facility when there is no network adequacy and is not included under this
provision as a transplant.
7. For a transplant under study in an ongoing phase I or II clinical trial as set forth in the United States
Food and Drug Administration (FDA) regulation, regardless of whether the trial is subject to FDA
oversight.
8. The acquisition cost for the organ or bone marrow, when provided at an unauthorized facility or
not obtained through the Center of Excellence, a network facility, or in our approved non-network
facility when there is no network adequacy.
9. For any transplant services and/or travel related expenses for enrollee and donor, when preformed
outside of the United States.
10. The following ancillary items listed below, will not be subject to member reimbursement under
this contract:
a. Alcohol/tobacco
b. Car Rental (unless pre-approved by Case Management)
c. Vehicle Maintenance for motorized and hybrid, and electric car (includes: any
repairs/parts, labor, general maintenance, towing, roadside assistance, etc.)
d. Parking, such as but not limited to hotel, valet or any offsite parking other than hospital.
e. Storage rental units, temporary housing incurring rent/mortgage payments.
f. Utilities, such as gas, water, electric, housekeeping services, lawn maintenance, etc.
g. Speeding tickets
h. Entertainment (e.g., movies, visits to museums, additional mileage for sightseeing, etc.)
i. For any services related to pet care, boarding, lodging, food, and/or travel expenses; other
than those related to certified/registered service animal(s).
j. Expenses for persons other than the patient and his/her covered companion
k. Expenses for lodging when enrollee is staying with a relative
l. Any expense not supported by a receipt
m. Upgrades to first class travel (air, bus, and train)
n. Personal care items (e.g., shampoo, deodorant, clothes)
o. Luggage or travel related items including passport/passport card, REAL ID travel ids, travel
insurance, TSA pre-check, and early check-in boarding fees, extra baggage fees
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p. Souvenirs (e.g., t-shirts, sweatshirts, toys)
q. Telephone calls/mobile bills, replacement parts, or cellular purchases of any type
r. All other items not described in the contract as eligible expenses
11. Any fuel costs/charging station fees for electric cars, not related to travel to and from the Center of
Excellence or our approved facility, when there is no network adequacy
Organ Transplant Medication Notification

At least 60 days prior to making any formulary change that alters the terms of coverage for a patient
receiving immunosuppressant drugs or discontinues coverage for a prescribed immunosuppressant drug
that a patient is receiving, we must, to the extent possible, notify the prescribing physician and the patient,
or the parent or guardian if the patient is a child, or the spouse of a patient who is authorized to consent to
the treatment of the patient. The notification will be in writing and will disclose the formulary change,
indicate that the prescribing physician may initiate an appeal, and include information regarding the
procedure for the prescribing physician to initiate the contract's appeal process.
As an alternative to providing written notice, we may provide the notice electronically if, and only if, the
patient affirmatively elects to receive such notice electronically. The notification shall disclose the
formulary change, indicate that the prescribing physician may initiate an appeal, and include information
regarding the procedure for the prescribing physician to initiate the contract's appeal process.
At the time a patient requests a refill of the immunosuppressant drug, we may provide the patient with the
written notification required above along with a 60-day supply of the immunosuppressant drug under the
same terms as previously allowed.
Urgent Care
Benefits for eligible expenses for urgent care will be determined as shown on your Schedule of Benefits. A
copayment amount, in the amount indicated on your Schedule of Benefits, will be required for each urgent
care visit. Urgent care means the delivery of medical care in a facility dedicated to the delivery of scheduled
or unscheduled, walk-in care outside of a hospital emergency room/treatment room department or
provider’s office. The necessary medical care is for a condition that is not life-threatening.
Pediatric Vision Expense Benefits

Covered service expenses in this benefit subsection include the following services performed by an
optometrist, therapeutic optometrist, or ophthalmologist for an eligible child under the age of 19 who is an
enrollee:
1. Routine vision screening, including dilation with refraction every calendar year;
2. One pair of prescription lenses (single vision, lined bifocal, lined trifocal, or lenticular) in glass or
plastic, or initial supply of medically necessary contacts every calendar year;
a. Other lens options included are: Fashion and Gradient Tinting, Ultraviolet Protective
Coating, Oversized and Glass-Grey #3 Prescription Sunglass lenses, Polycarbonate lenses,
Blended Segment lenses, Intermediate Vision lenses, Standard Progressives, Premium
Progressives (Varilux®, etc.), Photochromic Glass Lenses, Plastic Photosensitive Lenses
(Transitions®), Polarized Lenses, Standard Anti-Reflective (AR) Coating, Premium AR
Coating, Ultra AR Coating, and Hi-Index Lenses
3. One pair of prescription frames per calendar year;
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4. Scratch-resistant coating; and
5. Low vision aids as medically necessary.
Covered service expenses and supplies do not include:

1. Visual therapy;
2. Two pair of glasses as a substitute for bifocals;
3. Replacement of lost or stolen eyewear;
4. Any vision services, treatment or material not specifically listed as a covered service;
5. Non-network providers;
6. Discount for laser vision correction;
7. Lasik surgery.
Pediatric Services will extend through the end of the plan year in which they turn 19 years of age.
Wellness and Other Program Benefits

Benefits may be available to enrollees for participating in certain programs that we may make available in
connection with this contract. Such programs may include wellness programs, disease or care
management programs. These programs may include a reward or an incentive, which you may earn by
completing different activities.
If you have a medical condition that may prohibit you from participating in these programs, we may
require you to provide verification, such as an affirming statement from your physician, that your medical
condition makes it unreasonably difficult or inadvisable to participate in the wellness or health
improvement program, in order for you to receive the reward or incentive.
You may obtain information regarding the particular programs available at any given time by visiting our
website at Ambetter.SuperiorHealthPlan.com or by contacting Member Services by telephone at 1-877-
687-1196 (Relay Texas/TTY 1-800-735-2989). The benefits are available as long as coverage remains
active, unless changed by us as described in the programs’ terms and conditions. Upon termination of
coverage, program benefits are no longer available.
All enrollees are automatically eligible for the program benefits upon obtaining coverage. The programs
are optional, and the benefits are made available at no additional cost to the enrollees. The programs and
benefits available at any given time are made part of this contract by this reference and are subject to
change by us through updates available on our website or by contacting us.
Enrollees can earn rewards for focusing on their total health. The “My Health Pays” enrollee rewards
program may offer rewards when enrollees participate in activities focused on eating right, moving more,
saving smart and living well. Enrollees may have the opportunity to earn rewards for completing activities
in the categories below:
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Behavior/Action Notes
Program Activation and Rewards for activating and
Onboarding onboarding onto the program
Online Activities (Power ups and Frequent online activities
Challenges) providing educational content
and calls to action focused on
targeted wellness behaviors and
healthy living
Clinical Activities Clinical activities focused on
health management, including
recommended preventive
screenings and disease
management participation
Earned rewards may be used to shop for items at the online My Health Pays Rewards Store or may be
converted into dollars and spent on health care related items. The rewards may be applied towards social
determinants.
Rewards for participating in a wellness program are available to all enrollees. If you think you might be
unable to meet a standard for a reward under this wellness program, you might qualify for an opportunity
to earn the same reward through an alternative means. Enrollees should contact Member Services by
telephone at 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989) so they can work with you (and, if you
wish, with your doctor) to find a wellness program that offers the same reward and is right for you in light
of your health.
Care Management Programs

