Ambetter Health Plans Texas
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About Ambetter
Ambetter Superior Health Plans is the Health Insurance Marketplace (HIM) option operated by CeltiCare, a subsidiary of the Centene Corporation. AmBetter offers lower premiums in bronze, silver and gold coverage categories with a full-price (unsubsidized) premium compared to BCBS of Texas. But the real savings is with the Silver plans, with AmBetter’s cheapest plan carrying a monthly premium 30% lower than a comparable BlueCross BlueShield Texas plan. Ambetter offers only HMO plans or Exclusive Provider Organization (EPO) plans on the exchange. No PPO plans are currently available in the Texas individual marketplace Ambetter has been selling policies on the ACA exchange in Texas since it opened in 2014 has a significant presence in Texas — including Austin, San Antonio and El Paso among other regions. It added 12 counties for 2018 including Tarrant, Denton, Dallas and Rockwall.
Ambetter Silver:
The best value and the most balance between your monthly premium payments and out-of-pocket expenses. Recommended if you:
- See your primary care physician for preventive care every year
- Don’t anticipate any major ongoing medical needs
- Want a monthly premium that fit most budgets
- Want Out-of-pocket expenses that fit most budgets
Ambetter Gold:
Peace of mind for all your healthcare needs. Recommended if you:
- Will use coverage often
- Have an ongoing medical condition that needs treatment
- Want additional security and peace of mind
- Don’t mind higher monthly premiums
- Want lower out-of-pocket costs
Ambetter Value
Recommended if you:
- Want to use your primary care physician for all referrals
- Don’t mind your care being coordinated through a PCP
- Don’t mind needing referrals to see a specialist.
Ambetter Virtual Access (HMO)
Recommended if you:
- Prefer connecting with your doctor virtually
- Don’t already have a preferred PCP
- Want $0 virtual visit copays
- Don’t mind a referral being needed to visit a hospital or specialist
The Good
- Member resources
- Unique features
- My Health Pays
- Dental and vision
Member Resources
Ambetter members are given access to an online portal, through which they can make all their payments, view their plan benefits, and take care of logistics like obtaining a member ID card. The member portal offers extra features too, such as providing reminders for members when they are due for another doctor’s visit or allowing them to take a health risk assessment to determine which steps they can take to live healthier. There’s also a section for member news alerts and, of course, social media accounts with Ambetter that members can connect to. If you’re looking to get an Ambetter plan, you can view their health plans by first selecting the state you live in and then selecting a metal type for the plan tier you’re most interested in.
From there, your options open up to several different plans with varying prices and benefits. Members can track their claims 24/7 through the online portal, as well as connect with member services or a nurse hotline at any hour of the day. The subsidy estimator in the online account also helps members see how much they would receive for reimbursement for a treatment with their benefits. Admittedly, many of the resources available to members do not extend far beyond the basic ones supplied by other health insurance companies. Nonetheless, Ambetter’s online portal and customer service mediums do make members’ experience more convenient and secure.
Unique Features
Ambetter provides more than just logistical tools for members. Many of the extra features they offer also send the message that they want their members to get healthier and stay healthier. These tools include a 24/7 nurse hotline that members can access for questions and medical needs. There are also health-promoting programs such as the StartSmart for Your Baby program, which provides support for expecting mothers. Ambetter has support for members coping with behavioral health issues, chronic illnesses, and similar struggles as well. My Health Pays is a rewards program offered by Ambetter, and through it members can be reimbursed for gym memberships and even earn back money for getting a wellness exam or a flu shot. This money can then be used toward a copay or monthly premium down the road.
My Health Pays
Members earn rewards for taking charge of their health! Use rewards to help pay for healthcare related costs like premium payments, doctor copays, deductibles or coinsurance.
$0 copay
For virtual urgent care visits including mental and behavioral health on most plans
24/7 Nurse Line
Customers have 24/7 access to a nurse and can contact this healthcare professional for sudden medical concerns and other questions. Round-the-clock support like this adds reassurance to members’ experience.
