Ambetter Insurance Plan Guide for Texas 2023

All You Need to Know About Ambetter Insurance Plans for 2023 in Texas

Ensuring your family has the coverage they need is the most important item on your checklist when shopping for health insurance. The worst thing you want to do is to purchase an insurance policy, then when you go to use it, find that it does not provide the coverage you thought it did. We at Cover Mile are here to help you understand what Ambetter health insurance has to offer. Through this plan guide, we aim to show you what their coverage chart means to you.

Health Insurance Terms to Understand

Before we start, we want to provide you with a few common definitions you will come across while you are insurance shopping. Understanding these terms will aid you in selecting the best health coverage that will best fit your situation.

DeductibleDeductibles are the amount you will pay out-of-pocket before your insurance begins to pay its portion. This is the step before your co-insurance portion kicks in. Ambetter has deductibles between $0 and $8700, depending on the insurance plan you select. Deductibles are based on the calendar year and refresh each year. They will also determine how much you will pay for your policy. The higher your deductible, the lower your premium will be; the lower your deductible, the higher your premium. Your deductible is broken down into two parts:

            Individual: This is the per-person amount you will pay.

            Family: This is the amount you pay for the entire family.

You will see these labeled on your Summary of Benefits, often in fraction form. For instance, $750 Individual/$2250 Family. Each member has their own $750 deductible to meet. You can read more about deductibles through the above link.

Co-insurance – Co-insurance is where your insurance kicks in and begins once you meet your deductible. This is cost sharing between you and the insurance company, usually based on a percentage and shown as 70/30. The 70 is the percentage of the medical bills the insurance company will pay, and the 30 is the amount you will pay. Co-insurance is refreshed each year.

Out-of-Pocket Max- Your insurance has a failsafe. It is called the out-of-pocket max. It helps those with large families, those who visit the doctor regularly, and those with chronic medical conditions. When you meet your deductible, pay through your co-insurance, and reach your out-of-pocket amount listed in your policy, your insurance will begin to pay 100 percent of medical expenses for that person listed on the policy. This continues for the remainder of the calendar year.

Primary Care Physician – Your Primary Care Physician (PCP) is the main doctor you visit for your medical care. Ambetter is both an HMO and an EPO. First, with an HMO, you are required to coordinate all treatment through them. However, you can see a doctor outside of the network with the insurance company’s permission when medically necessary. With Ambetter EPOs network, you must remain within their network of doctors and facilities, or you will not have coverage. This rule does not apply if you are in an emergency.

Co-pay – Co-pays are the doctor and facility fees you pay for your visit. They can be a flat dollar amount or a percentage depending on the plan and the type. Keep in mind that this fee is for a visit alone and not for any treatment you receive. However, some visits fee will cover some items like a well check-up. See your medical plan for details.

Now that you know the basics of health insurance, let’s get into the plans Ambetter offers.

Ambetter and the Affordable Care Act

Ambetter health insurance plans are part of the Affordable Care Act. They are broken down into Bronze, Silver, and Gold metals. Most of their plans are offered on the Marketplace website.

The one thing you will discover unique about Ambetter is that in Texas, they do not offer a Bronze metal plan. This was a change for 2023. We are listing a wide choice of plans they offer based on price, deductible, and co-insurance.

To simplify our table, you will see the Individual and Family Deductibles and Out-of-Pocket Max expressed as a fraction. The first number is your Individual amount, and the second is your Family. All numbers are for in-network providers.

Ambetter HMO Bronze

Ambetter does not offer a Bronze metal health plan in Texas. They had offered them in 2022, but for 2023, this level is no longer offered. You can contact Ambetter directly for more information.

Ambetter HMO Silver

Ambetter Silver has over 30 plans. All of which are available on the Marketplace. Silver plans qualify for ACA Cost Sharing reductions. This means applicants can use their premium tax credits toward purchasing their health insurance plan.

Together, Ambetter has six Virtual Access categories. 94%, 87%, 73%, Zero cost, Standard and Limited. Let’s take a look at some of these plans. Keep in mind that to take advantage of the Cost Sharing benefits, one must qualify for the plan levels listed below.

