This notice is to advise you of certain coverage and/or benefits provided  by your contract with Ambetter from Superior HealthPlan.

Mastectomy or Lymph Node Dissection

Minimum Inpatient Stay: If due to treatment of breast cancer, any person covered by this plan has either a mastectomy or a lymph node dissection, this plan will provide coverage for inpatient care for a minimum of:

1. 48 hours following a mastectomy, and
2. 24 hours following a lymph node dissection

The minimum number of inpatient hours is not required if the covered person receiving the treatment and the attending physician determine that a shorter period of inpatient care is appropriate.

Prohibitions: We may not (a) deny any covered person eligibility or continued eligibility or fail to renew this plan solely to avoid providing the minimum inpatient hours; (b) provide money payments or rebates to encourage any covered person to accept less than the minimum inpatient hours; (c) reduce or limit the amount paid to the attending physician, or otherwise penalize the physician, because the physician required a covered person to receive the minimum inpatient hours; or (d) provide financial or other incentives to the attending physician to encourage the physician to provide care that is less than the minimum hours.

If any person covered by this plan has questions concerning the above, please call Ambetter from Superior HealthPlan at 1-877-687-1196 Relay Texas/TTY 1-800-735-2989, or write us at:

Ambetter from Superior HealthPlan
5900 E. Ben White Blvd.
Austin, TX 78741

Coverage and/or Benefits for Reconstructive Surgery After Mastectomy - Enrollment

Coverage and/or benefits are provided to each covered person for reconstructive surgery after mastectomy, including:

1. all stages of the reconstruction of the breast on which mastectomy has been performed
2. surgery and reconstruction of the other breast to achieve a symmetrical appearance; and
3. prostheses and treatment of physical complications, including lymphedemas, at all stages of mastectomy

The coverage and/or benefits must be provided in a manner determined to be appropriate in consultation with the covered person and the attending physician.

Prohibitions: We may not (a) offer the covered person a financial incentive to forego breast reconstruction or waive the coverage and/or benefits shown above; (b) condition, limit, or deny any covered person’s eligibility or continued eligibility to enroll in the plan or fail to renew this plan solely to avoid providing the coverage and/or benefits shown above; or (c) reduce or limit the amount paid to the physician or provider, nor otherwise penalize, or provide a financial incentive to induce the physician or provider to provide care to a covered person in a manner inconsistent with the coverage and/or benefits shown above. For more information regarding deductible and coinsurance limitation applicable to your coverage visit: http://Ambetter.SuperiorHealthPlan.com/2023-brochures.html.

If any person covered by this plan has questions concerning the above, please call Ambetter from Superior HealthPlan at 1-877-687-1196 Relay Texas/TTY 1-800-735-2989, or write us at:

Ambetter from Superior HealthPlan
5900 E. Ben White Blvd.
Austin, TX 78741

Examinations for Detection of Prostate Cancer

Benefits are provided for each covered male for an annual medically recognized diagnostic examination for the detection of prostate cancer. Benefits include:

1. a physical examination for the detection of prostate cancer; and
2. a prostate-specific antigen test for each covered male who is:
   • at least 50 years of age; or
   • at least 40 years of age with a family history of prostate cancer or other prostate cancer risk factor.

If any person covered by this plan has questions concerning the above, please call Ambetter from Superior HealthPlan at 1-877-687-1196 Relay Texas/TTY 1-800-735-2989 , or write us at:

Ambetter from Superior HealthPlan
5900 E. Ben White Blvd.
Austin, TX 78741

Inpatient Stay following Birth of a Child

For each person covered for maternity/childbirth benefits, we will provide inpatient care for the mother and her newborn child in a health care facility for a minimum of:

1. 48 hours following an uncomplicated vaginal delivery, and
2. 96 hours following an uncomplicated delivery by cesarean section.

This benefit does not require a covered female who is eligible for maternity/childbirth benefits to (a) give birth in a hospital or other health care facility or (b) remain in a hospital or other health care facility for the minimum number of hours following birth of the child.

