Ambetter Health Plans Texas
Plan Overviews
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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.
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
My Health Pays is Ambetter’s rewards program to provide incentives for members to live healthier with better habits. You can earn money for taking a survey provided by Ambetter, getting a flu shot, or having your wellness exam, and this money can go toward your next premium.
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.
Service Areas
Ambetter plans are available in a select few states. These are Arkansas, Florida, Georgia, Mississippi, Illinois, Indiana, Massachusetts, New Hampshire, Ohio, Texas, Washington, and Wisconsin. If you don’t live in any of these states, then obviously Ambetter isn’t an option for you.
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.
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| Plan Name | Essential Care 1 (2019) – Standard | Essential Care 5 (2019) with 3 Free PCP Visits – Standard |
| Medical Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. (Ind/Fam) | $6,800/$13,600 | $6,800/$13,600 |
| Prescription Drug Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. (Ind/Fam) | Integrated with medical ded. | Integrated with medical ded. |
| Out-of-Pocket MaximumAn out-of-pocket maximum is the most you'll have to pay during a policy period (usually a year) for health care services (Ind/Fam) | $6,800/$13,600 | $6,800/$13,600 |
| Annual Well Visit/ Preventive Care | No charge | No charge |
| PCP Office Visit | No charge after ded. | No charge after ded. |
| Specialist Office Visit | No charge after ded. | No charge after ded. |
| Imaging (CT/PET Scans, MRIs) | No charge after ded. | No charge after ded. |
| X-rays & Diagnostic Imaging | No charge after ded. | No charge after ded. |
| Urgent Care | No charge after ded. | No charge after ded. |
| Emergency Room* | No charge after ded. | No charge after ded. |
| Emergency Transportation* | No charge after ded. | No charge after ded. |
| Inpatient Facility Fee | No charge after ded. | No charge after ded. |
| Inpatient Hospital Physician & Surgical Services | No charge after ded. | No charge after ded. |
| Outpatient Facility Fee | No charge after ded. | No charge after ded. |
| Outpatient Surgery Physician/Surgical Services | No charge after ded. | No charge after ded. |
| Labs & Diagnostics | No charge after ded. | No charge after ded. |
| Mental/Behavioral Health & Substance Use Disorder Outpatient Services | No charge after ded. | No charge after ded. |
| Rehabilitation Outpatient Services (Includes Speech, Occupational, Physical Therapy) | No charge after ded. | No charge after ded. |
| Skilled Nursing Facility | No charge after ded. | No charge after ded. |
| Pediatric Vision- Routine Eye Exam (1 visit per year) | 100% Covered | 100% Covered |
| Pediatric Vision- Eyeglasses (frames, 1 per year) | 100% Covered | 100% Covered |
| Pedicatric Vision- Lenses (per pair) | 100% Covered | 100% Covered |
| Pharmacy* (Generic / Preferred / Non-preferred / Specialty) | $20 / No charge after ded. / No charge after ded. / No charge after ded. | No charge after ded. / No charge after ded. / No charge after ded. / No charge after ded. |
| Plan Name | Balanced Care 1 (2016) – Standard | Balanced Care 2 (2016) – Standard | Balanced Care 10 (2016) – Standard |
| Medical Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim.(Ind/Fam) | $5,500/$11,000 | $6,500/$13,000 | $4,500/$9,000 |
| Prescription Drug Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. (Ind/Fam) | Integrated with medical ded. | Integrated with medical ded. | Integrated with medical ded. |
| Out-of-Pocket MaximumAn out-of-pocket maximum is the most you'll have to pay during a policy period (usually a year) for health care services (Ind/Fam) | $6,500/$13,000 | $6,500/$13,000 | $6,500/$13,000 |
| Annual Well Visit/ Preventive Care | No charge | No charge | No charge |
| PCP Office Visit | 30 | 30 | 20 |
| Specialist Office Visit | 60 | 60 | 40 |
| Imaging (CT/PET Scans, MRIs) | 20% after ded. | No charge after ded. | 20% after ded. |
| X-rays & Diagnostic Imaging | 20% after ded. | No charge after ded. | 20% after ded. |
| Urgent Care | 100 | 100 | 100 |
| Emergency Room* | 20% after ded. | No charge after ded. | 20% after ded. |
| Emergency Transportation* | 20% after ded. | No charge after ded. | 20% after ded. |
| Inpatient Facility Fee | 20% after ded. | No charge after ded. | 20% after ded. |