The Standard level is Ambetter’s primary plan if you do not want to apply for insurance with Cost Sharing reduction or do not qualify for premium tax credits.

HMO SilverVirtual Access Silver 94% AVVirtual Access Silver 87% AVVirtual Access Silver 73% AV Virtual Access Silver Standard
Out-of-Pocket Max$900/$1800$2800/$5600$6500/$1300$7400/$14,800
Primary Care Visit$15  $20  $30$40
Specialist Visit$30  $35  $70  $100
Emergency Room50%$5050%50%
Urgent Care$10  $10  $50$60
Virtual Visit$0$0$0$0
Inpatient Hospital50%50%50%50%
Outpatient Hospital50%50%50%50%
Prescription (Pharmacy)$0/$20/50%/ 50%*$5/$40/50%/ 50%*$5/$70/50%/ 50%*$5/$75/50%/ 50%*

*Prescription Tiers are Generic, Preferred. Non-Preferred. and Specialty

Ambetter Value Network

If you live within the following thirteen Texas counties, you have additional plan options called the Value Network.  

Bexar, Collin, Dallas, Denton, Fort Bend, Harris, Montgomery, Rockwall, Tarrant, Travis, and Williamson.

In the Value Network you find different categories: Complete, Clear, Focused, and Care Management Services (CMS.) Also, though we did not list them here, you have access to cost-sharing benefit plans (94/87/73/Zero/Ltd.). In addition, you can purchase Ambetter Standard plans on and off market if you do not qualify for subsidies or are searching for affordable health insurance in Texas within the silver category away from the Marketplace.

HMO SilverComplete Value Silver StandardClear Value Silver StandardFocused Value Silver Standard  CMS Standard Silver
Out-of-Pocket Max$8500/$17,000$5400/$10,800$7500/$15,000$8900/$17,800
Primary Care Visit$30  $0$45$40
Specialist Visit$60  $0$100$80
Emergency Room40%$050%40%
Urgent Care$60  $0$50$60
Virtual Visit$0$0$0$0
Inpatient Hospital40%0%50%40%
Outpatient Hospital40%0%50%40%
Prescription (Pharmacy)$5/$55/50%/ 50%*$0/$0/0%/ 0%*$5/$75/50%/ 50%*$20/$40/$80/ $350*

*Prescription Tiers are Generic, Preferred. Non-Preferred. and Specialty

Ambetter HMO Gold

Ambetter Gold has nine named plans; six are offered on the ACA Marketplace. They are divided like the silver plans were: Standard and cost-sharing. Their offerings are limited to Virtual Access and standard plans, but they have an additional category called Everyday.

Gold has the highest level of coverage and provides the lowest deductibles, co-pays, and overall out-of-pocket insurance cost. However, with the level of coverage, you will find a higher price tag. Gold plans are best suited for those who visit the doctor frequently, those with critical illnesses, and individuals who expect to seek advanced medical care in the near future.

HMO GoldVirtual Access Standard CMS Standard Virtual AccessEveryday Value Standard
Out-of-Pocket Max$8700/$17,400$8700/$17,400$7500/$15,000
Primary Care Visit$20  $30  $35
Specialist Visit$45$60  $55
Virtual Visit$0$0$0
Emergency Room25% 25%35%
Urgent Care$30  $45  $35
Inpatient Hospital25%25%35%
Outpatient Hospital25%25%35%
Prescription (Pharmacy)$5/$50/25%/25%*$15/$30/$60/$250*$5/$60/50%/50%*

*Prescription Tiers are Generic, Preferred. Non-Preferred. and Specialty

Care Management Services (CMS) Plans

In both the Gold metal levels, you have seen a CMS plan. These are Care Management Service plans for those with special needs. If you have a complex medical condition or a family member with special needs, Ambetter offers this medical plan that will work with you and your doctors to provide the care you require. It can help you coordinate services and locate community resources that will develop a plan to meet your needs and assist your caregiver in providing the medical care required.  

Ambetter EPO Plans

Ambetter offers EPO plans on both Silver and Gold levels. The advantage of the EPO level is that you are given an Adult Dental and Vision option. The EPO option also includes the ability to add a Health Savings Account to your health insurance plan.

