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You have healthcare needs. We have a group of providers just for you.
Start here to get the most from your plan. Your Ambetter Value Plan is designed to give you one convenient go-to resource for all your care: your Medical Group.
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:
- 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 Information
Where to go for care
- Visit the Online Member Account to view your assigned PCP and Medical Group. Your assigned PCP and Medical Group will be listed under the "Your PCP" tile on the left-hand side of the page.
- Make an appointment with your assigned PCP.
Changing your PCP or Medical Group
If you are unable to see your PCP, you can be seen by another PCP within your Medical Group. Remember, the PCP you choose must be within your Medical Group.
If you want to see a PCP in a different in-network Medical Group, you can change your Medical Group and PCP using the Online Member Account. You can also change your Medical Group by calling Member Services. You’ll need to change your Medical Group before you visit a PCP in a Medical Group other than your assigned Medical Group.
- Visit the Online Member Account and select “View PCPs” under the “Your PCP” tab.
- Select “Switch Medical Group” then select your county from the drop down to see available Medical Groups in your county. You can click “See in-network PCPs” to see a list of in-network PCPs within that Medical Group.
- Click “Select Medical Group” to change your Medical Group.
Ambetter Value Plan Information
As a member on our Value Plan, you will be assigned to a Medical Group as well as a PCP within that Medical Group.
If you need care outside of what your PCP can provide, they will coordinate a referral for you. For example, if necessary, a PCP may refer you to a specialist. A referral is required for all medically necessary health care services not provided by your PCP. This excludes emergency care, urgent care, mental health, substance use disorders, OB/GYN, and any state-mandated exemptions.
Ambetter Health Value Plan options are offered in the following areas:
- Fort Bend
Essential Benefits and So Much More
You're covered on essential benefits. All health plans offered on the Health Insurance Marketplace include certain items or services. These are called Essential Health Benefits (EHBs). When you choose Ambetter Health, you're covered on these essential medical care and wellness services:
- Emergency Care
- Outpatient or Ambulatory Care
- Preventive & Wellness Care
- Maternity & Newborn Care
- Pediatric Care
- Mental Health & Substance Abuse Care
- Laboratory Services
- Prescription Drugs
- Therapy Services
Virtual 24/7 Care
Virtual 24/7 Care* is a great option for urgent care around the clock. If there is a need after your PCP's hours or you have an urgent need but cannot get in with your PCP fast enough, Ambetter Health's Virtual 24/7 Care is here to help. It is available to use whenever and wherever works best for you.
Before you start using Virtual 24/7 Care, you will need to set up your account at AmbetterTelehealthTX.com.
Virtual 24/7 Care providers can be reached by phone or video when you need medical care, a diagnosis or a prescription. Choose to receive immediate care or schedule an appointment for a time that fits in your schedule.
Contact Virtual 24/7 Care for illnesses such as: colds, flu and fevers, rash, skin conditions, sinus problems, allergies, upper respiratory infections, bronchitis, pink eye.
24/7 Nurse Advice Line
Our free 24/7 nurse advice line makes it easy to get answers to your health questions. You don’t even have to leave home! Staffed by licensed nurses, our nurse advice line runs 24 hours a day, 7 days a week. Call 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989) if you have questions about:
- Your health, medications, or a chronic condition
- Whether you should go to the emergency room (ER) or see your PCP
- What to do for a sick child
- How to handle a condition in the middle of the night
- Accessing our online health information library
- Urgent care
Want to check if your prescriptions are covered? Ambetter Health works closely with doctors and pharmacists to make sure we cover a variety of medications for you and your family.
My Health Pays® Rewards Program
Our My Health Pays® ** program is available to Ambetter Health members. It’s a rewards program that pays you for the healthy decisions you’re already making each and every day. Completed your annual wellness screening? You get points for that. Want to learn new ways to be healthy? You can get rewards for that, too. And the best part, you can turn those rewards into dollars for your everyday needs like utilities, groceries, and your monthly premium.