We understand special health needs and are prepared to help you manage any that you may have. Our Care
Management services can help with complex medical or behavioral health needs. If you qualify for Care
Management, we will partner you with a care manager. Care managers are registered nurses or social
workers that are specially trained to help you:
• Better understand and manage your health conditions
• Coordinate services
• Locate community resources
Your care manager will work with you and your doctor to help you get the care you need. If you have a
severe medical condition, your care manager will work with you, your PCP (PCP) and other providers to
develop a care plan that meets your needs and your caregiver’s needs. If you think you could benefit from
our Care Management program, please call Member Services at 1-877-687-1196 (Relay Texas/TTY 1-800-
735-2989).
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GENERAL NON-COVERED SERVICES AND EXCLUSIONS
No benefits will be provided or paid for:
1. Any service or supply that would be provided without cost to the enrollee or enrollee in the absence
of insurance covering the charge.
2. Expenses, fees, taxes, or surcharges imposed on the enrollee or enrollee by a provider (including a
hospital) but that are actually the responsibility of the provider to pay.
3. Any services performed by a member of an enrollee’s immediate family, including someone who is
related to an enrollee by blood, marriage or adoption or who is normally a member of the enrollee’s
household. This exclusion does not apply to eligible expenses rendered from a dental provider for
dental benefits.
4. Any services not identified and included as covered service expenses under the contract. You will be
fully responsible for payment for any services that are not covered service expenses.
5. Any services where other coverage is primary to Ambetter must be first paid by the primary payor
prior to consideration for coverage under Ambetter.
6. For any non-medically necessary court ordered care for a medical/surgical or mental
health/substance use disorder diagnosis, unless required by state law.
Even if not specifically excluded by this contract, no benefit will be paid for a service or supply unless it is:
1. Administered or ordered by a provider; and
2. Medically necessary to the diagnosis or treatment of an injury or illness, or covered under the
Preventive Care Services provision.
Covered service expenses will not include, and no benefits will be provided or paid for any charges that are
incurred:
1. For services or supplies that are provided prior to the effective date or after the termination date of
this contract.
2. For any portion of the charges that are in excess of the eligible expense.
3. For weight modification, or for surgical treatment of obesity, including wiring of the teeth and all
forms of intestinal bypass surgery.
4. For cosmetic breast reduction or augmentation, except for the medically necessary treatment of
Gender Dysphoria.
5. The reversal of sterilization and reversal of vasectomies.
6. For abortion (unless the life of the mother would be endangered if the fetus were carried to term or
delivered).
7. For treatment of malocclusions, disorders of the temporomandibular joint, or craniomandibular
disorders, except as described in covered service expenses.
8. For expenses for television, telephone, or expenses for other persons.
9. For marriage, family, or child counseling for the treatment of premarital, marriage, family, or child
relationship dysfunctions.
10. For telephone consultations between providers, except those meeting the definition of telehealth
services or telemedicine medical services, or for failure to keep a scheduled appointment.
11. For stand-by availability of a medical practitioner when no treatment is rendered.
29418TX014-2023 87
12. For dental service expenses, including braces for any medical or dental condition, surgery and
treatment for oral surgery.
13. For cosmetic treatment, except for reconstructive surgery for mastectomy or that is incidental to or
follows surgery or an injury from trauma, infection or diseases of the involved part that was
covered under the contract or is performed to correct a birth defect.
14. For mental health examinations and services involving:
a. Services for psychological testing associated with the evaluation and diagnosis of learning
disabilities;
b. Marriage counseling;
c. Pre-marital counseling;
d. Court ordered care or testing, or required as a condition of parole or probation. Benefits
will be allowed for services that would otherwise be covered under this contract;
e. Testing of aptitude, ability, intelligence or interest;
f. Evaluation for the purpose of maintaining employment. Benefits will be allowed for
services that are medically necessary and would otherwise be covered under this contract.
15. For charges related to, or in preparation for, tissue or organ transplants, except as expressly
provided for under the Transplant Services provision.
16. For eye refractive surgery, when the primary purpose is to correct nearsightedness, farsightedness,
or astigmatism.
17. While confined primarily to receive rehabilitation, custodial care, educational care, or nursing
services (unless expressly provided for in this contract).
18. For vocational or recreational therapy, vocational rehabilitation, outpatient speech therapy, or
occupational therapy, except as expressly provided for in this contract.
19. For eyeglasses, contact lenses, eye refraction, visual therapy, or for any examination or fitting
related to these devices, except as expressly provided in this contract.
20. For experimental or investigational treatment(s) or unproven services. The fact that an experimental
or investigational treatment or unproven service is the only available treatment for a particular
condition will not result in benefits if the procedure is considered to be an experimental or
investigational treatment or unproven service for the treatment of that particular condition.
21. For treatment received outside the United States, except for a medical emergency while traveling
for up to a maximum of 90 consecutive days.
22. As a result of an injury or illness arising out of, or in the course of, employment for wage or profit, if
the enrollee is insured, or is required to be insured, by workers' compensation insurance pursuant
to applicable state or federal law. If you enter into a settlement that waives an enrollee's right to
recover future medical benefits under a workers' compensation law or insurance plan, this
exclusion will still apply. In the event that the workers' compensation insurance carrier denies
coverage for an enrollee's workers' compensation claim, this exclusion will still apply unless that
denial is appealed to the proper governmental agency and the denial is upheld by that agency.
23. For fetal reduction surgery.
24. Except as specifically identified as a covered service expense under the contract, services or
expenses for alternative treatments, including acupressure, acupuncture, aroma therapy,
hypnotism, massage therapy, rolfing, and other forms of alternative treatment as defined by the
Office of Alternative Medicine of the National Institutes of Health.
29418TX014-2023 88
25. As a result of any injury sustained during or due to participating, instructing, demonstrating,
guiding, or accompanying others in any of the following: professional or Semi-professional sports;
intercollegiate sports (not including intramural sports); racing or speed testing any non-motorized
vehicle or conveyance (if the enrollee is paid to participate or to instruct); rodeo sports; horseback
riding (if the enrollee is paid to participate or to instruct); rock or mountain climbing (if the enrollee
is paid to participate or to instruct); or skiing (if the enrollee is paid to participate or to instruct).
26. As a result of any injury sustained while operating, riding in, or descending from any type of
aircraft if the enrollee is a pilot, officer, or enrollee of the crew of such aircraft or is giving or
receiving any kind of training or instructions or otherwise has any duties that require him or her to
be aboard the aircraft.
27. As a result of any injury sustained while at a residential treatment facility.
28. For the following miscellaneous items (except where required by federal or state law): in vitro
fertilization, Artificial Insemination (except when required by federal or state law), biofeedback;
care or complications resulting from non-covered services; chelating agents; domiciliary care; food
and food supplements, except for what is indicated in the Medical Foods section routine foot care,
foot orthotics or corrective shoes; health club memberships, unless otherwise covered; home test
kits; care or services provided to a non-enrollee biological parent; nutrition or dietary
supplements; pre-marital lab work; processing fees; private duty nursing; rehabilitation services
for the enhancement of job, athletic or recreational performance; routine or elective care outside
the service area; treatment of spider veins; transportation expenses, unless specifically described in
this contract.
29. Services of a private duty registered nurse rendered on an outpatient basis.
30. Diagnostic testing, laboratory procedures, screenings or examinations performed for the purpose
of obtaining, maintaining or monitoring employment.
31. For any medicinal and recreational use of cannabis or marijuana.
32. Vehicle installations (modifications) which may include, but are not limited to: adapted seat
devices, door handle replacements, lifting devices, roof extensions and wheelchair securing
devices.
33. Surrogacy Arrangement. Health care services, including supplies and medication relating to a
Surrogacy Agreement, to a Surrogate, including an enrollee acting as a Surrogate or utilizing the
services of a Surrogate who may or may not be an enrollee, and any child born as a result of a
Surrogacy Arrangement. This exclusion applies to all health care services, supplies and medication
relating to a Surrogacy Agreement, to a Surrogate including, but not limited to:
a. Prenatal care;
b. Intrapartum care (or care provided during delivery and childbirth);
c. Postpartum care (or care for the Surrogate following childbirth);
d. Mental Health Services related to the Surrogacy Arrangement;
e. Expenses relating to donor semen, including collection and preparation for implantation;
f. Donor gamete or embryos or storage of same relating to a Surrogacy Arrangement;
g. Use of frozen gamete or embryos to achieve future conception in a Surrogacy Arrangement;
h. Preimplantation genetic diagnosis relating to a Surrogacy Arrangement;
i. Any complications of the child or Surrogate resulting from the pregnancy;
j. Any other health care services, supplies and medication relating to a Surrogacy
Arrangement; or
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k. Any and all health care services, supplies or medication provided to any child birthed by a
surrogate as a result of a surrogacy arrangement are also excluded, except where the child
is the adoptive child of insureds possessing an active contract with us and/ or the child
possesses an active contract with us at the time of birth.
34. For all health care services obtained at an urgent care center that is a non-network provider.
35. For expenses, services, and treatments from a naprapathic specialists for conditions caused by
contracted, injured, spasmed, bruised, and/or otherwise affected myofascial or connective tissue.
36. For expenses, services, and treatments from a naturopathic specialists for treatment of prevention,
self-healing and use of natural therapies.
37. Medical necessity of services or supplies, to the extent such services or supplies are provided as
part of a hospice care program; or
38. Dry needling.
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TERMINATION
Termination Of Contract
All coverage will cease on termination of this contract. This contract will terminate on the earliest of:
1. Nonpayment of premiums when due, subject to the Grace Period provision in this contract.
2. For any reason or event of non-renewal or cancellation as outlined in the Guaranteed Renewable
provision.
a. The last day of coverage is the last day of the month following the month in which the
notice is sent by us unless you request an earlier termination effective date.
3. For dependent enrollee reaching the limiting age of 26, coverage under this contract will terminate
at 11:59 p.m. on the last day of the year in which the dependent enrollee reaches the limiting age of
turns 26.
a. Coverage may be extended beyond the limiting age for a dependent eligible child who is not
capable of self-sustaining employment due to mental disabilities or physical disability and
is mainly dependent on you for support and maintenance.
4. You obtain other minimum essential coverage.
Refund upon Cancellation