EPO Silver, just like HMO plans, offer a variety of plans on their Silver platform. With an EPO, you are required to use only the doctors and facilities within your coverage area. If you see a doctor not approved by Ambetter, you will most likely pay out-of-pocket for your visit and treatment received. However, if there is an emergency situation you can receive treatment with Ambetter’s approval.

EPO SilverComplete Silver StandardClear Silver StandardFocused Silver Standard CMS Standard
Out-of-Pocket Max$8500/$17,000$5400/$10,800$7500/$15,000$8900/$17,800
Primary Care Visit$30  $0  $45$40
Specialist Visit$60  $0  $100  $80
Emergency Room40%$050%40%
Urgent Care$60  $0  $60$60
Virtual Visit$0$0$0$0
Inpatient Hospital40%0%50%40%
Outpatient Hospital40%0%50%40%
Prescription (Pharmacy)$5/$55/50%/ 50%*$0/$0/0%/ 0%*$5/$75/50%/ 50%*$20/$40/$80/ $350*

*Prescription Tiers are Generic, Preferred. Non-Preferred. and Specialty

EPO Gold plans have a lower deductible and co-insurance; this provides you with greater coverage. However, for that coverage, you will pay a higher premium. Health insurance in Texas is a balance. Pay a little more now or pay more later when you receive the health care services.

EPO GoldComplete Gold StandardClear Gold StandardCMS StandardEveryday Standard
Out-of-Pocket Max$7500/$15,000$8700/$17,400$8700/$14,000$7500/$15,000
Primary Care Visit$15  $25  $30$35
Specialist Visit$35  $60  $60  $55
Emergency Room20%30%25%35%
Urgent Care$35  $35  $45  $35
Virtual Visit$0$0$0$0
Inpatient Hospital20%30%25%35%
Outpatient Hospital20%30%25%35%
Prescription (Pharmacy)$5/$30/30%/ 30%*$5/$40/50%/ 50%*$15/$30/$30/ $250*$5/$60/50%/ 50%*

*Prescription Tiers are Generic, Preferred. Non-Preferred. and Specialty

Ambetter EPO Adult Dental and Vision Insurance

Ambetter EPO plans offer the option of including Adult Dental and Vision. Their health insurance plans are identical to the ones lined out above, only with the addition of the following:

  • Routine eye care – one visit and one item per year with a dollar allowance on hardware.
  • Dental care – visit and items limit per year. $1000 annual limit per person per year.

Keep in mind that this is for adult services. Ambetter health insurance does not cover children’s dental services. It does cover as part of its health insurance policies children’s vision. This coverage includes one visit and one vision item per year.

Ambetter and Health Savings Accounts (HSAs)

Ambetter offers a variety of HSA medical plans. Health Savings Accounts are a savings vehicle one can use to fund medical expenses. They are often tied to a High Deductible Health Plan (HDHP). These plans are lower priced and can benefit those who are healthy, rarely visit the doctor, or are only concerned about the more significant medical expenses. If you want to learn more about HSAs, it is best to contact a tax professional because they involve opening a savings account along with your insurance policy. We at Cover Mile can provide you with information on the health insurance end and answer any questions you may have.

Ambetter and Medicare

If you are near Medicare age, an Ambetter policyholder, and are looking for a Medicare Advantage plan, Ambetter has a Medicare partner, Allwell. You can make a smooth transition from your health insurance policy into Medicare Advantage. If you have additional questions about Medicare, Cover Mile can assist with answering them. Visit our website for more information.

Finding a Doctor or Facility in Your Network

Both HMOs and EPOs require you to remain within your network to use benefits. Only HMOs allow you to use out-of-network facilities when medically necessary and with Ambetter approval. However, both HMOs and EPOs allow benefits to be used out-of-network in the event of an emergency where transportation to an in-network facility would be life-threatening.

Ambetter allows you to search for doctors and facilities near you on their website. You select your location, the plan you are on, then how you want to access your care: find a facility, access Virtual Access/Telehealth benefits, or talk to a nurse via their helpline.

Benefit Notices:

Keep in mind that the above is a summary of highlights only.