Dental and Vision
Dental and vision coverage are available with Ambetter, but the benefits and availability of each are entirely specific to the state you live in and the type of plan you’ve signed up for. Dental coverage, for example, is not available in Texas, but vision insurance is. Dental coverage includes exams, cleanings, and screenings, overall, and vision benefits include yearly eye exams and glasses or contacts.
The Bad
- Types of plans offered (HMO, EPO – no PPO or HSA plans)
- Service areas
- Service areas
- Access to plan information
Types of Plans Offered
It’s somewhat difficult to access specific information about the types of health plans Ambetter has. Their website primarily just explains the metal tiers for their plans, as well as how essential health benefits are covered by every plan. But to find out what kinds of plans these are (such as HMO, PPO, etc.), not to mention what prices and benefits you qualify for, you’ll have to contact a representative. Up front, it’s important to know that Ambetter is part of the Health Insurance Marketplace (HIM). It’s Centene’s option for HIM plans, which is intended for people who don’t have health insurance and maybe don’t qualify for typical plans. In HIM territory, Medicare isn’t an option, for example, because if you qualify for Medicare, that’s the legal option for you to get rather than taking advantage of a plan like Ambetter’s. Medicaid and CHIP are HIM plans, though. Ambetter has PPOs, HMOs, and EPOs.
They don’t offer HSAs though. They’ve divided their plans into three metal tiers: Bronze, Silver, and Gold. All three of these tiers cover “essential health benefits,” Ambetter’s term for services like preventative and emergency care, therapy, behavioral health help, medications, maternity, and hospitalization. But the difference in the tiers comes in the costs for premiums and out-of-pocket expenses. Bronze plans have the lowest premiums but the highest OOP costs, and Gold has the highest premiums but the lowest OOP costs. Silver, of course, is the in the middle.
No Mobile App
Unlike many of its competitors, Ambetter doesn’t have a mobile app. Some companies provide this for members to access their accounts right from their phones, making communication and logistics much easier. Ambetter hasn’t provided this yet, making account management slightly less convenient than with other companies.
Access to Plan Information
Ultimately, it’s kind of hard to find specific information about the health plans at Ambetter. The company doesn’t provide enough assistance with truly understanding HIM plans, knowing which types are available up front, and comparing the costs of these plans in one place.
Ambetter Texas Coverage Map
2024 Texas Coverage Map
2024 County Coverage:
- 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
- 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
Ambetter Silver
Ambetter Silver:
The best value and the most balance between your monthly premium payments and out-of-pocket expenses. Silver Care plans provide the best value and most balance between your monthly premium payments and out-of-pocket costs, especially if you’re eligible for financial assistance. Recommended if you:
- See your primary care physician for preventive care every year
- Don’t anticipate any major ongoing medical needs
- Want a monthly premium that fit most budgets
- Want Out-of-pocket expenses that fit most budgets
Standard Cost Share Silver Plan Comparison (On-Exchange)
| Plan Name | Deductible | Out of Pocket Max | PCP / Specialist | Virtual 24/7 Care | Urgent Care | Labs Outpatient | Preferred Generic Rx | Generic Rx |
| Complete Silver | $6,000 | $8,500 | $30 / $60 | No charge | $60 | $30 | $3 Copay per prescription |
$20 Copay per prescription |
| Clear Silver | $5,400 | $5,400 | No charge after ded | No charge | No charge after ded | No charge after ded | No charge after deductible |
No charge after deductible |
| Focused Silver | $6,300 | $8,000 | $45 / $100 | No charge | $60 | $50 | $3 Copay per prescription |
$25 Copay per prescription |
| Standard Silver | $5,900 | $9,100 | $40 / $80 | $40 | $60 | 40% after ded | $20 Copay per prescription | $20 Copay per prescription |
