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Every time you receive care,make sure to stay within theAmbetter network.Get your free copy of ourProvider Directory bycalling Member Services at1-877-687-1169 (Relay Florida:1-800-955-8770).We’re proud to offer you quality care in Florida. Our provider network is thegroup of doctors, hospitals and other healthcare providers who have agreedto provide you with your healthcare services.To search our Provider Directory, visit Ambetter.SunshineHealth.com/findadoc anduse our Find a Provider tool. This tool will have the most up-to-date informationabout our provider network. It can help you find a primary care provider (PCP),pharmacy, lab, hospital or specialist. You can narrow your search by: Provider specialty ZIP code Gender Languages spoken Whether or not he/she is currently accepting new patientsA Provider Directory is a listingof providers near you.Ambetter from Sunshine Health: 1-877-687-1169 (Relay Florida: 1-800-955-8770) Ambetter.SunshineHealth.com 7MEMBERSHIP & COVERAGE INFORMATIONFinding The Right Care

Your member ID card is proof that you have health insurance with us. It mayseem small, but it’s very important.Here are some things to keep in mind: Keep this card with you at all times You will need to present this card anytime you receive healthcare services You should have received your Ambetter member ID card with yourmember welcome packet materials. If you don’t get your member ID cardbefore your coverage begins, call Member Services at 1-877-687-1169(Relay Florida: 1-800-955-8770). We will send you another card.If you need a temporary ID card or if you would like to request a new one, log into your secure member account.Here is an example of what a member ID card typically looks like:IN NETWORKCOVERAGEONLYIN NETWORKCOVERAGE ONLYSubscriber: [Jane Doe]Subscriber: [John[JaneDoe]Member:Doe]Member:[JohnDoe]Effective Date ofPolicy#:[XXXXXXXXX]Effective DateofPolicy #:ID #: [UXXXXXXXXX[XXXXXXXXX] r ID #:[Ambetter[UXXXXXXXXX] Care 1]RxBIN#: 008019Plan:BalancedRx BIN#: 008019Plan:[Ambetter Balanced Care 1]CopaysCoinsurance (Med/Rx): [50%/30%]Copays[ 5]PCP:Coinsurance(Med/Rx):(Med/Rx): [ 500/ 250][50%/30%][ 5]DeductiblePCP:[ 10]Specialist:[ 500/ 250]Deductible(Med/Rx): [ 5/ 25][ 10]Rx(Generic/Brand):Specialist: [ 250]ER:[ 5/ 25]Rx (Generic/Brand):[ .SunshineHealth.com]Member/Provider Services:Medical Claims:Member/Provider Services:Medical 169][SunshineHealthRelayFL: [1-800-955-8770]Attn:CLAIMSRelayNurseFL: xCLAIMS501024/7 Nurse Line:[1-877-687-1169]PO Box 5010 MOFarmington,Farmington, MONumbers below for providers:63640-5010]Numbers belowfor providers:PharmacyHelp Desk:[1-855-310-1486] 63640-5010]PharmacyHelpDesk: [1-855-310-1486]EDIPayor ID:[68069]EDI HelpPayorDesk:ID: [68069]EDI[Ambetter.SunshineHealth.com]EDI Help Desk: [Ambetter.SunshineHealth.com]Additional information can be found in your Evidence of Coverage. If you have an Emergency, call 911 or go to thenearestEmergencyRoomEmergencygivenby a providerin theplan’s networkAdditionalinformationcan(ER).be foundin yourservicesEvidenceof Coverage.If younothavean Emergency,callwill911 beor coveredgo to thewithoutauthorization.Receivingnon-emergentcare bythroughthe ERorinwithnon-participatingprovidermaynearest priorEmergencyRoom (ER).Emergencyservices givena providernottheaplan’snetwork will becoveredresultin priora changeto memberReceivingresponsibility.For houtauthorization.non-emergentcarecoveragethrough theER or withvisita non-participatingprovider mayresult in a change to member responsibility. For updated coverage information, visit Ambetter.SunshineHealth.com.AMB15-FL-C-00032 2015 Celtic Insurance Company. All rights reserved.AMB15-FL-C-00032 2015 Celtic Insurance Company. All rights reserved.BackAmbetter from Sunshine Health: 1-877-687-1169 (Relay Florida: 1-800-955-8770) Ambetter.SunshineHealth.com 8MEMBERSHIP & COVERAGE INFORMATIONYour Ambetter Member ID Card