| Inpatient Hospital Physician & Surgical Services | 20% after ded. | No charge after ded. | 20% after ded. |
| Outpatient Facility Fee | 20% after ded. | No charge after ded. | 20% after ded. |
| Outpatient Surgery Physician/Surgical Services | 20% after ded. | No charge after ded. | 20% after ded. |
| Labs & Diagnostics | 20% after ded. | No charge after ded. | 20% after ded. |
| Mental/Behavioral Health & Substance Use Disorder Outpatient Services | 30 | 30 | 20 |
| Rehabilitation Outpatient Services (Includes Speech, Occupational, Physical Therapy) | 20% after ded. | No charge after ded. | 20% after ded. |
| Skilled Nursing Facility | 20% after ded. | No charge after ded. | 20% after ded. |
| Pediatric Vision- Routine Eye Exam (1 visit per year) | 100% Covered | 100% Covered | 100% Covered |
| Pediatric Vision- Eyeglasses (frames, 1 per year) | 100% Covered | 100% Covered | 100% Covered |
| Pedicatric Vision- Lenses (per pair) | 100% Covered | 100% Covered | 100% Covered |
| Pharmacy* (Generic / Preferred / Non-preferred / Specialty) | $10 / $50 / 20% after Rx ded. / 20% after Rx ded. | $15 / $50 / No charge after ded. / No charge after ded. | $10 / $50 / 20% after ded. / 20% after ded. |
| Plan Name | Secure Care 1 (2016) with 3 Free PCP Visits – Standard |
| Medical Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. (Ind/Fam) | $1,000/$2,000 |
| Prescription Drug Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. (Ind/Fam) | $500/$1,000 |
| Out-of-Pocket MaximumAn out-of-pocket maximum is the most you'll have to pay during a policy period (usually a year) for health care services (Ind/Fam) | $6,350/$12,700 |
| Annual Well Visit/ Preventive Care | No charge |
| PCP Office Visit | 20% after ded. |
| Specialist Office Visit | 20% after ded. |
| Imaging (CT/PET Scans, MRIs) | 20% after ded. |
| X-rays & Diagnostic Imaging | 20% after ded. |
| Urgent Care | 20% after ded. |
| Emergency Room* | $250 after ded. |
| Emergency Transportation* | 20% after ded. |
| Inpatient Facility Fee | 20% after ded. |
| Inpatient Hospital Physician & Surgical Services | 20% after ded. |
| Outpatient Facility Fee | 20% after ded. |
| Outpatient Surgery Physician/Surgical Services | 20% after ded. |
| Labs & Diagnostics | 20% after ded. |
| Mental/Behavioral Health & Substance Use Disorder Outpatient Services | 20% after ded. |
| Rehabilitation Outpatient Services (Includes Speech, Occupational, Physical Therapy) | 20% after ded. |
| Skilled Nursing Facility | 20% after ded. |
| Pediatric Vision- Routine Eye Exam (1 visit per year) | 100% Covered |
| Pediatric Vision- Eyeglasses (frames, 1 per year) | 100% covered |
| Pedicatric Vision- Lenses (per pair) | 100% covered |
| Pharmacy* (Generic / Preferred / Non-preferred / Specialty) | $10 / $25 after Rx ded. / $75 after Rx ded. / 30% after Rx ded. |
Ambetter Texas Plans
Ambetter Texas Coverage Map
Plan Brochures
| Plan Name | Deductible | Out-Of-Pocket | Coinsurance | Brochures | Summary of Benefits |
| Ambetter Secure Care 1 (2016) with 3 Free PCP Visits (Zero Cost Share) | $0 | $0 | 0% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 1 (2016) (Zero Cost Share) | $0 | $0 | 0% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 2 (2016) (Zero Cost Share) | $0 | $0 | 0% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 10 (2016) (Zero Cost Share) | $0 | $0 | 0% Coinsurance | View PDF | View PDF |
| Ambetter Essential Care 1 (2016) (Zero Cost Share) | $0 | $0 | 0% Coinsurance | View PDF | View PDF |
| Ambetter Essential Care 5 (2016) with 3 Free PCP Visits (Zero Cost Share) | $0 | $0 | 0% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 1 (2016) + Vision (Zero Cost Share) | $0 | $0 | 0% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 2 (2016) + Vision (Zero Cost Share) | $0 | $0 | 0% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 10 (2016) + Vision (Zero Cost Share) | $0 | $0 | 0% Coinsurance | View PDF | View PDF |
| Ambetter Essential Care 1 (2016) + Vision (Zero Cost Share) | $0 | $0 | 0% Coinsurance | View PDF | View PDF |
| Ambetter Essential Care 5 (2016) with 3 Free PCP Visits + Vision (Zero Cost Share) | $0 | $0 | 0% Coinsurance | View PDF | View PDF |
| Ambetter Secure Care 1 (2016) with 3 Free PCP Visits (Limited Cost Share) | $1,000 | $6,350 | 20% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 1 (2016) (Limited Cost Share) | $5,500 | $6,500 | 20% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 2 (2016) (Limited Cost Share) | $6,500 | $6,500 | 0% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 10 (2016) (Limited Cost Share) | $4,500 | $6,500 | 20% Coinsurance | View PDF | View PDF |