Visit the My Health Pays® page to learn more.
Ambetter Member Perks
The Ambetter Member Perks Program is available exclusively to Ambetter Health members. The program is brought to you by Abenity. As an Ambetter Health member, you can now enjoy healthy discounts to help you be well, stay well, and save smart. Start enjoying all the discounts available to you including restaurants, computers, hotels, retailers, and more! Ambetter Member Perks. The benefits you deserve!
Referrals from your PCP are required for all medically necessary health care services not provided by your PCP1. This excludes emergency care, urgent care, mental health, substance use disorders, OB/GYN, and any state-mandated exemptions. Your PCP will coordinate a referral if you need to see a specialist. Without a referral, your claim may not be covered1.
Here’s what you need to do:
1. View your PCP
If you have not done so already, view your assigned PCP and Medical Group on the Online Member Account.
2. Meet With Your PCP
Your PCP will help coordinate all your health care services and provide any necessary referrals. During your PCP visit you should discuss your goals, follow up with your care team, and obtain any necessary referrals1
- If you have an appointment already scheduled with a specialist and do not yet have a referral from your PCP, you will need to contact your PCP first. You will need to get a referral from your PCP before the specialist visit.
- If you do not have a referral from your PCP, your specialist visit may not be covered. The claim will be denied, and it won’t be paid.
3. Schedule specialist visit
Your PCP can help refer you to an in-network specialist for any care outside of their scope. Members can see any in-network specialist with a referral, but your PCP must make a referral to the specific specialist you wish to see before the specialist visit.
Referrals are NOT required for the following services:
- Emergency care
- Urgent care
- Mental health, behavioral health, and substance abuse services
- Obstetrical and gynecological care
- Any state mandated exceptions1
Where to go for care
With Ambetter Health, you have many options to support your physical and mental health. If your injury is minor and not life threatening (like a sprain or a cold), your first choice should be to call your PCP. If you can’t wait for an appointment with your PCP, consider one of the options below. Have a question about your prescriptions, refills, over-the-counter medicine, or side effects? Your local pharmacist also can help you at no cost over the phone or in person.
Virtual 24/7 Care
Virtual 24/7 Care* gives you easy access to care for non-emergency issues. You can get medical advice, a diagnosis or a prescription using your mobile phone, tablet or computer. With 24-hour access, you can choose to receive immediate care or schedule an appointment that fits in your schedule. Virtual 24/7 Care is like a PCP and treats things like cold, flu, fever, respiratory infections, pink eye, anxiety, depression, and prescribes medication or refills. Before you start using Virtual 24/7 Care, you will need to set up your account at member.teladoc.com/ambetter.html.
24/7 Nurse Advice Line
Not sure where to go for care? Call our 24-hour nurse advice line at 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989). It is a cost-free service connecting you to a registered nurse who can help you find a doctor or learn where to go for care. They can help answer health questions including what to do for a sick child and whether you should go to the ER or see your PCP.
Urgent care is for when you have an injury or illness that must be treated within 24 to 72 hours and is not life threatening. Go to an urgent care clinic if you need care and your PCP is unable to see you and you want to receive in-person care. You do not need an appointment to be seen. Consider urgent care for small wounds, simple sprains and broken bones, ear infections, and urinary tract infections.
Be sure to choose an in-network urgent care center to save on costs. Use the Ambetter Guide to find an urgent care near you.
Emergency Room (ER)
If you have a life-threatening injury or illness, do not wait! Call 911 or go directly to the ER. A medical emergency is a sudden illness or condition that could result in serious harm to you and needs care right away. For example, bleeding that will not stop, severe pain, chemical poisoning, drug overdose or thoughts of harming yourself or others. Choose other care options if your injury is minor to maximize your benefits and lower your costs. Consider all your options before going to the ER.