We will refund any premium paid and not earned due to contract termination. You may cancel the contract
at any time by providing written notice to the entity in which you enrolled. Such cancellation shall become
effective upon receipt, or on such later date specified in the notice. If you cancel, we shall promptly return
any unearned portion of the premium paid, but in any event shall return the unearned portion of the
premium within 30 days. The earned premium shall be computed on a pro-rata basis. Cancellation shall be
without prejudice to any claim originating prior to the effective date of the cancellation.
Discontinuance
90-Day Notice: If we discontinue offering and decide not to renew all contracts issued on this form, with
the same type and level of benefits, for all residents of the state where you reside, we will provide a written
notice to you at least 90 days prior to the date that we discontinue coverage. You will be offered an option
to purchase any other coverage in the individual market we offer in your state at the time of
discontinuance of this contract. This option to purchase other coverage will be on a guaranteed issue basis
without regard to health status.
180-Day Notice: If we discontinue offering and decide not to renew all individual contracts in the
individual market in the state where you reside, we will provide a written notice to you and the
Commissioner of Insurance at least 180 days prior to the date that we stop offering and terminate all
existing individual contracts in the individual market in the state where you reside.
Portability Of Coverage
If a person ceases to be an enrollee due to the fact that the person no longer meets the definition of
dependent enrollee under the contract, the person will be eligible for continuation of coverage. If elected,
we will continue the person's coverage under the contract by issuing an individual contract. The premium
rate applicable to the new contract will be determined based on the residence of the person continuing
coverage. All other terms and conditions of the new contract, as applicable to that person, will be the same
29418TX014-2023 91
as this contract, subject to any applicable requirements of the State in which that person resides. Any
deductible amounts and maximum benefit limits will be satisfied under the new contract to the extent
satisfied under this contract at the time that the continuation of coverage is issued. (If the original
coverage contains a family deductible which must be met by all enrollees combined, only those expenses
incurred by the enrollee continuing coverage under the new contract will be applied toward the
satisfaction of the deductible amount under the new contract.)
If an enrollee’s coverage terminates due to a change in marital status, you may be issued coverage that
most nearly approximates the coverage of the contract which was in effect prior to the change in marital
status.
Notification Requirements
It is the responsibility of you or your former dependent enrollee to notify us within 31 days of your legal
divorce or your dependent enrollee's marriage. You must notify us of the address at which their
continuation of coverage should be issued.
Reinstatement
For coverage purchased outside of the Health Insurance Marketplace, if your contract lapses due to
nonpayment of premium, it may be reinstated provided:
1. We receive from you a written application for reinstatement within one year after the date
coverage lapsed; and
2. The written application for reinstatement is accompanied by the required premium payment.
For coverage purchased through the Health Insurance Marketplace, the Health Insurance Marketplace
should be contacted for reinstatement.
Premium accepted for reinstatement may be applied to a period for which premium had not been paid. The
period for which back premium may be required will not begin more than 60 days before the date of
reinstatement.
The Rescissions provision will apply to statements made on the reinstatement application, based on the
date of reinstatement.
Changes may be made in your contract in connection with the reinstatement. These changes will be sent to
you for you to attach to your contract. In all other respects, you and we will have the same rights as before
your contract lapsed.
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THIRD PARTY LIABILITY AND COORDINATION OF BENEFITS
As used herein, the term “third party” means any party that is, or may be, or is claimed to be responsible
for illness or injuries to an enrollee. Such injuries or illness are referred to as “third party injuries.” Third
party includes any parties actually, possibly or potentially responsible for payment of expenses associated
with the care or treatment of third party injuries, to the extent permitted by Texas law.
If an enrollee's illness or injury is caused by the acts or omissions of a third party, we will not cover a loss to
the extent that it is paid as part of a settlement or judgment by any third party.
If this plan provides benefits under this contract to a enrollee for expenses incurred due to third party
injuries, then Celtic retains the right to repayment of the full cost of all benefits provided by this plan on
behalf of the enrollee that are associated with the third party injuries. Celtic’s rights of recovery apply to
any recoveries made by or on behalf of the enrollee from any sources, including but not limited to:
1. Payments made by a third party or any insurance company on behalf of the third party;
2. Any payments or awards under an uninsured or underinsured motorist coverage policy if the
enrollee or enrollee’s immediate family did not pay the premiums for the coverage;
3. Any Workers’ Compensation or disability award or settlement;
4. Medical payments coverage under any automobile policy, premises or homeowners medical
payments coverage or premises or homeowners insurance coverage; and
5. Any other payments from a source intended to compensate an enrollee for third party injuries.
By accepting benefits under this plan, the enrollee specifically acknowledges Celtic’s right of subrogation.
When this plan provides health care benefits for expenses incurred due to third party injuries, the plan
shall be subrogated to the enrollee’s rights of recovery against any party to the extent of the full cost of all
benefits provided by this plan, to the extent permitted by Texas law. Celtic may proceed against any party
with or without the enrollee’s consent.
By accepting benefits under this plan, the enrollee also specifically acknowledges Celtic’s right of
reimbursement. This right of reimbursement attaches, to the extent permitted by Texas law, when this
plan has provided health care benefits for expenses incurred due to third party injuries and the enrollee or
the enrollee’s representative has recovered any amounts from any source, to the fullest extent permitted by
law. By providing any benefit under this plan, Celtic is granted an assignment of the proceeds of any
settlement, judgment or other payment received by you to the extent of the full cost of all benefits provided
by this plan. Celtic’s right of reimbursement is cumulative with and not exclusive of the plan’s subrogation
right and Celtic may choose to exercise either or both rights of recovery.
As a condition for our payment, the enrollee or anyone acting on his or her behalf (including, but not
limited to, the guardian, legal representatives, estate, or heirs) agrees:
1. To fully cooperate with us in order to obtain information about the loss and its cause.
2. To immediately inform us in writing of any claim made or lawsuit filed on behalf of an enrollee in
connection with the loss.
3. To include the amount of benefits paid by us on behalf of an enrollee in any claim made against any
third party.
29418TX014-2023 93
4. That we:
a. Will have a lien on all money received by an enrollee in connection with the loss we have
provided or paid to the extent permitted by Texas law.
b. May give notice of that lien to any third party or third party's agent or representative.
c. Will have the right to intervene in any suit or legal action to protect our rights.
d. Are subrogated to all of the rights of the enrollee against any third party to the extent
permitted by Texas law of the benefits paid on the enrollee's behalf.
e. May assert that subrogation right independently of the enrollee.
5. To take no action that prejudices our reimbursement and subrogation rights. This includes, but is
not limited to, refraining from making any settlement or recovery which specifically attempts to
reduce or exclude the full cost of all benefits provided by this plan to the extent permitted by Texas
law.
6. To sign, date, and deliver to us any documents we request that protect our reimbursement and
subrogation rights.
7. To not settle any claim or lawsuit against a third party without providing us with written notice
within 30 days prior to the settlement.
8. To reimburse us from any money received from any third party, to the extent permitted by Texas
law for benefits we paid for the third party injury, whether obtained by settlement, judgment, or
otherwise, and whether or not the third party's payment is expressly designated as a payment for
medical expenses.
9. That we may reduce other benefits under the contract by the amounts an enrollee has agreed to
reimburse us.
We have a right to be reimbursed in full regardless of whether or not the enrollee is fully compensated by
any recovery received from any third party by settlement, judgment, or otherwise.
In the event of a recovery from a third party, we will pay attorney fees or costs associated with the
enrollee's claim or lawsuit only to the extent required by Texas law unless otherwise agreed.
If a dispute arises as to the amount an enrollee must reimburse us, the enrollee (or the guardian, legal
representatives, estate, or heirs of the enrollee) agrees to place sufficient funds in an escrow or trust
account to satisfy the maximum lien amount asserted by us until the dispute is resolved.
COORDINATION OF THIS CONTRACT’S BENEFITS WITH OTHER BENEFITS
The Coordination of Benefits (COB) provision applies when a person has health care coverage under more
than one plan. Plan is defined below.
The order of benefit determination rules govern the order in which each plan will pay a claim for benefits.
The plan that pays first is called the primary plan. The primary plan must pay benefits in accord with its
policy terms without regard to the possibility that another plan may cover some expenses. The plan that
pays after the primary plan is the secondary plan. The secondary plan may reduce the benefits it pays so
that payments from all plans equal 100 percent of the total allowable expense.
29418TX014-2023 94
DEFINITIONS
(a) A "plan" is any of the following that provides benefits or services for medical or dental care or
treatment. If separate contracts are used to provide coordinated coverage for members of a group, the
separate contracts are considered parts of the same plan and there is no COB among those separate
contracts.
(1) Plan includes: group, blanket, or franchise accident and health insurance policies, excluding
disability income protection coverage; individual and group health maintenance organization
evidences of coverage; individual accident and health insurance policies; individual and group
preferred provider benefit plans and exclusive provider benefit plans; group insurance contracts,
individual insurance contracts and subscriber contracts that pay or reimburse for the cost of dental
care; medical care components of individual and group long-term care contracts; limited benefit
coverage that is not issued to supplement individual or group in-force policies; uninsured
arrangements of group or group-type coverage; the medical benefits coverage in automobile
insurance contracts; and Medicare or other governmental benefits, as permitted by law.
(2) Plan does not include: disability income protection coverage; the Texas Health Insurance Pool;
workers' compensation insurance coverage; hospital confinement indemnity coverage or other
fixed indemnity coverage; specified disease coverage; supplemental benefit coverage; accident only
coverage; specified accident coverage; school accident-type coverages that cover students for
accidents only, including athletic injuries, either on a "24-hour" or a "to and from school" basis;
benefits provided in long-term care insurance contracts for non-medical services, for example,
personal care, adult day care, homemaker services, assistance with activities of daily living, respite
care, and custodial care or for contracts that pay a fixed daily benefit without regard to expenses
incurred or the receipt of services; Medicare supplement policies; a state plan under Medicaid; a
governmental plan that, by law, provides benefits that are in excess of those of any private
insurance plan; or other nongovernmental plan; or an individual accident and health insurance
policy that is designed to fully integrate with other policies through a variable deductible.
Each contract for coverage under (a)(1) or (a)(2) is a separate plan. If a plan has two parts and
COB rules apply only to one of the two, each of the parts is treated as a separate plan.
“This plan" means, in a COB provision, the part of the contract providing the health care benefits to
which the COB provision applies and which may be reduced because of the benefits of other plans. Any
other part of the contract providing health care benefits is separate from this plan. A contract may
apply one COB provision to certain benefits, such as dental benefits, coordinating only with like
benefits, and may apply other separate COB provisions to coordinate other benefits.
The order of benefit determination rules determine whether this plan is a primary plan or secondary
plan when the person has health care coverage under more than one plan. When this plan is primary, it
determines payment for its benefits first before those of any other plan without considering any other
plan's benefits. When this plan is secondary, it determines its benefits after those of another plan and
may reduce the benefits it pays so that all plan benefits equal 100 percent of the total allowable
expense.
29418TX014-2023 95
(b) "Allowable expense" is a health care expense, including deductibles, coinsurance, and copayments, that
is covered at least in part by any plan covering the person. When a plan provides benefits in the form of
services, the reasonable cash value of each service will be considered an allowable expense and a
benefit paid. An expense that is not covered by any plan covering the person is not an allowable
expense. In addition, any expense that a health care provider or physician by law or in accord with a
contractual agreement is prohibited from charging a covered enrollee is not an allowable expense.
The following are examples of expenses that are not allowable expenses:
(1) The difference between the cost of a semi-private hospital room and a private hospital room is not
an allowable expense, unless one of the plans provides coverage for private hospital room
expenses.
(2) If a person is covered by two or more plans that do not have negotiated fees and compute their
benefit payments based on the usual and customary fees, allowed amounts, relative value schedule
reimbursement methodology, or other similar reimbursement methodology, any amount in excess
of the highest reimbursement amount for a specific benefit is not an allowable expense.
(3) If a person is covered by two or more plans that provide benefits or services on the basis of
negotiated fees, an amount in excess of the highest of the negotiated fees is not an allowable
expense.
(4) If a person is covered by one plan that does not have negotiated fees and that calculates its benefits
or services based on usual and customary fees, billed amounts, relative value schedule
reimbursement methodology, or other similar reimbursement methodology, and another plan that
provides its benefits or services based on negotiated fees, the primary plan's payment arrangement
must be the allowable expense for all plans. However, if the health care provider or physician has
contracted with the secondary plan to provide the benefit or service for a specific negotiated fee or
payment amount that is different than the primary plan's payment arrangement and if the health
care provider's or physician's contract permits, the negotiated fee or payment must be the allowable
expense used by the secondary plan to determine its benefits.
(5) The amount of any benefit reduction by the primary plan because a covered enrollee has failed to
comply with the plan provisions is not an allowable expense. Examples of these types of plan
provisions include second surgical opinions, prior authorization of admissions, and preferred
health care provider and physician arrangements.
(6) When an enrollee is also a Medicare beneficiary, and Medicare is primary, the allowable expense is
Medicare’s allowable amount.
(c) "Billed amount" is the amount of a billed charge that a carrier determines to be covered for services
provided by a non-network provider or physician. The allowed amount includes both the carrier's
payment and any applicable deductible, copayment, or coinsurance amounts for which the enrollee is
responsible.
29418TX014-2023 96
(d) "Closed panel plan" is a plan that provides health care benefits to covered enrollees primarily in the
form of services through a panel of health care providers and physicians that have contracted with or
are employed by the plan, and that excludes coverage for services provided by other health care
providers and physicians, except in cases of emergency or referral by a panel member.
(e) "Custodial parent" is the parent with the right to designate the primary residence of a child by a court
order under the Texas Family Code or other applicable law, or in the absence of a court order, is the
parent with whom the child resides more than one-half of the calendar year, excluding any temporary
visitation.
ORDER OF BENEFIT DETERMINATION RULES

