AMB-TX-HP-SHP_20210614 AMBETTER FROM SUPERIOR

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AMBETTER FROM SUPERIOR HEALTHPLAN

HEALTH MAINTENANCE ORGANIZATION

WRITTEN DESCRIPTION OF COVERAGE

PROVIDED BY AMBETTER FROM SUPERIOR HEALTHPLAN

(Hereafter referred to as “Ambetter from Superior HealthPlan”)

The entity providing this coverage to you is an HMO, Superior HealthPlan. Your Evidence of

Coverage only provides benefits for services received from participating providers, except as

otherwise noted in the contract and written description or as otherwise required by law.

A network means a group of providers or facilities (including, but not limited to hospitals,

inpatient mental healthcare 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

healthcare services to our enrollees for an agreed upon fee. Enrollees will receive most, if not

all, of their healthcare services by accessing the network.

For additional information please write or call:

Ambetter from Superior HealthPlan

5900 E. Ben White Blvd.

Austin, TX 78741

1-877-687-1196

A network provider (or participating provider) means any 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.

Covered Services and Benefits

The Ambetter from Superior HealthPlan Summary of Benefits and plan brochures for all plan

options can be found at the links below. These documents will explain all covered services and

benefits, including payment for services of a participating provider and non-participating

provider, and prescription drug coverage, both generic and name brand after the deductible

has been met.

The summary of benefits will also provide an explanation of your financial responsibility for

payment for any premiums, deductibles, copayments, coinsurance or other out-of-pocket

expenses for non-covered or non-participating services. Please note that we will pay the

negotiated fee or usual and customary rate to non-participating or non-network providers, as

explained under the “eligible service expense” definition found in your contract.

Bronze/Essential Care Plans

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Silver/ Balanced Care Plans

Gold/Secure Care Plans

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.

Ambulance Services

Covered service expenses will include ambulance services for local 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.

Air Ambulance Service Benefits

Covered service expenses will include ambulance services for ground, water, fixed wing and

rotary wing air transportation 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.

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

5. When an enrollee is required by us to move from a non-network provider to a network

provider.

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 healthcare 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

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agency of the United States;

3. who is certified as a provider under the TRICARE military health system; or

4. who is acting under the supervision of a health care practitioner.

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.

Mental Health and Substance Use Disorder Benefits

Covered inpatient and outpatient mental health and/or substance use disorder services are as

follows:

Inpatient

1. Inpatient psychiatric hospitalization;

2. Inpatient detoxification treatment;

3. Observation;

4. Crisis stabilization;

5. Inpatient rehabilitation;

6. Residential treatment facility for mental health and substance use; and

7. 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; and

12. Medication Assisted Treatment – combines behavioral therapy and medications to treat

substance use disorders;

13. Transcranial Magnetic Stimulation (TMS);

14. Assertive Community Treatment (ACT).

Chiropractic Services

Chiropractic services are covered when a participating chiropractor finds that the services are

medically necessary to treat or diagnose neuromusculoskeletal disorders on an outpatient basis.

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Dialysis Services

Covered service expenses and supplies include:

1. Services provided in an outpatient dialysis facility or when services are provided in the

home by a preferred 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.

Radiology, Imaging and Other Diagnostic Testing

Medically necessary radiology services, imaging and tests performed are a covered service (e.g.,

X-ray, MRI, CT scan, PET/SPECT, mammogram, ultrasound).

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 U.S. 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.

Home Health Care Service Expense Benefits

Coverage is provided for Medically Necessary in-network care provided at the enrollee’s home

and are limited to the following charges:

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.

8. Sleep studies.

Hospice Care Benefits

Hospice care benefits are allowable for a terminally ill enrollee receiving medically necessary care

under a hospice care program. Covered services and supplies include:

1. Room and board in a hospice while the enrollee is an inpatient.

2. Occupational therapy.

3. Speech-language therapy.

4. Respiratory therapy.

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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. Counseling the enrollee regarding his or her terminal illness.

8. Terminal illness counseling of the enrollee's immediate family.

9. Bereavement counseling.

Respite Care Expense Benefits

Respite care is only for home and inpatient locations, and are not only subject to deductible.