| Complete Silver + Vision + Adult Dental | $6,000 | $8,500 | $30 / $60 | No charge | $60 | $30 | $3 Copay per prescription |
$20 Copay per |
| Standard Silver + Vision + Adult Dental | $5,900 | $9,100 | $40 / $80 | $40 | $60 | 40% after ded | $20 Copay per prescription |
$20 Copay per prescription |
| Focused Silver + Vision + Adult Dental | $6,300 | $8,000 | $45 / $100 | No charge | $60 | $50 | $3 Copay per prescription |
$25 Copay per prescription |
| Clear Silver + Vision + Adult Dental | $5,400 | $5,400 | No charge after ded | No charge | No charge after ded | No charge after ded | No charge after deductible |
No charge after deductible |
| Ambetter Virtual Access Silver (Virtual PCP selection required) | $5,700 | $7,400 | $40 / $100 | No charge | $60 | $50 | $3 Copay per prescription |
$25 Copay per prescription |
| Standard Ambetter Virtual Access Silver (Virtual PCP selection required) |
$5,900 | $9,100 | $40 / $80 | $40 | $60 | 40% after ded | $20 Copay per prescription |
$20 Copay per prescription |
| Complete VALUE Silver | $6,000 | $8,500 | $30 / $60 | No charge | $60 | $30 | $3 Copay per prescription |
$20 Copay per prescription |
| Clear VALUE Silver | $5,400 | $5,400 | No charge after ded | No charge | No charge after ded | No charge after ded | No charge after deductible |
No charge after deductible |
| Focused VALUE Silver | $6,300 | $8,000 | $45 / $100 | No charge | $60 | $50 | $3 Copay per prescription |
$25 Copay per prescription |
| Standard Silver VALUE | $5,900 | $9,100 | $40 / $80 | $40 | $60 | 40% after ded | $20 Copay per prescription |
$20 Copay per prescription |
Ambetter Gold
Ambetter Gold:
Peace of mind for all your healthcare needs. You’ll have peace of mind for all your healthcare needs with Gold Care. Expect higher monthly premium payments to help limit your out-of-pocket costs later. Recommended if you:
- Will use coverage often
- Have an ongoing medical condition that needs treatment
- Want additional security and peace of mind
- Don’t mind higher monthly premiums
- Want lower out-of-pocket costs
Standard Cost Share Gold Plan Comparison (On-Exchange)
| Plan Name | Deductible | Out of Pocket Max | PCP / Specialist | Virtual 24/7 Care | Urgent Care | Labs Outpatient | Preferred Generic Rx | Generic Rx |
| Complete Gold | $1,450 | $7,500 | $15 / $35 | No charge | $35 | $15 | $3 Copay per prescription |
$15 Copay per prescription |
| Everyday Gold | $750 | $7,500 | $35 / $55 | No charge | $35 | $45 | $3 Copay per prescription |
$15 Copay per prescription |
| Clear Gold | $900 | $8,700 | $25 / $60 | No charge | $60 | 30% after ded | $3 Copay per prescription |
$15 Copay per prescription |
| Standard Gold | $1,500 | $8,700 | $30 / $60 | $30 | $45 | 25% after ded | $15 Copay per prescription | $15 Copay per prescription |
| Complete Gold + Vision + Adult Dental | $1,450 | $7,500 | $15 / $35 | No charge | $35 | $15 | $3 Copay per prescription |
$15 Copay per prescription |
| Standard Gold + Vision + Adult Dental | $1,500 | $8,700 | $30 / $60 | $30 | $45 | 25% after ded | $15 Copay per prescription | $15 Copay per prescription |
| Everyday Gold + Vision + Adult Dental | $750 | $7,500 | $35 / $55 | No charge | $35 | $35 | $3 Copay per prescription |
$15 Copay per prescription |
| Clear Gold + Vision + Adult Dental | $900 | $8,700 | $25 / $60 | No charge | $60 | 30% after ded | $3 Copay per prescription |
$15 Copay per prescription |
| Ambetter Virtual Access Gold (Virtual PCP selection required) | $950 | $8,700 | $20 / $45 | No charge | $30 | $20 | $3 Copay per prescription |
$15 Copay per prescription |
| Standard Ambetter Virtual Access Gold (Virtual PCP selection required) |
$1,500 | $8,700 | $30 / $60 | $30 | $45 | 25% after ded | $15 Copay per prescription | $15 Copay per prescription |
| Everyday VALUE Gold | $750 | $7,500 | $35 / $55 | No charge | $35 | $35 | $3 Copay per prescription |
$15 Copay per prescription |
| Standard Gold VALUE | $1,500 | $8,700 | $30 / $60 | $30 | $45 | 25% after ded | $15 Copay per prescription | $15 Copay per prescription |
Ambetter Value
Ambetter Value
Recommended if you:
- Want to use your primary care physician for all referrals
- Don’t mind your care being coordinated through a PCP
- Don’t mind needing referrals to see a specialist.