When a person is covered by two or more plans, the rules for determining the order of benefit payments
are as follows:
(a) The primary plan pays or provides its benefits according to its terms of coverage and without regard to
the benefits under any other plan.
(b) Except as provided in (c), a plan that does not contain a COB provision that is consistent with this
policy is always primary unless the provisions of both plans state that the complying plan is primary.
(c) Coverage that is obtained by virtue of membership in a group that is designed to supplement a part of a
basic package of benefits and provides that this supplementary coverage must be excess to any other
parts of the plan provided by the contract holder. Examples of these types of situations are major
medical coverages that are superimposed over base plan hospital and surgical benefits, and insurance
type coverages that are written in connection with a closed panel plan to provide non-network
benefits.
(d) A plan may consider the benefits paid or provided by another plan in calculating payment of its
benefits only when it is secondary to that other plan.
(e) If the primary plan is a closed panel plan and the secondary plan is not, the secondary plan must pay or
provide benefits as if it were the primary plan when a covered enrollee uses a non-contracted health
care provider or physician, except for emergency services or authorized referrals that are paid or
provided by the primary plan.
(f) When multiple contracts providing coordinated coverage are treated as a single plan under this
subchapter, this section applies only to the plan as a whole, and coordination among the component
contracts is governed by the terms of the contracts. If more than one carrier pays or provides benefits
under the plan, the carrier designated as primary within the plan must be responsible for the plan's
compliance with this subchapter.
(g) If a person is covered by more than one secondary plan, the order of benefit determination rules of this
subchapter decide the order in which secondary plans' benefits are determined in relation to each
other. Each secondary plan must take into consideration the benefits of the primary plan or plans and
29418TX014-2023 97
the benefits of any other plan that, under the rules of this contract, has its benefits determined before
those of that secondary plan.
(h) Each plan determines its order of benefits using the first of the following rules that apply.
(1) Nondependent or Dependent. The plan that covers the person other than as a dependent, for
example as an employee, enrollee, policyholder, subscriber, or retiree, is the primary plan, and the
plan that covers the person as a dependent is the secondary plan. However, if the person is a
Medicare beneficiary and, as a result of federal law, Medicare is secondary to the plan covering the
person as a dependent and primary to the plan covering the person as other than a dependent,
then the order of benefits between the two plans is reversed so that the plan covering the person as
an employee, enrollee, policyholder, subscriber, or retiree is the secondary plan and the other plan
is the primary plan. An example includes a retired employee.
(2) Dependent Child Covered Under More Than One Plan. Unless there is a court order stating
otherwise, plans covering a dependent child must determine the order of benefits using the
following rules that apply.
(A) For a dependent child whose parents are married or are living together, whether or not they
have ever been married:
(i) The plan of the parent whose birthday falls earlier in the calendar year is the primary plan;
or
(ii) If both parents have the same birthday, the plan that has covered the parent the longest is
the primary plan.
(B) For a dependent child whose parents are divorced, separated, or not living together, whether
or not they have ever been married:
(i) if a court order states that one of the parents is responsible for the dependent child's health
care expenses or health care coverage and the plan of that parent has actual knowledge of
those terms, that plan is primary. If the parent with responsibility has no health care
coverage for the dependent child’s health care expenses, and that parent’s spouse does, then
the spouse’s plan is the primary plan. This rule applies to plan years commencing after the
plan is given notice of the court decree.
(ii) if a court order states that both parents are responsible for the dependent child's health
care expenses or health care coverage, the provisions of (h)(2)(A) must determine the
order of benefits.
(iii) if a court order states that the parents have joint custody without specifying that one
parent has responsibility for the health care expenses or health care coverage of the
dependent child, the provisions of (h)(2)(A) must determine the order of benefits.
(iv) if there is no court order allocating responsibility for the dependent child's health care
expenses or health care coverage, the order of benefits for the child are as follows:
(I) the plan covering the custodial parent;
(II) the plan covering the spouse of the custodial parent;
(III) the plan covering the noncustodial parent; then
(IV) the plan covering the spouse of the noncustodial parent.
29418TX014-2023 98
(C) For a dependent child covered under more than one plan of individuals who are not the parents
of the child, the provisions of (h)(2)(A) or (h)(2)(B) must determine the order of benefits as if
those individuals were the parents of the child.
(D) For a dependent child who has coverage under either or both parents' plans and has his or her
own coverage as a dependent under a spouse's plan, (h)(5) applies.
(E) In the event the dependent child's coverage under the spouse's plan began on the same date as
the dependent child's coverage under either or both parents' plans, the order of benefits must
be determined by applying the birthday rule in (h)(2)(A) to the dependent child's parent(s)
and the dependent's spouse.
(3) Active, Retired, or Laid-off Employee. The plan that covers a person as an active employee, that is,
an employee who is neither laid off nor retired, is the primary plan. The plan that covers that same
person as a retired or laid-off employee is the secondary plan. The same would hold true if a person
is a dependent of an active employee and that same person is a dependent of a retired or laid-off
employee. If the plan that covers the same person as a retired or laid-off employee or as a
dependent of a retired or laid-off employee does not have this rule, and as a result, the plans do not
agree on the order of benefits, this rule does not apply. This rule does not apply if (h)(1) can
determine the order of benefits.
(4) COBRA or State Continuation Coverage. If a person whose coverage is provided under COBRA or
under a right of continuation provided by state or other federal law is covered under another plan,
the plan covering the person as an employee, enrollee, subscriber, or retiree or covering the person
as a dependent of an employee, enrollee, subscriber, or retiree is the primary plan, and the COBRA,
state, or other federal continuation coverage is the secondary plan. If the other plan does not have
this rule, and as a result, the plans do not agree on the order of benefits, this rule does not apply.
This rule does not apply if (h)(1) can determine the order of benefits.
(5) Longer or Shorter Length of Coverage. The plan that has covered the person for the longer period
of time is the primary plan, and the plan that has covered the person the shorter period of time is
the secondary plan.
(6) If the preceding rules do not determine the order of benefits, the allowable expenses must be
shared equally between the plans meeting the definition of plan. In addition, this plan will not pay
more than it would have paid had it been the primary plan.
EFFECT ON THE BENEFITS OF THIS PLAN

(a) When this plan is secondary, it may reduce its benefits so that the total benefits paid or provided by all
plans are not more than the total allowable expenses. In determining the amount to be paid for any
claim, the secondary plan will calculate the benefits it would have paid in the absence of other health
care coverage and apply that calculated amount to any allowable expense under its plan that is unpaid
by the primary plan. The secondary plan may then reduce its payment by the amount so that, when
combined with the amount paid by the primary plan, the total benefits paid or provided by all plans for
29418TX014-2023 99
the claim equal 100 percent of the total allowable expense for that claim. In addition, the secondary
plan must credit to its plan deductible any amounts it would have credited to its deductible in the
absence of other health care coverage.
(b) When an enrollee is also a Medicare beneficiary, this plan is secondary. In that case, the allowable
expense is reduced to reflect Medicare’s allowable amount. At no point should this plan’s allowable
amount exceed what the plan would pay if the plan was primary. Enrollees may no longer be eligible to
receive a premium subsidy for the Health Insurance Marketplace plan once Medicare coverage
becomes effective.
(c) If a covered enrollee is enrolled in two or more closed panel plans and if, for any reason, including the
provision of service by a non-panel provider, benefits are not payable by one closed panel plan, COB
must not apply between that plan and other closed panel plans.
COMPLIANCE WITH FEDERAL AND STATE LAWS CONCERNING CONFIDENTIAL INFORMATION