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. Daily room and board and nursing services while confined in an intensive care unit.

3. Inpatient use of an operating, treatment, or recovery room.

4. Outpatient use of an operating, treatment, or recovery room for surgery.

5. Services and supplies, including drugs and medicines, which are routinely provided by

the hospital to persons for use only while they are inpatient.

6. Emergency treatment of an injury or illness, even if confinement is not required. See

your Schedule of Benefits for limitations.

7. Administration of whole blood and blood plasma. (Note: Whole blood, including the

cost of blood, blood plasma, and blood expanders that are not replaced by or for the

enrollee).

8. Meals and special diets when medically necessary.

9. Private Duty Nursing when medically necessary.

10. Short term rehabilitation therapy services when in an acute hospital setting.

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.

Durable Medical Equipment

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.

Medical and Surgical Supplies

Coverage for non-durable medical supplies and equipment for management of disease and

treatment of medical and surgical conditions.

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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.

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 caesarean

delivery. Coverage will include post-delivery care for a mother and newborn who are discharged

before the expiration of the minimum hours of coverage.

Newborn Charges

Medically necessary services, including hospital services, are provided for a covered newborn

child immediately after birth.

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.

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.

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).

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.

Preventive Care Services

Covered services include the charges incurred by an enrollee for the following preventive health

services if appropriate for that enrollee in accordance with the following recommendations and

guidelines:

 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.

Additional Preventive Care Services include:

 Preventive Care Services for Children

 Preventive Care Services for Women, including Pregnant Women

 Preventive Services for Adults

 Routine Exams and Immunizations

 Certain Tests for Detection of Human Papillomavirus, Ovarian and Cervical Cancer

 Mammography Screening and Diagnostic Imaging

 Detection and Prevention of Osteoporosis

 Certain Tests for Detection of Prostate Cancer

 Early Detection Tests for Cardiovascular Disease

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 Screening Tests for Hearing Impairment

 Contraceptive Care

 Medically Necessary Vision Services

Sleep Studies

Sleep studies are covered when determined to be medically necessary.

Transplant Services

Transplants are a covered benefit when an enrollee is accepted as a transplant candidate and

pre-authorized in accordance with the contract.

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;

4. Scratch-resistant coating; and

5. Low vision aids as medically necessary.

Emergency Care Service and Benefits

Your Evidence of Coverage provides coverage for medical emergencies wherever they occur.

In an emergency, always call 911 or go to the nearest hospital emergency room (ER).

Anything that could endanger your life (or your unborn child’s life, if you’re pregnant) without

immediate medical attention is considered an emergency situation. 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, you should contact the network provider or behavioral health practitioner

before going to the hospital emergency room/treatment room. He/she can help you determine

if you need emergency care or treatment for an accidental injury and recommend that care. If

you cannot reach your provider and you believe the care you need is an emergency, you

should go to the nearest emergency facility, whether or not the facility is a preferred/network

provider.

If admitted for the emergency condition immediately following the visit, prior authorization of the

inpatient hospital admission will be required, and inpatient hospital expenses will apply. All

treatment received during the first 48 hours following the onset of a medical emergency will be

eligible for network benefits. After 48 hours, network benefits will be available only if you use

preferred/network providers. If after the first 48 hours of treatment following the onset of a

medical emergency, and if you can safely be transferred to the care of a preferred/network

provider but are treated by a non-network provider, only out-of-network benefits will be

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available.

Your contract also covers after-hours care. Sometimes you need medical help for non-life

threatening conditions when your PCP’s office is closed. If this happens, you have options. You

can call our 24/7 Nurse Advice Line at 1-877-687-1196. A registered nurse is always available

and ready to answer your health questions. You can get medical advice, a diagnosis or a

prescription by phone or video by using our Telehealth services 24/7. Visit our website for

details. You can also go to an urgent care center. An urgent care center provides fast, hands-

on care for illnesses or injuries that aren’t life threatening but still need to be treated within 24

hours. Typically, you will go to an urgent care if your PCP cannot get you in for a visit right

away. Common urgent care issues include sprains, ear infections, high fevers and flu

symptoms or vomiting.