Visit us online atAmbetter.SunshineHealth.com!Our website helps you getthe answers you need to getthe right care, the right way.Our website includes a secureportal for you to check thestatus of your claim, view yourEvidence of Coverage (EOC), orunderstand your out-of-pocketcosts and copays. It can alsoshow your progress towardsmeeting your annual deductible.Did you know you can always access helpful resources and information aboutyour plan? It’s all on our website! Visit Ambetter.SunshineHealth.com and takecharge of your health.On our website, you can: Find a primary care provider (PCP) Locate other providers, like a pharmacy Find health information Learn about programs and services that can help you get and stay healthyUse your online member account to: Pay your monthly bill Print a temporary ID card or request a new one View your claims status and payment information Read your member materials (your Evidence of Coverage,Schedule of Benefits, this handbook) Track your My Health Pays rewards Complete your health assessmentAmbetter from Sunshine Health: 1-877-687-1169 (Relay Florida: 1-800-955-8770) Ambetter.SunshineHealth.com 9MEMBERSHIP & COVERAGE INFORMATIONGet Online And Get In Control

Covered Services Medical Service Expense BenefitsCovered Services Medical Service Expense BenefitsEvery time you receive care,make sure to stay within theAmbetter network.Prior authorization means aservice needs to be approvedbefore you go to the provider.Your Schedule of Benefits canbe found online. Just log in toyour online member account.We want to meet your healthcare needs. So our plansprovide coverage for a wide range of medical andbehavioral health services.For a service to be covered and eligible for reimbursement, it must be: Described in your policy Medically necessary Prescribed by your treating provider or primary care provider (PCP) Authorized by us (when required)– For example:» Services from or visits to an out-of-network providerCertain surgical proceduresInpatient hospital admissionsWant to see if a service needs authorizing or check on the status of a servicethat was submitted for authorization? Call Member Services at 1-877-687-1169(Relay Florida: 1-800-955-8770). If you do not have prior authorization beforeyou receive the services, you may be held responsible for total payment. Youcan learn more about prior authorizations on page 36.You can find information about your specific copayments, cost sharing anddeductible in your Schedule of Benefits. For a list of exclusions, refer to yourEvidence of Coverage.Ambetter from Sunshine Health: 1-877-687-1169 (Relay Florida: 1-800-955-8770) Ambetter.SunshineHealth.com 10COVERED SERVICES MEDICAL SERVICE EXPENSE BENEFITSWhat Does Your Plan Cover?

Remember to use an in-networkprovider when you get yourpreventive care services. Useour Find a Provider tool onAmbetter.SunshineHealth.comto see if a provider is in-network.Preventive care services are regular health checkups that are designed to catchproblems before they start. Stay up-to-date with these services — they canhelp you stay as healthy as possible! Be sure to schedule appointments for yourpreventive care visits.We cover these preventive care services: To see all of your coveredpreventive care services, referto your Evidence of Coverage.Forall adultsAnnual wellness examsBlood pressurescreeningsCholesterol screeningsImmunizationsand vaccines, likethe flu vaccine, asrecommended by theCenters for DiseaseControl and Prevention(CDC) ForwomenAnnual well-womanexamsMammography examsBreastfeeding supportand suppliesPregnancy-relatedservices- Rh incompatibilityscreenings- Gestational diabetesscreenings- Iron deficiencyscreenings For infants, childrenand adolescentsWell-child visitsImmunizationsand vaccines,as recommendedby the CDCNewborn screenings,like a hearingscreening and a gs for childrenage 3 and underObesity screeningsand counselingWe cover: Preventive services that are recommended by the United States PreventiveServices Task Force as a Grade A or B to: http://www.uspreventiveservicestaskforce.org/.Use this link to all preventive services covered at no cost underthe Affordable Care Act. Immunizations and vaccines recommended by the CDC Women’s preventive care supported by the Health Resources and ServicesAdministration (HRSA) The schedule of wellness visits for infants, children and adolescentsrecommended by the American Academy of PediatricsAmbetter from Sunshine Health: 1-877-687-1169 (Relay Florida: 1-800-955-8770) Ambetter.SunshineHealth.com 11COVERED SERVICES MEDICAL SERVICE EXPENSE BENEFITSHere’s What Your Plan Covers