–The benefits above represent what a member would pay using a participating provider. When a non-participating provider is used, benefits are reduced.

–You may be required to pay costs up to the deductible before your plan begins to pay for covered services. What is shown is the per-person deductible and out-of-pocket maximum. Some services your deductible does not apply, i.e., doctors’ visits and prescription coverage.

–All percentages shown are of the allowable amount for covered services.

–Four prescription drug payment level tiers: Generic, Preferred. Non-Preferred. and Specialty

Prescription Coverage with Ambetter

Ambetter provides prescription coverage for its members. Each plan has different coverage levels depending on the policy purchased.  

  • Two Generic Co-Pay levels The generic level listed in our table is for the lower cost, Preferred Generic Retail. Ambetter has another generic level, Generic Retail. It is a higher cost for a different level brand of prescription drug.
  • Drug Cost PortalYou can see your drug’s cost before purchasing it. You input the name of your prescription and find out the general price of it before you submit it.
  • Prior AuthorizationIn some cases, you will need prior approval to fill prescriptions. Ambetter may suggest a more cost-effective drug instead of a prescribed prescription.
  • Mail order – Depending on your drug benefit, you may be able to receive your prescription mailed to your home. A three-month supply will save you on prescription costs as you will only be billed for 2.5x of your prescription cost.

Ambetter can help you find a pharmacy in your area through its website.

At Cover Mile, we desire to assist you in finding the health insurance in Texas that best suits you and your family. We will take the time to talk you through each plan, help you understand each Ambetter plan, and help you sign up for Affordable Care Act insurance. Contact us today.

Frequently Asked Questions

  1. Is Ambetter Medicaid?

    No. Ambetter is Affordable Care Act health insurance. However, one can qualify for subsidies if they meet certain income requirements and apply for Silver metal plans.

  2. Is Ambetter an HMO or PPO?

    Ambetter is not a PPO (Preferred Provider Organization). Ambetter is an HMO (Health Maintenance Organization) as well as an EPO (Exclusive Provider Organization). Both plans offer a network of providers that subscribers must visit in order to receive benefits. If they receive treatment outside of this network, they will not have coverage. HMOs are the more lenient. You may be able to receive out-of-network benefits with the approval of Ambetter.

  3. Does Ambetter Have an App?

    No, they do not have a mobile app. But you can still access your online member account through a smartphone. You can access Telehealth services for chats, emails, and video doctors. You can also view and pay your bills here.

  4. Does Ambetter cover pre-existing conditions?

    Yes. Since Ambetter is part of the Affordable Care Act, it is mandated to cover pre-existing conditions. This would include substance abuse, behavioral health, and mental health conditions.

  5. Does Ambetter cover surgery?

    Yes, however, only if the surgery is medically necessary. Four are listed on the Summary of Benefits exclusion list: Acupuncture, Bariatric surgery, cosmetic surgery, and abortion. Abortion may be allowed if the mother’s life is in danger if the fetus is carried to full term or delivered.

  6. Does Ambetter cover eye exams?

    Only Children’s eye exams are covered at no charge on all plans, with one visit per year and one item per year. Some EPO plans cover adult eye exams with the same stipulation.

  7. What type of insurance is Ambetter?

    Ambetter is considered private health insurance. It is sold as both an HMO and EPO. You can purchase it both on the ACA Marketplace as well as off-market through Ambetter directly. You can also contact Cover Mile for assistance with finding the best Ambetter policy for your family.

  8. How much is Ambetter insurance?

    Premiums will depend on many factors. However, your health will not be one of them. Since it is Affordable Care Act insurance, your health cannot be weighed into determining your premium. The three factors that will determine your premium are your age, where you live, and who will be included in your policy. Tobacco use will also determine how much you will pay for health insurance. From there, your income will determine if you qualify for subsidies that can assist you in paying for your health insurance policy.

  9. Is Ambetter Insurance Good?

    Ambetter has many health insurance plans to choose from. They seem to be designed for those wanting to use their subsidies. They have multiple selections, and if you can weed through the offerings, you can find a plan designed for your situation. That is why you have Cover Mile in your corner. We can assist you in that process. Contact us today.