Out-of-Area Service and Benefits

When outside of the service area, routine or maintenance care is not covered. However, your

Evidence of Coverage covers emergency care out of the service area, subject to deductibles,

coinsurance and maximum out of pockets, as listed in the Covered Healthcare Services and

Supplies section of your contract. A definition of the Ambetter from Superior HealthPlan service

area is defined within this document.

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 ID card for further information.

Hospital Based Providers

When receiving care on or after 1/1/2020, at a network hospital or other facility, it is possible that

some hospital-based providers (for example, anesthesiologists, emergency room providers,

radiologists, pathologists) may not be under contract with Ambetter as network providers. If

appropriate notice is provided to and acknowledged by you before rendering services, these

providers cannot bill you for the difference between Ambetter’s eligible service expense and the

provider’s billed charge – this is known as “balance billing”, unless a notice and disclosure

statement was signed ten days prior to receiving care. 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 Ambetter. You may not be balance billed for non-emergency ancillary

services (emergency medicine, anesthesiology, pathology, radiology, diagnostic imaging,

laboratory services, 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. If you are ever balance billed contact Member Services immediately at the

number listed on the back of your ID card.

Although healthcare services may be or have been provided to you at a healthcare facility that

is a member of the provider network used by Ambetter, other professional services may be or

have been provided at or through the facility by physicians and other medical practitioners who

are not members of that network.

If you receive a bill for emergent, covered services prior to 1/1/2020, rendered at a non-

network facility or by a non-network provider, you must submit that bill and all related

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documentation to the Texas Department of Insurance to initiate a request for balance billing

mediation. A copy of the request form may be obtained by calling 1-800-252-3439.

Enrollee's Financial Responsibility

The following are the features of your Evidence of Coverage with Ambetter from Superior

HealthPlan that require you to assume financial responsibility for payment of premiums,

deductibles, coinsurance or any other out-of-pocket expenses for non-covered services. You

will be fully responsible for payment for any services that are not covered service expenses or

are obtained out-of-network, with the exception of emergency services or prior authorized out-

of-network services including access to non-participating providers when a participating

provider is not reasonably available to you.

Premium Payment

PREMIUMS ARE SUBJECT TO CHANGE AT CONTRACT RENEWAL. Renewal premiums for

this contract will increase periodically depending upon your age and plan year.

Each premium is to be paid to us 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 advanced

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

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 advanced premium tax credits on behalf of the enrollee from the

Department of the Treasury, and will return the advanced 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

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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 HHS, as necessary, of the non-payment of

premiums, the enrollee, as well as providers of the possibility of denied claims when the

enrollee is in the grace period.

Deductibles

In addition to your premium, your Evidence of Contract requires you to pay the amount of the

deductible from one of the available plan options for each covered person for each calendar

year.

The benefits of the plan 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 participant under your coverage each calendar

year.

This deductible, unless otherwise indicated, will be applied to all categories of eligible service

expenses before benefits are available under the plan.

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 on 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.

After the deductible is satisfied, regular contract benefits will pay for covered expenses at the

coinsurance percentage level for covered inpatient and outpatient expenses each calendar year.

Your Evidence of Coverage payments may be limited by contract exclusions and limitations. You

will be responsible for any charge that is left unpaid after Ambetter from Superior HealthPlan

has paid up to its contract limits and obligations.

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 plan is in force under the contract if the charge for the

service or supply qualifies as an eligible service expense.

When the annual out-of-pocket maximum has been met, additional covered service expenses

will be provided or payable at 100% 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 service expenses.

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The applicable deductible amount(s), coinsurance, and copayment amounts are shown on

the Schedule of Benefits.

Note: The bill you receive for services or supplies from a non-network provider may be

significantly higher than the eligible service expenses for those services or supplies. In addition

to the deductible amount, copayment amount, and coinsurance, you are responsible for the

difference between the eligible service expense and the amount the provider bills you for the

services or supplies. Any amount you are obligated to pay to the provider in excess of the

eligible service expense will not apply to your deductible amount or out-of-pocket maximum.

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

fifteenth day of the month will become effective on the first day of the following month. Requests

between the sixteenth 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.

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Evidence of Coverage Limitations 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 an enrollee or 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.