Ambetter’s Value Plans are affordably priced plans that feature specific health care providers and hospitals. Members on our Value plans will be assigned to a PCP within a Medical Group who will coordinate their care. These plans require referrals for most care outside of what the PCP can provide, such as seeing a specialist. Ambetter Value Plans are available in select counties in Texas and are in Silver and Gold plan metal levels. Learn more about Ambetter Value Plan.
Your Medical Group is an assigned group of providers. You will be assigned to a primary care provider (PCP) in your Medical Group to get care. This will ensure that the services you receive will be covered by your plan. Your PCP can help you with:
- Prescriptions
- Lab tests
- Imaging services, like x-rays, ultrasounds or CT scans
- Referrals for doctors other than a PCP, like a cardiologist, dermatologist or dietitian1
Note: If you need care beyond what your PCP provides, you will need to get a referral from your PCP for that care1. Without a PCP referral, your claims may be denied.
Ambetter Value plan options are offered in the following areas:
- Bexar
- Collin
- Dallas
- Denton
- Fort Bend
- Harris
- Montgomery
- Rockwall
- Tarrant
- Travis
- Williamson
Ambetter Virtual Access (HMO)
Ambetter Virtual Access (HMO)
Recommended if you:
- Prefer connecting with your doctor virtually
- Don’t already have a preferred PCP
- Want $0 virtual visit copays
- Don’t mind a referral being needed to visit a hospital or specialist
Our Ambetter Virtual Access plans provide you with a full virtual primary care experience. Ambetter Virtual Access members are assigned a Teladoc Primary Care Provider (PCP). The Teladoc PCP can order labs, imaging, write prescriptions, and make referrals for on-the-ground care as needed. To see a specialist, members will simply request a referral from their Virtual Access PCP. Learn More about Ambetter Virtual Access Plan.
Ambetter Virtual Access Plan options are offered in the following areas:
- 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
- Zapata
Plan Brochures
Coming soon
2024 CORE Network Highlights
2024 Core Network with Baylor Scott & White
Baylor Scott & White Health is the largest non-profit healthcare system in Texas based in Dallas. Baylor Scott & White Health hospitals provide access to care to the underserved and uninsured in collaboration with other affiliates across their system.
Baylor Scott & White Overall: U.S. News & World Report’s “Best Hospitals Guide” consistently ranks Baylor University Medical Center as a high-performing hospital.
Baylor Scott & White Health Network:
- The Core network includes the robust set of BS&W North Texas affiliated facilities & providers.
- 32 of BS&W hospitals are included in the Core network
- As a system, BS&W has 800 patient care sites, 7,500 active physicians, and 49,000 employees
- Baylor University Medical Center has 844 licensed beds and serves as the flagship hospital of Baylor Scott & White Health –North Texas
2024 Core Network with Memorial Hermann System
Memorial Hermann Health System is the largest not-for-profit health system in southeast Texas. They actively partner with community health organizations to bring accessible healthcare to the underserved/uninsured communities throughout Houston.
Memorial Hermann System Overall: Memorial Hermann System in Houston, TX is nationally ranked in 4 pediatric specialties and rated high performing in 7 adult specialties and 13 procedures and conditions.
Memorial Hermann Hospital Network:
- 15 hospitals
- 8 Cancer Centers
- 5 Heart & Vascular Institutes
- 38 sports medicine and rehabilitation centers, in addition to other outpatient and rehabilitation centers.