Watch the video to learn more about your choices for care when you’re sick or hurt. View video.
988 Suicide and Crisis Lifeline
The 988 Lifeline provides confidential help for mental health, drug use, or suicidal concerns when you need it quickly. To connect:
- Call 988 to talk (available in many languages) or
- Text 988 (English only) or
- Chat via https://suicidepreventionlifeline.org/ (English only)
988 can help you or a family member if you are thinking about suicide or have anxiety, depression or concerns about alcohol or drug use. It can also help for thoughts of hurting yourself or others.
Frequently Asked Questions
Visit the Online Member Account. To see your assigned Medical Group, choose “Your PCP” on the left side of the page. To find a PCP in that group, choose the Ambetter Guide. Select your state and the “VALUE 2024” network. Search for a PCP and enter your ZIP code. On the results page, select your assigned Medical Group from the drop-down menu. You’ll then be able to see all the PCPs within that Medical Group. Choose one and schedule an appointment.
Yes. You can change your Medical Group to a different in-network Medical Group as long as that group is accepting new patients. Log into the Online Member Account and choose “Your PCP” on the left side of your screen, then make your selection. You can also change your Medical Group by calling Member Services.
Yes. You can see any PCP in your assigned Medical Group. You can search doctors in your group using the Ambetter Guide. Select your state and the “VALUE 2024” network. Choose “Search for PCP” and look for your assigned Medical Group in the drop-down menu. You’ll then be able to see all the available PCPs within your Medical Group.
You can access urgent care virtually or in-person without a referral. For Virtual 24/7 Care*, visit your Online Member Account and select “Virtual 24/7 Care” on the right side of the homepage to schedule your visit. For in-person urgent care, visit the Ambetter Guide, choose the “Value” network and search for “Urgent Care” to find nearby in-network urgent care facilities.
If your PCP offers the telehealth option, you can see that doctor either in-person or virtually.
A referral is a written order from your PCP for you to see a specialist or get certain medical services. In many cases, if you don’t get a referral first, your coverage may not pay for the services1.
A specialist is a doctor who focuses on a specific type of medicine, such as cardiology, oncology or neurology. These doctors work with your PCP to make sure any specific condition you may have gets the most advanced care.
In most cases, yes1. You should consult your PCP to determine next steps.
You need a referral for most care beyond what your PCP provides1. This is even true for specialist visits scheduled before you became an Ambetter Value member. In this case, you would first need to check the Ambetter Guide to see if your cardiologist is still in-network with your Ambetter Value Plan. Second, you would need to schedule a visit with a PCP from your assigned Medical Group and ask that doctor for a referral. If the cardiologist you’re scheduled to see is in-network, the PCP can refer you to that doctor. If not, your PCP can provide a referral to an in-network cardiologist. You will need this referral before your cardiologist visit for that visit to be covered.
We encourage you to continue your care. Ambetter Health will honor claims from your specialist within the first 30 days from your effective date. After the first 30 days, claims without a referral will be denied.
Prescriptions or referrals from any doctor other than your PCP will be covered as long as your PCP refers you directly to that physician.
Ambetter Value Plan is available in the following counties in Texas: Bexar, Collin, Dallas, Denton, Fort Bend, Harris, Montgomery, Rockwall, Tarrant, Travis and Williamson.
1 Referrals are required for all medically necessary health care services not provided by a member’s PCP excluding emergency care, urgent care, mental health care, treatment for substance use disorders, OB/GYN visits, and any state-mandated exemptions. PT is exempt from referrals.
**Formerly known as Ambetter Telehealth. Cost sharing may apply when using Virtual 24/7 Care or Virtual Primary Care. Ambetter Health does not provide medical care. Medical care is provided by individual providers which are independent contractors and not agents of Ambetter Health.
**Funds expire immediately upon termination of insurance coverage. My Health Pays® rewards cannot be used for pharmacy copays. Restrictions