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 the 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, except as expressly provided for under the Benefits

After Coverage Terminates clause in this contract's Termination section.

2. For any portion of the charges that are in excess of the eligible service 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 where a woman is at serious risk of substantial impairment of a major bodily

function unless the abortion is performed).

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, except those meeting the definition of telehealth services or

telemedicine medical services, or for failure to keep a scheduled appointment.

11. For services provided outside of a primary care provider visit, when a referral is not

obtained through your primary care provider, except in an emergency, or as specified

elsewhere in this contract.

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12. For stand-by availability of a medical practitioner when no treatment is rendered.

13. For dental service expenses, including braces for any medical or dental condition,

surgery and treatment for oral surgery, except as expressly provided for under your

Dental Benefit Rider, if applicable.

14. 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.

15. For mental health exams 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 are medically necessary and would

otherwise be covered under this contract;

e. Testing of aptitude, ability, intelligence or interest; or

f. Evaluation for the purpose of maintaining employment. Benefits will be allowed

for services that would otherwise be covered under this contract.

16. For charges related to, or in preparation for, tissue or organ transplants, except as

expressly provided for under the Transplant Services provision.

17. For eye refractive surgery, when the primary purpose is to correct nearsightedness,

farsightedness, or astigmatism.

18. While confined primarily to receive rehabilitation, custodial care, educational care, or

nursing services (unless expressly provided for in this contract).

19. For vocational or recreational therapy, vocational rehabilitation, outpatient speech

therapy, or occupational therapy, except as expressly provided for in this contract.

20. For alternative or complementary medicine using non-orthodox therapeutic practices that

do not follow conventional medicine. These include, but are not limited to, wilderness

therapy, outdoor therapy, boot camp, equine therapy, and similar programs.

21. 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.

22. For treatment received outside the United States, except for a medical emergency

while traveling.

23. 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.

24. As a result of:

a. For any illness or injury incurred as a result of the enrollee being intoxicated, as

defined by applicable state law in the state in which the loss occurred, or under the

influence of illegal narcotics or controlled substance unless administer or

prescribed by a physician, except as expressly provided under the Mental Health

and Substance Abuse Expense Benefit and excluding presence of mental health

AMB-TX-HP-SHP_20210614

and substance abuse disorders.

25. For or related to treatment of hyperhidrosis (excessive sweating).

26. For fetal reduction surgery.

27. 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.

28. 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).

29. 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.

30. As a result of any injury sustained while at a residential treatment facility.

31. For the following miscellaneous items: in vitro fertilization, artificial insemination (except

where 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;

32. Services of a private duty registered nurse rendered on an outpatient basis.

33. Diagnostic testing, laboratory procedures, screenings, or examinations performed for the

purpose of obtaining, maintaining, or monitoring employment.

34. For any medicinal and recreational use of cannabis or marijuana.

35. 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;

AMB-TX-HP-SHP_20210614

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

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 enrollee’s possessing an active

contract with us and/ or the child possesses an active contract with us at the time of

birth.

36. 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.

37. For all health care services obtained at an Urgent Care Facility that is a non-network

provider

Non-Covered Services and Exclusions:

No benefits will be paid under this benefit subsection 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, blood, or blood plasma, except when used for preventative care

and listed on the formulary.

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 on the formulary. This exclusion does not

apply to prescribed FDA approved contraceptive methods

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. 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.

AMB-TX-HP-SHP_20210614

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 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.

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 dispensed from a non-lock-in pharmacy while enrollee is in opioid lock-in

program.

20. For any drug related to surrogate pregnancy.

21. For any drug used to treat hyperhidrosis.

22. 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.

23. 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.

24. For any prescription or over the counter version of vitamin(s) unless otherwise included on

the formulary.

25. Medication refills where an enrollee has more than 15 days' supply of medication on hand.

Lock-in program

To help 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

member 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.

Prior Authorization Requirements for Services

Some medical, pharmaceutical and behavioral health covered services require prior

authorization. In general, network providers do not need to obtain authorization from Ambetter

from Superior HealthPlan prior to providing a service or supply to an enrollee. However, there

are some covered services for which you must obtain the prior authorization.