If a covered mother or her newborn child is discharged before the 48 or 96 hours has expired, we will provide coverage for postdelivery care. Postdelivery care includes parent education, assistance and training in breast-feeding and bottle-feeding and the performance of any necessary and appropriate clinical tests. Care will be provided by a physician, registered nurse or other appropriate licensed health care provider, and the mother will have the option of receiving the care at her home, the health care provider’s office or a health care facility.

Prohibitions. We may not (a) modify the terms of this coverage based on any covered person requesting less than the minimum coverage required; (b) offer the mother financial incentives or other compensation for waiver of the minimum number of hours required; (c) refuse to accept a physician’s recommendation for a specified period of inpatient care made in consultation with the mother if the period recommended by the physician does not exceed guidelines for prenatal care developed by nationally recognized professional associations of obstetricians and gynecologists or pediatricians; (d) reduce payments or reimbursements below the usual and customary rate; or (f) penalize a physician for recommending inpatient care for the mother and/or the newborn child.

If any person covered by this plan has questions concerning the above, please call Ambetter from Superior HealthPlan at 1-877-687-1196 Relay Texas/TTY 1-800-735-2989, or write us at:

Ambetter from Superior HealthPlan
5900 E. Ben White Blvd.
Austin, TX 78741

Coverage for Tests for Detection of Colorectal Cancer

Benefits are provided, for each person enrolled in the plan who is 50 years of age or older and at normal risk for developing colon cancer, for expenses incurred in conducting a medically recognized screening examination for the detection of colorectal cancer. Benefits include the covered person’s choice of:

1. a fecal occult blood test performed annually and a flexible sigmoidoscopy performed every five years, or
2. a colonoscopy performed every 10 years.

If any person covered by this plan has questions concerning the above, please call Ambetter from Superior HealthPlan at, 1-877-687-1196 Relay Texas/TTY 1-800-735-2989 or write us at:

Ambetter from Superior HealthPlan
5900 E. Ben White Blvd.
Austin, TX 78741

Coverage of Tests for Detection of Human Papillomavirus, Ovarian Cancer, and Cervical Cancer

Coverage is provided for each woman enrolled in the plan who is 18 years of age or older for expenses incurred for an annual, medically recognized diagnostic examination for the early detection of ovarian and cervical cancer. Coverage required under this section includes a CA 125 blood test and, at a minimum, a conventional Pap smear screening or a screening using liquid-based cytology methods, as approved by the FDA, alone or in combination with a test approved by the FDA for the detection of the human papillomavirus.

Notice of Coverage for Acquired Brain Injury

Your health benefit plan coverage for an acquired brain injury includes the following services when they are medically necessary:

• Cognitive rehabilitation therapy
• Cognitive communication therapy
• Neurocognitive therapy and rehabilitation
• Neurobehavioral, neurophysiological, neuropsychological, and psychophysiological testing and treatment
• Neurofeedback therapy and remediation
• Postacute transition services and community reintegration services, including outpatient day treatment services or other post-acute-care treatment services
• Reasonable expenses related to periodic reevaluation of the care of an individual covered under the plan who has incurred an acquired brain injury, has been unresponsive to treatment, and becomes responsive to treatment at a later date, at which time the cognitive rehabilitation services would be a covered benefit.

The fact that an acquired brain injury does not result in hospitalization or acute-care treatment does not affect the right of the insured or the enrollee to receive the preceding treatments or services commensurate with their condition. Post-acute-care treatment or services may be obtained in any facility where those services may legally be provided, including acute or postacute rehabilitation hospitals and assisted living facilities regulated under the Health and Safety Code.

You may obtain additional information from the Texas Department of Insurance regarding your rights by contacting them. Their website is www.tdi.texas.gov. Their toll-free telephone number is 1-800-252-3439. Their address is 1601 Congress Avenue, Austin, TX 78701.

Notice of Special Toll‐Free Complaint Number

TO MAKE A COMPLAINT ABOUT A PRIVATE PSYCHIATRIC HOSPITAL, CHEMICAL DEPENDENCY TREATMENT CENTER, OR PSYCHIATRIC OR CHEMICAL DEPENDENCY SERVICES AT A GENERAL HOSPITAL, CALL: 1‐800‐832‐9623

Your complaint will be referred to the state agency that regulates the hospital or chemical dependency treatment center.