Refer to your Evidence ofCoverage to get the details foreach covered service. Somehave certain exclusions andlimitations.We only cover in-networkservices (unless it’s anemergency service). If you goto an out-of-network providerwithout prior approval, youwill be responsible for allcosts associated with thoseservices. Make sure yourproviders are in-network byusing our Find a Provider tool onAmbetter.SunshineHealth.com Acquired brain injury servicesAmbulance servicesAutism Spectrum Disorder servicesBehavioral health services and benefits for mental healthcareEmergency careHabilitation, rehabilitation and extended care facility benefitsHome healthcare servicesHospice careMedical and surgical benefits, including:– Hospital servicesSurgery servicesPhysician services (primary care providers [PCP] and specialists)Professional servicesMedical suppliesDiagnostic ntal services as result of an injuryDiabetic equipment and suppliesChiropractic servicesMaternity careDurable medical equipmentSpeech and hearing benefitsOutpatient prescription benefits (see Pharmacy Benefits on page 31)Preventive healthcare services, based on US Preventive Task Force(USPSTF) recommendationsTransplant servicesPediatric vision servicesDiagnostic procedures to determine the cause of infertility and/orcorrection of a medical condition or defect causing infertilityYour Plan May Include* Routine adult vision services (preventive eye exams, glasses and/orcontact lenses) Preventive and basic adult dental services Three free visits as a part of your benefits. This includes only the actualvisit with your PCP. Any labs, radiology (X-rays), minor surgeries or otherservices provided during the visit will be subject to your deductible andco-insurance. Preventive care visits, such as your annual well-visit exam,are not included as part of the free visits. We cover your preventive carevisits separately.*Coverage varies depending on your plan. See your Schedule of Benefits for yourspecific coverage information.Ambetter from Sunshine Health: 1-877-687-1169 (Relay Florida: 1-800-955-8770) Ambetter.SunshineHealth.com 12COVERED SERVICES MEDICAL SERVICE EXPENSE BENEFITSYour Plan Also Covers

Your Evidence of Coveragehas a full list of coveragelimitations and exclusions,plus a list of which healthcareservices are covered on yourparticular plan.The Ambetter Drug List, orformulary, has a complete listof all covered medications.Read your copy atAmbetter.SunshineHealth.comWe offer many important wellness benefits and healthscreenings. However, there are still some things that yourcoverage doesn’t include.Usually, we only cover services and supplies that are: Administered or ordered by your physician Medically necessary to diagnose or treat your injury or illness Covered under preventive careIn general, we don’t cover: Services or supplies that are provided before coverage begins orafter it ends Charges that are greater than the eligible service expense Weight control services Infertility services or medications Breast reduction or augmentation (unless medically necessary) Cosmetic treatment (except for reconstructive surgery following a coveredsurgery or injury, or services that are performed to correct a birth defect ina child who has been a member since birth) Diagnosis or treatment of learning disabilities, attitudinal disorders ordisciplinary problems Eye refractive surgery (to correct nearsightedness, farsightednessor astigmatism) Experimental or investigative treatment or unproven services Treatment received outside the United States (except for a medicalemergency while traveling for up to 90 consecutive days) Intentionally self-inflicted bodily harm Illness or injury incurred as a result of a member’s intoxication, exceptas expressly provided for under the Mental Health and Substance UseDisorder benefits provision Services or expenses for alternative treatments, including acupressure,acupuncture, aromatherapy, hypnotism, massage therapy rolfing andother forms of alternative treatmentAmbetter from Sunshine Health: 1-877-687-1169 (Relay Florida: 1-800-955-8770) Ambetter.SunshineHealth.com 13COVERED SERVICES MEDICAL SERVICE EXPENSE BENEFITSWhat’s Not Covered?