Enrollees are required to obtain a referral from their PCP for in-network specialists or other

providers for additional healthcare services deemed medically necessary. A referral is required

prior to a non-emergent visit with a practitioner outside of your PCP care services (excluding

emergencies, urgent care, behavioral/mental health care services, and ob/gyn services). This

includes, but is not limited to, in-person office visits, specialist consultations, and diagnostic

testing, as well as visits to an in-network facility. Emergency Room services do not require a

referral. You do not need a referral from your network primary care physician for in-network

mental or behavioral health services, obstetrical or gynecological treatment and may seek care

directly from a network obstetrician or gynecologist.

For services or supplies that require prior authorization, as shown on the Schedule of Benefits,

you must obtain prior authorization from us before you or your dependent enrollee:

AMB-TX-HP-SHP_20210614

1. Receive a service or supply from a non-network provider;

2. Are admitted into a network facility by a non-network provider; or

3. Receive a service or supply from a network provider to which you or your dependent

enrollee were referred by a non-network provider.

To obtain prior authorization or to confirm that a network provider has obtained prior

authorization, contact Ambetter from Superior HealthPlan by telephone at the telephone number

listed on your identification card before the service or supply is provided to the enrollee. Failure

to comply with the prior authorization requirements may result in benefits being reduced or not

covered. 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. Please see your contract and Schedule of Benefits for specific details.

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 3 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.

4. For post-service requests, within 30 calendar days of receipt of the request.

Continuity of Treatment In The Event of Termination of a Preferred Provider's Participation in

the Plan

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 member 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 the health plan 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.

AMB-TX-HP-SHP_20210614

Complaint Procedures

You may file a complaint regarding any aspect of the plan. We will not take any action against

you due solely that you, your representative or your provider files a complaint against us.

You must send your complaint in writing to the address below. You can call Member Services at

1-877-687-1196 (Relay Texas/TTY 1-800-735-2989) for assistance.

You should send your written complaint to:

Ambetter from Superior HealthPlan Complaint Department

5900 E. Ben White Blvd.

Austin, TX 78741

Fax: 1-800-310-0943

Expedited Complaints: If your complaint concerns an emergency or a situation in which you may

be forced to leave the hospital prematurely, we will resolve it no later than 7 2 h o u r s

f r o m the time that we receive it. Within 72 hours, you will get a letter with the resolution to

your complaint.

Non-Expedited (Standard) Complaints: If the complaint is not expedited, you will get the

resolution within thirty (30) calendar days of the date we receive the complaint.

Appealing a Complaint Resolution: If you aren’t satisfied with the resolution to your complaint,

you can request an appeal of the complaint resolution. You must do so within 90 days from the

date of the incident. In response to your complaint appeal, we will hold a complaint appeal panel

at a location in your area. A complaint appeal panel includes our staff, provider(s) and

enrollee(s). You will receive a hearing packet five days before the appeal panel hearing. You

may attend the hearing, have someone represent you at the hearing or have a representative

attend the hearing with you. The panel will make a recommendation for the final decision on

your complaint. You will receive our final decision within 30 days of your complaint appeal

request.

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 (1) business day after the

request is received.

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.

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.

Access to OB/GYN Services

Female enrollees shall have direct access to an OB/GYN (who is a network provider) for female

AMB-TX-HP-SHP_20210614

services. You do not need a referral from your network primary care physician for obstetrical or

gynecological treatment and may seek care directly from a network obstetrician or gynecologist.

AMB-TX-HP-SHP_20210614

Network Information

A current list of preferred providers, including names, locations of physicians and health care

providers and which preferred providers are not accepting new patients can be found by visiting

and using our Find a Provider tool: Ambetter.SuperiorHealthPlan.com/findadoc

This tool will have the most up-to-date information about our provider network. It can help you

find a Primary Care Provider (PCP), pharmacy, lab, hospital or specialist. The search can be

narrowed by:

 Provider specialty

 ZIP code

 Gender

 Languages spoken

 Whether or not he/she is currently accepting new patients

You can find all of the information listed below on our website using the Find a Provider tool.

You can also call Member Services to get information on providers’ medical school and

residency information.