Certain facts about health care coverage and services are needed to apply these COB rules and to
determine benefits payable under this plan and other plans. This plan will comply with federal and state
law concerning confidential information for the purpose of applying these rules and determining benefits
payable under this plan and other plans covering the person claiming benefits. Each person claiming
benefits under this plan must give the plan any facts it needs to apply those rules and determine benefits.
FACILITY OF PAYMENT
A payment made under another plan may include an amount that should have been paid under this plan. If
it does, this plan may pay that amount to the organization that made that payment. That amount will then
be treated as though it were a benefit paid under this plan. This plan will not have to pay that amount
again. The term "payment made" includes providing benefits in the form of services, in which case
"payment made" means the reasonable cash value of the benefits provided in the form of services.
RIGHT OF RECOVERY
If the amount of the payments made by this plan is more than it should have paid under this COB provision,
it may recover the excess from one or more of the persons it has paid or for whom it has paid or any other
person or organization that may be responsible for the benefits or services provided for the covered
enrollee. The "amount of the payments made" includes the reasonable cash value of any benefits provided
in the form of services.
29418TX014-2023 100
ENROLLEE CLAIM REIMBURSEMENT
Notice of Claim
We must receive notice of claim within 30 days of the date the loss began or as soon as reasonably possible.
We must receive a request for reimbursement through receipt of a claim within 90 days of the date of
service.
Proof of Loss
We must receive written proof of loss within 90 days of the loss or as soon as reasonably possible. Proof of
loss furnished more than one year late will not be accepted, unless you or your covered dependent enrollee
had no legal capacity to submit such proof during that year.
Claim Submission
Providers will typically submit claims on your behalf, but sometimes you may have to pay for a covered
service and file a claim for reimbursement. This may happen if:
1. Your provider is not contracted with us.
2. You have an out-of-area emergency.
If you have paid for services we agreed to cover, you can request reimbursement for the amount you paid,
less any deductible, copayment or cost sharing that is your financial responsibility.
To request reimbursement for a covered service, you need a copy of the detailed claim from the provider.
You also need to submit a copy of the member reimbursement claim form posted at
Ambetter.SuperiorHealthPlan.com under “Member Resources”. Send all the documentation to us at the
following address:

Attn: Claims Department- Member Reimbursement
P.O. Box 5010
Farmington, MO 63640-3800
After getting your claim, we will let you know we have received it, begin an investigation and request all
items necessary to resolve the claim. We will do this in 15 days or less.
We will notify you, in writing, that we have either accepted or rejected your claim for processing within 15
days after receiving all items necessary to resolve your claim. If we accept your claim, we will make
payment within five business days after notifying you of the payment of your claim. If we reject your claim,
we will give you the reason your claim is rejected. If we are unable to come to a decision about your claim
within 15 days, we will let you know and explain why we need additional time, and will make our decision
to accept or reject your claim no later than the 45th day after our notice about the delay for paper claims or
no later than the 30th day after our notice about the delay for electronic claims.
29418TX014-2023 101
Claim Forms
The insurer, on receipt of a notice of claim, will provide to the claimant the forms usually provided by the
insurer for filing proof of loss. If the forms are not provided before the 16th day after the date of the notice,
the claimant shall be considered to have complied with the requirements of this contract as to proof of loss
on submitting, within the time fixed in the contract for filing proofs of loss, written proof covering the
occurrence, the character, and the extent of the loss for which the claim is made.
Proof of Loss
For a claim for loss for which this contract provides any periodic payment contingent on continuing loss, a
written proof of loss must be provided to the insurer at the insurer's designated office before the 91 st day
after the termination of the period for which the insurer is liable. For a claim for any other loss, a written
proof of loss must be provided to the insurer at the insurer's designated office before the 91 st day after the
date of the loss. Failure to provide the proof within the required time does not invalidate or reduce any
claim if it was not reasonably possible to give proof within the required time. In that case, the proof must
be provided as soon as reasonably possible but not later than one year after the date proof of loss is
otherwise required, except in the event of a legal incapacity.
Time of Payment of Claims

Indemnities payable under this contract for any loss, other than a loss for which this contract provides any
periodic payment, will be paid immediately on receipt of due written proof of the loss. Subject to due
written proof of loss, all accrued indemnities for a loss for which this contract provides periodic payment
will be paid monthly and any balance remaining unpaid on termination of liability will be paid immediately
on receipt of due written proof of loss.
Payment of Claims
Indemnity for loss of life will be payable in accordance with the beneficiary designation and the provisions
respecting indemnity payments that may be prescribed in this contract and effective at the time of
payment. If such a designation or provision is not then effective, the indemnity will be payable to the
enrollee's estate. Any other accrued indemnities unpaid at the enrollee's death may, at the option of the
insurer, be paid either in accordance with the beneficiary designation or to the enrollee's estate. All other
indemnities will be payable to the enrollee.
All benefits payable under this contract on behalf of a dependent enrollee who is insured by this contract
for which benefits for financial and medical assistance are being provided by Texas Health and Human
Services, shall be paid to said department whenever:
1. Texas Health and Human Services is paying benefits under the Human Resources Code, Chapter 31
or Chapter 32, i.e., financial and medical assistance service programs administered pursuant to the
Human Resources Code;
2. The parent who purchased the individual contract has possession or access to the child pursuant to
a court order, or is not entitled to access or possession of the child and is required by the court to
pay child support; and
3. The insurer or group nonprofit hospital service company must receive at its home office, written
notice affixed to the insurance claim when the claim is first submitted, and the notice must state
that all benefits paid pursuant to this section must be paid directly to Texas Health and Human
29418TX014-2023 102
Services.
Foreign Claims Incurred for Emergency Care

Medical emergency services is a covered service while traveling for up to a maximum of 90 consecutive days.
If travel extends beyond 90 consecutive days, no benefit coverage is provided for medical emergencies for
the entire period of travel including the first 90 days.
Claims incurred outside of the United States for emergency services and treatment of an enrollee must be
submitted in English or with an English translation, at the enrollee’s expense within 180 calendar days
from the date of service. Foreign claims must also include the applicable medical records in English or with
an English translation, at the enrollee’s expense to show proper proof of loss and evidence of payment(s) to
the provider.
Foreign claims must be submitted with the Member Reimbursement Medical Claim Form, along with all
requested documents as detailed on the claim form. All forms and member resources are available at
Ambetter.SuperiorHealthPlan.com.
The amount of reimbursement will be based on the following:

 Member’s benefit plan and member eligibility on date of service
 Member’s responsibility/share of cost based on date of service.
 Currency rate at the time of completed transaction, Foreign Country currency to United States
currency.
Once we have reviewed all the necessary documentation and the emergency claim has been processed, an
enrollee’s Explanation of Benefits (EOB) will be mailed. The EOB will identify member responsibility
according to the member benefit plan at the time of travel. If services are deemed as a true medical
emergency, enrollee will be issued reimbursement payment for any eligible incurred costs, minus member
cost share obligation.
Non-Assignment
The coverage, rights, privileges and benefits provided for under this contract are not assignable by you or
anyone acting on your behalf, except to a physician or other health care provider. Any assignment or
purported assignment of coverage, rights, privileges and benefits provided for under this contract that you
may provide or execute in favor of any hospital or any other person or entity other than a physician or
other health care provider shall be null and void and shall not impose any obligation on us.
No Third Party Beneficiaries

This contract is not intended to, nor does it, create or grant any rights in favor of any third party, including
but not limited to any hospital, provider or medical practitioner providing services to you, and this contract
shall not be construed to create any third party beneficiary rights.
29418TX014-2023 103
COMPLAINT AND APPEAL PROCEDURES
Complaint Process
“Complaint” means any dissatisfaction expressed by you orally or in writing to us with any aspect of our
operation, including but not limited to: dissatisfaction with plan administration; procedures related to
review or appeal of an adverse determination; the denial, reduction, or termination of a service for reasons
not related to medical necessity; the way a service is provided; or disenrollment decisions. An enrollee has
180 calendar days from the date of the incident to file a complaint. Complaints are considered standard
unless they concern an emergency or denial of continued stay for hospitalization, in which case they will be
considered expedited.
If you notify us orally or in writing of a complaint, we will, not later than the fifth business day after the date
of the receipt of the complaint, send to you a letter acknowledging the date we received your complaint. If
the complaint was received orally, we will enclose a one-page complaint form to be completed and returned
to us for prompt resolution of the complaint.
You should send your written complaint to:
Ambetter from Superior HealthPlan Complaint Department
Austin, TX 78741
Fax: 1-866-683-5369
After receipt of the written or oral complaint from you, we will investigate and send you a letter with our
resolution. The total time for acknowledging, investigating and resolving a standard complaint will not
exceed 30 calendar days after the date we receive your complaint.
For oral complaints received and not confirmed in writing, we will research the issue as best practice and
communicate findings to you verbally.
An expedited complaint concerning an emergency or denial of continued stay for hospitalization will be
resolved in one business day of receipt of your complaint. The investigation and resolution shall be
concluded in accordance with the medical immediacy of the case and we will send you a letter with our
resolution within three business days.
You may use the appeals process to resolve a dispute regarding the resolution of your complaint.
Complaint Appeals
1. If the complaint is not resolved to your satisfaction, you have the right either to appear in person
before a complaint appeal panel where you normally receive health care services, unless another site
is agreed to by you, or to address a written appeal to the complaint appeal panel. We shall complete
the appeals process not later than the 30th calendar day after the date of the receipt of the request
for appeal.
2. We shall send an acknowledgment letter to you not later the fifth business day after the date of
receipt of the request of the appeal.
3. We shall appoint members to the complaint appeal panel, which shall advise us on the resolution of
the dispute. The complaint appeal panel shall be composed of an equal number of our staff, providers,
29418TX014-2023 104
and enrollees. A member of the appeal panel may not have been previously involved in the disputed
decision.
4. Not later than the fifth business day before the scheduled meeting of the panel, unless you agree
otherwise, we shall provide to you or your designated representative:
a. any documentation to be presented to the panel by our staff;
b. the specialization of any providers consulted during the investigation; and
c. the name and affiliation of each of our representatives on the panel.
5. You, or your designated representative if you are a minor or disabled, are entitled to:
a. appear in person before the complaint appeal panel;
b. present alternative expert testimony; and
c. request the presence of and question any person responsible for making the prior determination
that resulted in the appeal.
6. Investigation and resolution of appeals relating to ongoing emergencies or denial of continued stays
for hospitalization shall be concluded in accordance with the medical immediacy of the case but in
no event to exceed one business day after your request for appeal.
7. Due to the ongoing emergency or continued hospital stay, and at your request, we shall provide, in
lieu of a complaint appeal panel, a review by a provider who has not previously reviewed the case
and is of the same or similar specialty as typically manages the medical condition, procedure, or
treatment under discussion for review of the appeal.
8. Notice of our final decision on the appeal must include a statement of the specific medical
determination, clinical basis, and contractual criteria used to reach the final decision.
Appeal of Adverse Determination