| Ambetter Essential Care 1 (2016) (Limited Cost Share) | $6,800 | $6,800 | 0% Coinsurance | View PDF | View PDF |
| Ambetter Essential Care 5 (2016) with 3 Free PCP Visits (Limited Cost Share) | $6,800 | $6,800 | 0% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 1 (2016) + Vision (Limited Cost Share) | $5,500 | $6,500 | 20% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 2 (2016) + Vision (Limited Cost Share) | $6,500 | $6,500 | 0% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 10 (2016) + Vision (Limited Cost Share) | $4,500 | $6,500 | 20% Coinsurance | View PDF | View PDF |
| Ambetter Essential Care 1 (2016) + Vision (Limited Cost Share) | $6,800 | $6,800 | 0% Coinsurance | View PDF | View PDF |
| Ambetter Essential Care 5 (2016) with 3 Free PCP Visits + Vision (Limited Cost Share) | $6,800 | $6,800 | 0% Coinsurance | View PDF | View PDF |
| Ambetter Secure Care 1 (2016) with 3 Free PCP Visits (Standard Cost Share) | $1,000 | $6,350 | 20% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 1 (2016) (Standard Cost Share) | $5,500 | $6,500 | 20% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 2 (2016) (Standard Cost Share) | $6,500 | $6,500 | 0% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 10 (2016) (Standard Cost Share) | $4,500 | $6,500 | 20% Coinsurance | View PDF | View PDF |
| Ambetter Essential Care 1 (2016) (Standard Cost Share) | $6,800 | $6,800 | 0% Coinsurance | View PDF | View PDF |
| Ambetter Essential Care 5 (2016) with 3 Free PCP Visits (Standard Cost Share) | $6,800 | $6,800 | 0% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 1 (2016) + Vision (Standard Cost Share) | $5,500 | $6,500 | 20% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 2 (2016) + Vision (Standard Cost Share) | $6,500 | $6,500 | 0% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 10 (2016) + Vision (Standard Cost Share) | $4,500 | $6,500 | 20% Coinsurance | View PDF | View PDF |
| Ambetter Essential Care 1 (2016) + Vision (Standard Cost Share) | $6,800 | $6,800 | 0% Coinsurance | View PDF | View PDF |
| Ambetter Essential Care 5 (2016) with 3 Free PCP Visits + Vision (Standard Cost Share) | $6,800 | $6,800 | 0% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 1 (2016) (73% AV Cost Share) | $3,500 | $5,000 | 20% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 2 (2016) (73% AV Cost Share) | $4,500 | $4,500 | 0% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 10 (2016) (73% AV Cost Share) | $4,000 | $5,000 | 20% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 1 (2016) + Vision (73% AV Cost Share) | $3,500 | $5,000 | 20% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 2 (2016) + Vision (73% AV Cost Share) | $4,500 | $4,500 | 0% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 10 (2016) + Vision (73% AV Cost Share) | $4,000 | $5,000 | 20% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 1 (2016) (87% AV Cost Share) | $350 | $2,250 | 20% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 2 (2016) (87% AV Cost Share) | $1,750 | $1,750 | 0% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 10 (2016) (87% AV Cost Share) | $1,000 | $1,750 | 20% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 1 (2016) + Vision (87% AV Cost Share) | $350 | $2,250 | 20% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 2 (2016) + Vision (87% AV Cost Share) | $1,750 | $1,750 | 0% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 10 (2016) + Vision (87% AV Cost Share) | $1,000 | $1,750 | 20% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 1 (2016) (94% AV Cost Share) | $0 | $650 | 20% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 2 (2016) (94% AV Cost Share) | $550 | $550 | 0% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 10 (2016) (94% AV Cost Share) | $250 | $550 | 20% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 1 (2016) + Vision (94% AV Cost Share) | $0 | $650 | 20% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 2 (2016) + Vision (94% AV Cost Share) | $550 | $550 | 0% Coinsurance | View PDF | View PDF |
| Ambetter Balanced Care 10 (2016) + Vision (94% AV Cost Share) | $250 | $550 | 20% Coinsurance | View PDF | View PDF |
Pharmacy Resources
- 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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