 Name, address, telephone numbers

 Professional qualifications

 Specialty

 Board certification status

A non-electronic copy may be obtained free of charge by contacting Member Services at 1-877-

687-1196 (Relay Texas/TTY 1-800-735-2989).

Texas Department of Insurance Notice

 A health maintenance organization (HMO) plan provides for services you receive from

out-of-network physicians or providers, with specific exceptions as described in your

evidence of coverage and below.

 You have the right to an adequate network of participating providers (known as

“network physicians and providers”).

o If you believe that the network is inadequate, you may file a complaint with the

Texas Department of Insurance at www.tdi.texas.gov/consumer.complfrm.html.

 If your HMO approves a referral for out-of-network services because no participating

provider is available, or if you have received out-of-network emergency care, your HMO

must, in most cases, resolve the non-participating provider's bill so that you only have

to pay any applicable coinsurance, copay, and deductible amounts.

 You may obtain a current directory of participating providers at the following website:

Ambetter from Superior HealthPlan or by calling 1-877-687-1196 (Relay Texas/ TTY 1-

800-735-2989 for assistance in finding available participating providers. If you relied on

materially inaccurate directory information, you may be entitled to have an out-of-

network claim paid at the in-network level of benefits, if you present a copy of the

inaccurate directory information to the HMO, dated not more than 30 days before you

received the service.

Ambetter from Superior HealthPlan Service Area and Number of Enrollees

Service area is any place that is within the counties in the state of Texas that Ambetter has

designated as the service area for this plan. Ambetter from Superior HealthPlan’s service area

includes the following counties: Aransas, Armstrong, Atascosa, Austin, Bandera, Bastrop, Bell,

AMB-TX-HP-SHP_20210614

Bexar, Blanco, Bosque, Brazoria, Brazos, Brewster, Brooks, Brown, Burleson, Burnet,

Caldwell, Calhoun, Cameron, Camp, Carson, Castro, Chambers, Cherokee, Coke, Coleman,

Collin, Collingsworth, 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, 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, Waller, Webb, Wharton,

Wheeler, Willacy, Williamson, Wise, Wood, and Zapata.

The number of effectuated members in Ambetter’s service area under the Superior HealthPlan

HMO license is currently unknown. Please refer to the table below for a breakdown of

effectuated members based on service area.

Service Area

Total

Effectuated

Members

Aransas

Armstrong

Atascosa

Austin

Bandera

Bastrop

Bell

Bexar

Blanco

Bosque

Brazoria

Brazos

Brewster

Brooks

Brown

Burleson

Burnet

Caldwell

Calhoun

Cameron

Camp

Carson

Castro

Chambers

AMB-TX-HP-SHP_20210614

Cherokee

Coke

Coleman

Collin

Collingsworth

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

Grayson

Gregg

Grimes

Guadalupe

Hamilton

Hardin

Harris

Hartley

Hays

Henderson

Hidalgo

AMB-TX-HP-SHP_20210614

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

AMB-TX-HP-SHP_20210614

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

Waller

Webb

Wharton

Wheeler

Willacy

Williamson

Wise

Wood

Zapata

AMB-TX-HP-SHP_20210614

Network Demographics

Provider Type

Service Area

Primary

Care

Pediatrics -

Routine/Primary

Care

Gynecology

(OB/GYN)