An "adverse determination" is a decision that is made by us or our Utilization Review Agent that the health
care services furnished or proposed to be furnished to you are not medically necessary or appropriate.
If you, your designated representative, or your provider of record disagree with the adverse determination,
you, your designated representative, or your provider may appeal the adverse determination orally or in
writing. An enrollee has 180 calendar days following receipt of a notification of an adverse determination to
file an appeal.
For a standard appeal, we will acknowledge your appeal within five business days after receiving a written
appeal of the adverse determination, we or our Utilization Review Agent will send you, your designated
representative, or your provider, a letter acknowledging the date of receipt of the appeal. The letter will also
include a list of documents that you, your designated representative, or your provider should send to us or
to our Utilization Review Agent for the appeal. The appeal will be resolved no later than 30 calendar days
after the date we or our Utilization Review Agent receives the appeal.
If you, your designated representative, or your provider orally appeal the adverse determination, we or our
Utilization Review Agent will send you, your designated representative, or your provider a one-page appeal
form. You are not required to return the completed form, but we encourage you to because it will help us
resolve your appeal. If additional time is needed due to matters beyond our control, you or your designated
representative will be notified before the 30th calendar day with specific reasons why the additional time is
needed and the additional time will be no greater than 15 calendar days.
29418TX014-2023 105
Expedited appeals of adverse determinations involving ongoing emergencies or denials of continued stays
in a hospital, denials of prescription drugs, intravenous infusions, or a denied step therapy protocol
exception will be resolved no later than one working day after the request is received.
You can also request an expedited appeal for an urgent care denial. We will answer your appeal for
urgent care within one working day or 72 hours, whichever is lesser, upon receipt of your request. You
can request an expedited appeal for urgent care if:
1. You think the denial could seriously hurt your life or health.
2. Your provider thinks that you will experience severe pain without the denied care or treatment.
External Review
If the appeal of the adverse determination is denied, you or your designated representative have the right to
request an external review of that decision. The external review organization is not affiliated with us or our
Utilization Review Agent. You may also request an external review without first completing an internal
appeal if your internal appeal rights have already been exhausted.
In circumstances involving a life-threatening condition, emergency services, hospitalized enrollees, denials of

prescription drugs, intravenous infusions, or a denied step therapy protocol exception, you, your designated
representative, or your provider is entitled to an immediate external review without having to comply with
the procedures for internal appeals of adverse determinations.
You or your designated representative can ask for a standard external review within four months after the
date you receive the final internal appeal determination notice. Your request should be submitted directly
to the external review organization, and you must provide the following information: name and address,
phone number, email address, whether the request is urgent or standard, a completed Appointment of
Representative Form if someone is filing on your behalf, and a brief description of the reason you disagree
with our decision. When the external review organization completes its review and issues its decision, we
will abide by the decision.
The appeal procedures described above do not prohibit you from pursuing other appropriate remedies,
including injunctive relief, declaratory judgment, or other relief available under law, if you believe that the
requirement of completing the appeal and review process places your health in serious jeopardy.
Simultaneous Expedited Appeal and Expedited Internal Review

In the case of an appeal involving urgent care, you or your authorized representative may also request an
expedited internal review. A request for expedited internal appeal may be submitted orally or in writing by
the enrollee or their authorized representative; and all necessary information, including our benefit
determination on review, shall be transmitted between us and the enrollee or their authorized
representative by telephone, facsimile, or other expeditious method. You may also request an expedited
external review without first completing an internal appeal if your internal appeal rights have already been
exhausted.
Filing Complaints with the Texas Department of Insurance

Any person, including persons who have attempted to resolve complaints through our complaint system
process and who are dissatisfied with the resolution, may report an alleged violation to the Texas
29418TX014-2023 106
Department of Insurance electronically at www.tdi.texas.gov or by phone at 1-800-252-3439.
You may also send a printed copy of your complaint to the Texas Department of Insurance:
1. By mail: Texas Department of Insurance, Consumer Protection (111-1A), P.O. Box 149104, Austin,
Texas 78714-9091
2. In person or by delivery service: Texas Department of Insurance, Consumer Protection (111-1A),
333 Guadalupe St., Austin, Texas 78701
3. By fax: (512) 490-1007
4. By email: [email protected]
The Commissioner of Insurance shall investigate a complaint against us to determine compliance within 60
days after the Texas Department of Insurance’s receipt of the complaint and all information necessary for
the Department to determine compliance. The Commissioner may extend the time necessary to complete
an investigation in the event any of the following circumstances occur:
1. additional information is needed;
2. an on-site review is necessary; or
3. We, the provider, or you do not provide all documentation necessary to complete the investigation;
or other circumstances beyond the control of the Department occur.
Retaliation Prohibited
1. We will not take any retaliatory action, including refusal to renew coverage, against you because you
or person acting on your behalf has filed a complaint against us or appealed a decision made by us.
2. We shall not engage in any retaliatory action, including terminating or refusal to renew a contract,
against a provider, because the provider has, on your behalf, reasonably filed a complaint against us
or has appealed a decision made by us.
29418TX014-2023 107
Appeal and Grievance Filing and Key Communication Timelines
Timely Allowable
Acknowledgment Resolution
Filing Extension
180
30 Calendar
Standard Grievance Calendar 5 Business Days 30 Calendar Days
Days
Days
180
Expedited Grievance Calendar N/A 72 Hours
Days N/A
180
Standard Pre-Service
Calendar 5 Business Days 30 Calendar Days N/A
Appeal
Days
180
Expedited Pre-Service
Calendar N/A 72 Hours
Appeal N/A
Days
180
Standard Post-Service 30 Calendar
Calendar 5 Business Days 30 Calendar Days
Appeal Days
Days
External Review 4 Months N/A 15 Calendar Days N/A
Expedited External N/A

4 Months N/A 72 Hours
Review
29418TX014-2023 108
ENROLLEE RIGHTS AND RESPONSIBILITIES
We are committed to:
1. Recognizing and respecting you as an enrollee.
2. Encouraging open discussions between you, your provider and medical practitioners.
3. Providing information to help you become an informed health care consumer.
4. Providing access to covered services and our network providers.
5. Sharing our expectations of you as an enrollee.
6. Providing coverage regardless of age, ethnicity, race, religion, gender, sexual orientation, national
origin, physical or mental disability, or expected health or genetic status.
You have the right to:

1. Participate with your provider and medical practitioners in decisions about your health care. This
includes working on any treatment plans and making care decisions. You should know any possible
risks, problems related to recovery, and the likelihood of success. You shall not have any treatment
without consent freely given by you or your legally authorized representative. You should be
informed of your care options.
2. Know who is approving and performing the procedures or treatment. All likely treatment and the
nature of the problem should be explained clearly.
3. Receive the benefits for which you have coverage.
4. Be treated with respect and dignity.
5. Privacy of your personal health information, consistent with state and federal laws, and our
policies.
6. Receive information or make recommendations, including changes, about our organization and
services, our network of physicians, medical practitioners, hospitals, other facilities and your rights
and responsibilities.
7. Candidly discuss with your provider and medical practitioners appropriate and medically necessary
care for your condition, including new uses of technology, regardless of cost or benefit coverage.
This includes information from your PCP about what might be wrong (to the level known),
treatment and any known likely results. Your PCP can tell you about treatments that may or may
not be covered by this contract, regardless of the cost. You have a right to know about any costs you
will need to pay. This should be told to you in words you can understand. When it is not
appropriate to give you information for medical reasons, the information can be given to a legally
authorized representative. Your provider will ask for your approval for treatment unless there is an
emergency and your life and health are in serious danger.
8. Voice complaints about: our organization, any benefit or coverage decisions we (or our designated
administrators) make, your coverage, or care provided.
9. File an appeal if you disagree with certain decisions we have made.
10. See your medical records.
11. Be kept informed of covered and non-covered services, program changes, how to access services,
providers, advance directive information, authorizations, benefit denials, enrollee rights and
responsibilities, and our other rules and guidelines. We will notify you at least 60 days before the
effective date of the modifications. Such notices shall include the following:
a. Any changes in clinical review criteria; and
29418TX014-2023 109
b. A statement of the effect of such changes on the personal liability of the enrollee for the cost
of any such changes.
12. A current list of network providers. You can also get information on your network providers’
education, training, and practice.
13. Select a health plan or switch health plans, within the guidelines, without any threats or
harassment.
14. Adequate access to qualified medical practitioners and treatment or services regardless of age,
ethnicity, race, religion, gender, sexual orientation, national origin, physical or mental disability, or
expected health or genetic status.
15. Access medically necessary urgent and emergency services 24 hours a day and seven days a week.
16. Receive information in a different format in compliance with the Americans with Disabilities Act, if
you have a disability.
17. Refuse treatment to the extent the law allows without jeopardizing future treatment, and be
informed by your provider(s) of the medical consequences. You are responsible for your actions if
treatment is refused or if the PCP’s instructions are not followed. You should discuss all concerns
about treatment with your primary care physician. Your PCP can discuss different treatment plans
with you, if there is more than one option that may help you. You will make the final decision.
18. Select your primary care physician within the network. You also have the right to change your PCP
or request information on network providers close to your home or work.
19. Know the name and job title of people giving you care. You also have the right to know which
provider is your PCP.
20. An interpreter when you do not speak or understand the language of the area.
21. A second opinion by a network provider, if you want more information about your treatment or
would like to explore additional treatment options.
22. Make advance directives for health care decisions. This includes planning treatment before you
need it. Advance directives are forms you can complete to protect your rights for medical care. It
can help your PCP and other providers understand your wishes about your health. Advance
directives will not take away your right to make your own decisions and will work only when you
are unable to speak for yourself. Enrollees also have the right to refuse to make advance directives.
You should not be discriminated against for not having an advance directive. Examples of advance
directives include:
a. Living Will;
b. Health Care Power of Attorney; or
c. “Do Not Resuscitate” Orders.
You have the responsibility to:

1. Read this entire contract.
2. Treat all health care professionals and staff with courtesy and respect.
3. Give accurate and complete information about present conditions, past illnesses, hospitalizations,
medications, and other matters about your health that we or your medical practitioners need in
order to provide care. You should make it known whether you clearly understand your care and
what is expected of you. You need to ask questions of your provider until you understand the care
you are receiving.
4. Review and understand the information you receive about us. You need to know the proper use of
29418TX014-2023 110
covered services.
5. Show your enrollee identification card and keep scheduled appointments with your provider, and
call the provider’s office during office hours whenever possible if you have a delay or cancellation.
6. Know the name of your PCP. You should establish a relationship with your provider. You may
change your PCP verbally or in writing by contacting Member Services.
7. Read and understand to the best of your ability all materials concerning your health benefits or ask
for help if you need it.
8. Understand your health problems and participate, along with your healthcare professionals and
providers in developing mutually agreed upon treatment goals to the degree possible.
9. Follow the treatment plans and instructions for care that you have agreed on with your health care
professionals and provider.
10. Tell your health care professional and provider if you do not understand your treatment plan or
what is expected of you. You should work with your PCP to develop treatment goals. If you do not
follow the treatment plan, you have the right to be advised of the likely results of your decision.
11. Follow all contract guidelines, provisions, policies and procedures.
12. Use any emergency room only when you think you have a medical emergency. For all other care,
you should call your PCP.
13. When you enroll in this coverage, give all information about any other medical coverage you have.
If, at any time, you get other medical coverage besides this coverage, you must tell the entity with
which you enrolled.
14. Pay your monthly premium, deductible amount, copayment amounts, and coinsurance amounts on
time.
15. Inform the entity in which you enrolled for this contract if you have any changes to your name,
address, or family members covered under this contract within 60 days from the date of the event.
Texas Department of Insurance Notice

1. An exclusive provider benefit plan provides no benefits for services you receive from non-network
providers, with specific exceptions as described in your contract and below.
2. You have the right to an adequate network of network providers.
a. If you believe that the network is inadequate, you may file a complaint with the Texas
Department of Insurance.
3. If your insurer approves a referral for non-network services because no network provider is
available, or if you have received non-network emergency services, your insurer must, in most cases,
resolve the non-network provider's bill so that you only have to pay any applicable coinsurance,
copay, and deductible amounts.
4. You may obtain a current directory of network providers at the following website:
Ambetter.SuperiorHealthPlan.com or by calling 1-877-687-1196 (Relay Texas/TTY 1-800-735-
2989) for assistance in finding available network providers. If you relied on materially inaccurate
directory information, you may be entitled to have a non-network claim paid at the network level of
benefits.
29418TX014-2023 111
GENERAL PROVISIONS
Entire Contract
This contract, with the enrollment application, the Schedule of Benefits, and any amendments or riders
attached, is the entire contract between you and us. No agent may:
1. Change this contract;
2. Waive any of the provisions of this contract;
3. Extend the time for payment of premiums; or
4. Waive any of our rights or requirements.
Non-Waiver
If we or you fail to enforce or to insist on strict compliance with any of the terms, conditions, limitations or
exclusions of the contract, that will not be considered a waiver of any rights under the contract. A past
failure to strictly enforce the contract will not be a waiver of any rights in the future, even in the same
situation or set of facts.
Rescissions
No misrepresentation of fact made regarding an enrollee during the enrollment application process that
relates to insurability will be used to void/rescind the coverage or deny a claim unless:
1. The misrepresented fact is contained in a written enrollment application, including amendments,
signed by an enrollee;
2. A copy of the enrollment application, and any amendments, has been furnished to the enrollee(s) or
to the enrollee’s personal representative; and
3. The misrepresentation of fact was intentionally made and material to our determination to issue
coverage to any enrollee. An enrollee's coverage will be voided/rescinded and claims denied if that
person performs an act or practice that constitutes fraud. “Rescind” has a retroactive effect and
means the coverage was never in effect.
Repayment for Fraud, Misrepresentation or False Information

During the first two years an enrollee is covered under the contract, if an enrollee commits fraud,
intentional misrepresentation of a material fact or knowingly provides false information relating to the
eligibility of any enrollee under this contract or in filing a claim for contract benefits, we have the right to
demand that enrollee pay back to us all benefits that we provided or paid during the time the enrollee was
covered under the contract.
Conformity with State Laws

Any part of this contract in conflict with the laws of Texas on this contract's effective date or on any
premium due date is changed to conform to the minimum requirements of Texas state law.
Conditions Prior To Legal Action

Legal Actions: An action at law or in equity may not be brought to recover on this contract before the 61st
day after the date written proof of loss has been provided in accordance with the requirements of this
contract. An action at law or in equity may not be brought after the expiration of three years after the time
written proof of loss is required to be provided.
29418TX014-2023 112
On occasion, we may have a disagreement related to coverage, benefits, premiums, or other provisions
under this contract. Litigation is an expensive and time-consuming way to resolve these disagreements and
should be the last resort in a resolution process.
Personal Health Information (PHI)

Your health information is personal. We are committed to do everything we can to protect it. Your privacy
is also important to us. We have policies and procedures in place to protect your health records.
We protect all oral, written and electronic PHI. We follow Health Insurance Portability and Accountability
Act (HIPAA) requirements and have a Notice of Privacy Practices. We are required to notify you about
these practices every year. This notice describes how your medical information may be used and disclosed
and how you can get access to this information. Please review it carefully. If you need more information or
would like the complete notice, please visit https://ambetter.SuperiorHealthPlan.com/privacy-
practices.html or call Member Services at 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989).
We protect all of your PHI. We follow HIPAA to keep your health care information private.
Language
If you don’t speak or understand the language in your area, you have the right to an interpreter. For
language assistance, please visit: https://ambetter.SuperiorHealthPlan.com/language-assistance.html.
Time Limit on Certain Defenses:

(a) After the second anniversary of the date this contract is issued, a misstatement, other than a
fraudulent misstatement, made by the applicant in the enrollment application for the contract may not be
used to void the contract or to deny a claim for loss incurred or disability (as defined in the contract)
beginning after that anniversary.
(b) A claim for loss incurred or disability (as defined in the contract) beginning after the second
anniversary of the date this contract is issued may not be reduced or denied on the ground that a disease
or physical condition not excluded from coverage by name or specific description effective on the date of
loss existed before the effective date of coverage of this contract.
29418TX014-2023 113
Statement of Non-Discrimination
Ambetter from Superior HealthPlan complies with applicable Federal civil rights laws and does not discriminate on the basis of race,
color, national origin, age, disability, or sex. Ambetter from Superior HealthPlan does not exclude people or treat them differently
because of race, color, national origin, age, disability, or sex.
Ambetter from Superior HealthPlan:
• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
o Qualified sign language interpreters
o Written information in other formats (large print, audio, accessible electronic formats, other formats)
• Provides free language services to people whose primary language is not English, such as:
o Qualified interpreters
o Information written in other languages
If you need these services, contact Ambetter from Superior HealthPlan at 1-877-687-1196 (Relay Texas/TTY: 1-800-735-2989).
If you believe that Ambetter from Superior HealthPlan has failed to provide these services or discriminated in another way on the basis
of race, color, national origin, age, disability, or sex, you can file a complaint with:
Superior HealthPlan Complaints Department
5900 E Ben White Blvd., Austin, TX 78741
1-877-687-1196 (Relay Texas/TTY: 1-800-735-2989)
Fax 1-866-683-5369
You can file a complaint by mail, fax, or email. If you need help filing a complaint, Ambetter from Superior HealthPlan is available to
help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically
through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201,
1-800-368-1019, 800-537-7697 (TDD).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Declaración de no discriminación
Ambetter de Superior HealthPlan cumple con las leyes de derechos civiles federales aplicables y no discrimina basándose en la raza,
color, origen nacional, edad, discapacidad, o sexo. Ambetter de Superior HealthPlan no excluye personas o las trata de manera diferente
debido a su raza, color, origen nacional, edad, discapacidad, o sexo.
Ambetter de Superior HealthPlan:
• P
roporciona ayuda y servicios gratuitos a las personas con discapacidad para que se comuniquen eficazmente con
nosotros, tales como:
o Intérpretes calificados de lenguaje por señas
o Información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles, otros formatos)
• Proporciona servicios de idiomas a las personas cuyo lenguaje primario no es el inglés, tales como:
o Intérpretes calificados
o Información escrita en otros idiomas
Si necesita estos servicios, comuníquese con Ambetter de Superior HealthPlan a 1-877-687-1196 (Relay Texas/TTY: 1-800-735-2989).
Si considera que Ambetter de Superior HealthPlan no le ha proporcionado estos servicios, o en cierto modo le ha discriminado debido a
su raza, color, origen nacional, edad, discapacidad o sexo, puede presentar una queja ante:
Superior HealthPlan Complaints Department
5900 E Ben White Blvd., Austin, TX 78741
1-877-687-1196 (Relay Texas/TTY: 1-800-735-2989)
Fax 1-866-683-5369
Usted puede presentar una queja por correo, fax, o correo electrónico. Si necesita ayuda para presentar una queja, Ambetter de
Superior HealthPlan está disponible para brindarle ayuda.
También puede presentar una queja de violación a sus derechos civiles ante la Oficina de derechos civiles del Departamento de Salud
y Servicios Humanos de Estados Unidos (U.S. Department of Health and Human Services), en forma electrónica a través del portal
de quejas de la Oficina de derechos civiles, disponible en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o por correo o vía telefónica
llamando al: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington,
DC 20201, 1-800-368-1019, 800-537-7697 (TDD).
Los formularios de queja están disponibles en http://www.hhs.gov/ocr/office/file/index.html.
SHP_20163873A-AMBETTER 2020
AMB19-TX-C-00016 © 2019 Celtic Insurance Company. All rights reserved.
© 2019 Celtic Insurance Company. Todos los derechos reservados.
Si usted, o alguien a quien está ayudando, tiene preguntas acerca de Ambetter de Superior HealthPlan, tiene derecho a obtener
Spanish: ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1-877-687-1196
(Relay Texas/TTY 1-800-735-2989).
Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Ambetter from Superior HealthPlan, quý vị sẽ có quyền được giúp và
Vietnamese: có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 1-877-687-1196
(Relay Texas/TTY 1-800-735-2989).
如果您，或是您正在協助的對象，有關於 Ambetter from Superior HealthPlan 方面的問題，您有權利免費以您的母語得到幫助和訊