Be sure to call us and reportyour emergency within onebusiness day. You don’t needprior approval for emergencycare.When you’re outside of the service area, we can’t cover your routine ormaintenance care. However, we do cover emergency care out of theservice area.If you are temporarily out of the area and have a medical or behavioral healthemergency, call 911 or go to the nearest emergency room. Be sure to call us andreport your emergency within one business day. You don’t need prior approvalfor emergency care.Provider Billing: What To ExpectIf you receive a provider billthat doesn’t reflect yourcost share as listed in yourSchedule of Benefits, callMember Services right away:1-877-687-1169 (Relay Florida:1-800-955-8770).After receiving medical care, you may get a bill from your provider. Providerscan only bill you for your share of the cost of covered services. This includesyour deductible, copayment and cost sharing percentage. If you receive aprovider bill that doesn’t reflect your cost share as listed in your Schedule ofBenefits, contact us right away. This is very important.When receiving care at one of our in-network hospitals, it is possible thatsome hospital-based providers (for example, anesthesiologists, radiologists,pathologists) may not be under contract with us as in-network providers. Theseproviders may bill you for the difference between our allowed amount and theprovider’s billed charge — this is known as “balance billing.” We encourage youto inquire about the providers who will be treating you before you begin yourtreatment, so you can understand their participation status with us.You can call Member Services, mail or fax us the bill or statement you received.We will find out why the provider sent you a bill and get back to you as quicklyas possible.Ambetter from Sunshine Health1301 International Parkway, Suite 400Sunrise, Florida 33323Ambetter Member Services: 1-877-687-1169Relay Florida: 1-800-955-8770Fax: 1-877-941-8070Ambetter from Sunshine Health: 1-877-687-1169 (Relay Florida: 1-800-955-8770) Ambetter.SunshineHealth.com 14COVERED SERVICES MEDICAL SERVICE EXPENSE BENEFITSHow To Get Medical Care When You’reOut Of Town

Providers will typically submit claims on your behalf, but sometimes you may befinancially responsible for covered services. This usually happens if: Your provider is not contracted with us You have an out-of-area emergencyIf you have paid for services we agreed to cover, you can request reimbursementfor the amount you paid. We can adjust your deductible, copayment or costsharing to reimburse you.To request reimbursement for a covered service, you need a copy of the detailedclaim from the provider. You also need to submit an explanation of why you paidfor the covered services. Send this to us at the following address:Ambetter from Sunshine HealthAttn: Claims DepartmentP.O. Box 5010Farmington, MO 63640-5010After getting your claim, we will let you know we have received it, begin aninvestigation and request all items necessary to resolve the claim. We will dothis in 15 days or less.We will notify you, in writing, that we have either accepted or rejected yourclaim for processing within 15 days as well. If we are unable to come to adecision about your claim within 15 days, we will let you know and explain whywe need additional time.We will accept or reject your claim no later than 45 days after we receive it. Ifwe reject your claim, the notice will state the reason why. If we agree to pay allor part of your claim, we will pay it no later than the fifth business day after thenotice has been made.Ambetter from Sunshine Health: 1-877-687-1169 (Relay Florida: 1-800-955-8770) Ambetter.SunshineHealth.com 15COVERED SERVICES MEDICAL SERVICE EXPENSE BENEFITSHow To Submit A Claim ForCovered Services

If you need care that yourPCP cannot provide, he/shecan recommend a specialistprovider. Paper referrals aren’trequired.If you have a specific medical problem, condition, injury or disease, you willprobably need to see a specialist. A specialist is a provider who is trained in aspecific area of healthcare. To see a specialist, you should get a referral fromyour primary care provider (PCP).Here are some services that may require a referral from your PCP: Specialist services, including standing or ongoing referrals to a specificprovider Diagnostic tests (X-rays and labs) High-tech imaging (CT scans, MRIs, PET scans, etc.)* Scheduled outpatient hospital services Planned inpatient admission* Clinic services Renal dialysis (for kidney disease) Durable medical equipment (DME)* Home healthcare**Requires

Ambetter from Sunshine Health: 1-877-687-1169 (Relay Florida: 1-800-955-8770) Ambetter.SunshineHealth.com 2 MEMBER HANDBOOK OVERVIEW Member Handbook Overview . in your area by using the Provider Directory available on our website. Remember, your PCP, also known as a personal doctor, is the main doctor you will see for most