Psychiatry

Surgery

Acute

General

Hospital

Aransas

Armstrong

Atascosa

Austin

Bandera

Bastrop

Bell

Bexar

1621

405

617

105

804

Blanco

Bosque

Brazoria

110

Brazos

272

Brewster

Brooks

Brown

Burleson

Burnet

Caldwell

Calhoun

Cameron

442

119

130

160

Camp

Carson

Castro

Chambers

Cherokee

Coke

Coleman

Collin

754

150

218

400

Collingsworth

Comal

Comanche

Concho

Cooke

Dallam

Dallas

1997

306

312

622

Deaf Smith

Delta

Denton

472

DeWitt

Donley

Ector

AMB-TX-HP-SHP_20210614

Edwards

El Paso

601

222

259

286

Ellis

226

Falls

Fannin

Fayette

Fisher

Fort Bend

331

Freestone

Frio

Galveston

Gillespie

Goliad

Gonzales

Grayson

Gregg

Grimes

Guadalupe

Hamilton

Hardin

Harris

2719

766

554

412

885

Hartley

Hays

150

Henderson

Hidalgo

952

300

198

257

Hill

Hood

Houston

Hunt

Irion

Jack

Jackson

Jefferson

Johnson

Kendall

Kerr

Kimble

Kinney

Lampasas

Lavaca

Lee

Leon

Liberty

Limestone

Llano

Madison

Mason

AMB-TX-HP-SHP_20210614

Matagorda

Maverick

McCulloch

McLennan

135

Medina

Menard

Milam

Mills

Mitchell

Montague

Montgomery

460

112

Nacogdoches

Navarro

Nueces

186

156

191

Oldham

Orange

Palo Pinto

Panola

Parker

Parmer

Potter

227

145

Rains

Randall

Real

Refugio

Robertson

Rockwall

Runnels

Rusk

San Jacinto

San Saba

Schleicher

Scurry

Sherman

Smith

153

Somervell

Starr

Sterling

Stonewall

Sutton

Tarrant

1546

222

340

105

451

Tom Green

216

Travis

1267

642

422

166

740

Trinity

Tyler

Val Verde

Van Zandt

AMB-TX-HP-SHP_20210614

Victoria

148

Waller

Webb

142

Wharton

Wheeler

Willacy

Williamson

430

200

230

Wise

Wood

Zapata

AMB-TX-HP-SHP_20210614

Waivers and Local Market Access Plan

A waiver and local market access plan applies to the services provided by the below listed

providers in each service area denoted by an “X.”

Provider Type

Service Area

Primary

Care

Pediatrics -

Routine/Primary

Care

Gynecology

(OB/GYN)

Psychiatry

Surgery

Acute

General

Hospital

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

Comal

Comanche

Concho

Cooke

Dallam

Dallas

Deaf Smith

Delta

AMB-TX-HP-SHP_20210614

Denton

DeWitt

Donley

Ector

Edwards

El Paso

Ellis

Falls

Fannin

Fayette

Fisher

Fort Bend

Freestone

Frio

Galveston

Gillespie

Goliad

Gonzales

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

AMB-TX-HP-SHP_20210614

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

AMB-TX-HP-SHP_20210614

Sutton

Tarrant

Tom Green

Travis

Trinity

Tyler

Val Verde

Van Zandt

Victoria

Waller

Webb

Wharton

Wheeler

Willacy

Williamson

Wise

Wood

Zapata

This access plan may be obtained by contacting Ambetter from Superior HealthPlan at 1-877-

687-1196 (Relay Texas/TTY: 1-800-735-2989).

AMB-TX-HP-SHP_20210614

Guaranteed Renewable

This contract is guaranteed renewable. That means that you have the right to keep the contract in force

with the same benefits, except that we may discontinue or terminate the contract if:

1. You fail to pay premiums as required under the contract;

2. You have performed an act or practice that constitutes fraud, or have made an intentional

misrepresentation of material fact, relating in any way to the contract, including claims for

benefits under the contract; or

3. We stop issuing the contract in Texas, but only if we notify you in advance.

Unless the contract is 'noncancellable,' as defined in the contract, we have the right to raise rates on

your contract at each time of renewal, in a manner consistent with the contract and Texas law. We will

provide a written notice of increase in a charge for coverage not less than 60 days before the date the

increase takes effect. If the contract is noncancellable, our right to raise rates is limited by the definition

of 'noncancellable' contained in the contract, and by Texas law.

Annually, we may change the rate table used for this contract form. Each premium will be based on the

rate table in effect on that premium's due date. The plan, and age of covered 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.

At least 31 days notice of any plan to take an action or make a change permitted by this clause will be

delivered to you at your last address as shown in our records. We will make no change in your premium

solely because of claims made under this contract or a change in a covered enrollee’s health. While this

contract is in force, we will not restrict coverage already in force. If we discontinue offering and refuse 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.

Annually, we must file this product, the cost share and the rates associated with it for approval.

Guaranteed renewable means that your plan 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 or (2) there is fraud or an intentional material misrepresentation made by or with

the knowledge of an enrollee in filing a claim for covered services.

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.