Chinese:
息。如果要與一位翻譯員講話，請撥電話 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989)。
만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 Ambetter from Superior HealthPlan 에 관해서 질문이 있다면 귀하는 그러한 도움과
Korean: 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는 1-877-687-1196
(Relay Texas/TTY 1-800-735-2989) 로 전화하십시오.
‫ لديك الحق في الحصول على المساعدة والمعلومات الضرورية بلغتك‬، Ambetter from Superior HealthPlan ‫إذا كان لديك أو لدى شخص تساعده أسئلة حول‬
Arabic:
.(Relay Texas/TTY 1-800-735-2989) 1-877-687-1196 ‫ للتحدث مع مترجم اتصل بـ‬.‫من دون أية تكلفة‬
‫ آپ کو بالمعاوضہ اپنی زبان میں مدد‬،‫ یا جن کی آپ مدد کررہے ہیں ان کے سواالت ہوں تو‬،‫ کے بارے میں آپ‬Ambetter from Superior HealthPlan ‫اگر‬
Urdu: ‫( پر کال کریں۔‬Relay Texas/TTY 1-800-735-2989 )،1-877-687-1196 ،‫اور معلومات حاصل کرنے کا حق ہے۔ کسی مترجم سے بات کرنے کے لیے‬
Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Ambetter from Superior HealthPlan, may karapatan ka
Tagalog: na makakuha nang tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa
1-877-687-1196 (Relay Texas/TTY 1-800-735-2989).
Si vous-même ou une personne que vous aidez avez des questions à propos d’Ambetter from Superior HealthPlan, vous avez le
French: droit de bénéficier gratuitement d’aide et d’informations dans votre langue. Pour parler à un interprète, appelez le 1-877-687-1196
(Relay Texas/TTY 1-800-735-2989).
आप या जिसकी आप मदद कर रहे हैं उनके, Ambetter from Superior HealthPlan के बारे में कोई सवाल हों, तो आपको बबना ककसी खर्च के
Hindi: अपनी भाषा में मदद और िानकारी प्राप्त करने का अधिकार है। ककसी दभ
ु ाषषये से बात करने के ललए 1-877-687-1196
(Relay Texas/TTY 1-800-735-2989) पर कॉल करें ।
‫ از اين حق برخورداريد که کمک و اطالعات را‬،‫ داريد‬Ambetter from Superior HealthPlan ‫ يا کسي که به او کمک مي کنيد سؤالي در مورد‬،‫اگر شما‬
Persian: ‫( تماس‬Relay Texas/TTY 1-800-735-2989) 1-877-687-1196 ‫بصورت رايگان به زبان خود دريافت کنيد۔ براي صحبت کردن با مترجم با شماره‬
‫بگيريد۔‬
Falls Sie oder jemand, dem Sie helfen, Fragen zu Ambetter from Superior HealthPlan hat, haben Sie das Recht, kostenlose Hilfe
German: und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer
1-877-687-1196 (Relay Texas/TTY 1-800-735-2989) an.
જે તમને અથવા તમે જેમની મદદ કરી રહ્યા હોય તેમને, Ambetter from Superior HealthPlan વવશે કોઈ પ્રશ્ન હોય તો તમને, કોઈ ખર્ચ વવના
Gujarati: તમારી ભાષામાાં મદદ અને માહહતી પ્રાપ્ત કરવાનો અવિકાર છે . દુ ભાવષયા સાથે વાત કરવા માટે 1-877-687-1196
(Relay Texas/TTY 1-800-735-2989) ઉપર કૉલ કરો.
В случае возникновения у вас или у лица, которому вы помогаете, каких-либо вопросов о программе страхования Ambetter
Russian: from Superior HealthPlan вы имеете право получить бесплатную помощь и информацию на своем родном языке. Чтобы
поговорить с переводчиком, позвоните по телефону 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989).
Ambetter from Superior HealthPlan について何かご質問がございましたらご連絡ください。ご希望の言語によるサポートや情報を無料でご提供い

Japanese:
たします。通訳が必要な場合は、1-877-687-1196 (Relay Texas/TTY 1-800-735-2989) までお電話ください。
ຖ້ າທ
່ ານ ຫ
ຼື ຄົ ນທ່ ທ
່ ານກ
ໍ າລັງຊ່ ວຍເຫ
ຼື ອ ມໍ ຄາຖາມກ ່ ຽວກັບ Ambetter from Superior HealthPlan, ທ ່ ຈະໄດ
່ ານມິສດທ ້ ຮັບການຊ
່ ວຍເຫ ໍ້ ມ
ຼື ອແລະຂ ູ ນ
Laotian: ຂ
່ າວສານທ ່ ເປັ ນພາສາຂອງທ ່ ານ ໂດຍບ ໍ່ ມຄ່ າໃຊ
້ ຈ ຼື່ ອຈະເວ
່ າຍ. ເພ ້ົ າກັບນາຍພາສາ, ໃຫ
້ ໂທຫາ 1-877-687-1196
(Relay Texas/TTY 1-800-735-2989).
SHP_20163873C-AMBETTER
AMB16-TX-C-00076
AMB16-TX-C-00076 © 2016 Celtic Insurance
© 2016 CelticCompany. All rights
Insurance Company. reserved.
All rights reserved.

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2023 Major Medical Expense

CELTIC INSURANCE COMPANY FOR AMBETTER FROM

Major Medical Expense Policy

CELTIC INSURANCE COMPANY FOR AMBETTER FROM SUPERIOR HEALTHPLAN

Celtic Insurance Company

THIS IS NOT A POLICY OF WORKERS' COMPENSATION INSURANCE. THE EMPLOYER

THIS POLICY IS NOT A MEDICARE SUPPLEMENT POLICY OR CERTIFICATE. If you are

Ambetter from Superior HealthPlan

To get information or file a complaint with your insurance company or HMO:

Mail: 5900 E. Ben White Blvd.

The Texas Department of Insurance

Call with a question: 1-800-252-3439

File a complaint: www.tdi.texas.gov

Mail: MC 111-1A, P.O. Box 149091, Austin, TX 78714-9091

¿Tiene una queja o necesita ayuda?

Ambetter from Superior HealthPlan

Teléfono gratuito: 1-877-687-1196

El Departamento de Seguros de Texas

queja ante el estado:

Llame con sus preguntas al: 1-800-252-3439

Presente una queja en: www.tdi.texas.gov

Correo electrónico: [email protected]

Dirección postal: MC 111-1A, P.O. Box 149091, Austin, TX 78714-9091

AGREEMENT AND CONSIDERATION

Celtic Insurance Company

Kevin J. Counihan, President

How To Contact Us:

Your Provider Directory

Your Enrollee Identification Card

Ten-Day Right to Examine this Contract

Protection from Balance Billing

Adverse determination means any decision by us which results in:

Center of Excellence means a hospital that:

Complications of pregnancy means:

Custodial care includes (but is not limited to) the following:

Diagnostic imaging means an imaging examination using mammography, ultrasound imaging, or

Extended care facility means an institution, or a distinct part of an institution, that:

Home health care agency means a business that:

Hospital is a licensed institution and operated pursuant to law that:

Necessary medical supplies means medical supplies that are:

Neurocognitive rehabilitation are services designed to assist cognitively impaired enrollees to

Neurophysiological testing is an evaluation of the functions of the nervous system.

Neuropsychological testing is the administering of a comprehensive battery of tests to evaluate

Neuropsychological treatment means interventions designed to improve or minimize deficits in

Spouse means the person to whom you are lawfully married.

Surgery or surgical procedure means:

Effective Date for Initial Dependent Enrollees

Coverage for a Newborn Child

Coverage for an Adopted Child

Adding Other Dependent Enrollees

In the case of erroneous enrollment, contract violation, or exceptional circumstances, coverage is

When an enrollee is not receiving a premium subsidy:

Third Party Payment of Premium or Cost Sharing

Change or Misstatement of Residence

Misstatement of Tobacco or Nicotine Use

The following are exceptions to the deductibles described above:

The deductible amount does not include any copayment amount.

Coinsurance Stop-Loss Amount

Individual Coinsurance Stop-Loss Amount

Family Coinsurance Stop-Loss Amount