- Memorial Hermann Texas Medical Center, the first hospital founded in the Texas Medical Center, has 1,034 beds.
2024 Core Network with Texas Health Resources (THR)
Texas Health Resources is one of the largest faith-based nonprofit health systems in the United States and the largest in North Texas in terms of inpatients and outpatients served. The health system includes Texas Health Physicians Group and hospitals under the banners of Texas Health Presbyterian, Texas Health Arlington Memorial, Texas Health Harris Methodist and Texas Health Huguley and serves more than 7 million TX residents.
Texas Health Resources System Overall: U.S. News & World Report’s Best Hospitals routinely ranks Texas Health hospitals among the best in Dallas-Fort Worth & Ranked nine years in a row on Fortune’s 100 Best Companies to Work For® list and Fortune’s Best Workplaces in Health Care
THR Hospital Network:
- 29hospitals with 4,180 licensed beds
- 32 surgery centers
- 18 urgent care centers
- 460+ PCPs across 130 locations
- 360+ specialists across 80 locations
2024 VALUE Network Highlights
2024 Value Network Highlights
2024 Value Network with CHI St. Luke’s
CHI St. Luke’s Health based in Houston is a part of one of the largest health system and the second largest faith-based health system in the United States. Their facilities have been recognized as some of the best in the nation.
•
CHI St. Luke’s Overall: CHI St. Luke’s was an added provider for Houston Value plan in 2023. This provider is also contracted on our Core product. CHI St. Luke’s cares for the communities in and around the Texas Medical Center, Sugar Land, The Woodlands, Pasadena, Pearland, Springwoods Village, Holcombe, Northwest Houston, and the Galleria area.
CHI St. Luke’s Network:
- 6 CHI St Luke’s Houston area hospitals are included in Value network
- 1,181 beds across the 6 Houston area hospitals
2024 Value Network with HCA
HCA Healthcare is one of the nation’s leading providers of healthcare services dedicated to providing healthcare services that meet each community’s local healthcare needs. They seek to integrate various services to deliver patient care with maximum quality and efficiency.
HCA Overview:
- HCA is a keyprovider partner for the Value plan in 4 regions: Austin, Dallas, Houston and San Antonio
- HCA is also fully contracted on ourCore product
- As a learning health system, HCA Healthcare analyzes data gathered from 32 million+ patient encounters each year to develop technologies and best practices that improve patient care.
HCA Network:
- 48 HCA Hospital facilities, with plans to build 5additional hospitals
- 632 affiliated sites ranging from -General Acute Care, Psychiatric, Rehabilitation and Ambulatory Surgical Centers
- 92 urgent care locations, with plans to add 41more
Pharmacy Resources
Ambetter from Superior HealthPlan is committed to providing appropriate, high quality, and cost effective drug therapy to all Ambetter from Superior HealthPlan members. Ambetter works with providers and pharmacists to ensure that medications used to treat a variety of conditions and diseases are covered. Ambetter covers prescription medications and certain over-the-counter (OTC) medications when ordered by a practitioner. The pharmacy program does not cover all medications. Some medications require prior authorization (PA) or have limitations on age, dosage, and maximum quantities. Choosing a pharmacy Ambetter has a variety of convenient in-network pharmacies. These include: HEB, CVS and Walmart, as well as many independent pharmacies in your area. To find a network pharmacy near you, use the Find a Provider Tool and follow these steps:
- Enter your zip code or address, or click Use my Current location.
- Click Detailed Search and select Pharmacy from the Type of Provider drop-down menu.
- If you are looking for a specific pharmacy like Home Infusion Therapy or Long Term Care, select that under the Specialty drop-down menu. Otherwise, you can skip this step.
- If you need help finding a pharmacy, please call Member Services at 1-877-687-1196. Relay Texas/TTY users should call 1-800-735-2989.
More on Ambetter’s pharmacy program. To find the cost of your medications please use the Drug Cost Tool. Use the Preferred Drug List to find more information on the drugs that Ambetter covers.
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