Provider Network Design

We want you to be and stay healthy! Ambetter strives to provide access to a quality healthcare network with the goals:

• Keep our premiums affordable and lowering costs for members
• Focus on making providers available who have a history of better healthcare outcomes

The Ambetter network includes healthcare providers to deliver all of the services that the Affordable Care Act describes as Essential Health Benefits. These include:

• Preventive care
• Hospitalization coverage
• Emergency services
• And more (refer to your Evidence of Coverage (EOC) for the full list of benefits)

To accomplish these goals, Ambetter contracts with a full range of practitioners and providers such as:

• Primary care doctors
• Behavioral health practitioners
• Specialty physicians, such as cardiologists, neurologists, etc.
• Providers, including hospitals, pharmacies, medical equipment companies, etc.

Ambetter makes sure practitioners and providers of all types are available within a certain geographic mileage or driving time from each of our members’ homes to ensure you receive quality care in a timely manner.

Ambetter contracts with providers who accept our contract terms, meet our credentialing criteria, and agree to our reimbursement terms. We regularly review the provider network and make decisions about which providers remain in the network and if additional providers are needed, based on relevant factors that could include:

• The availability of certain types of practitioners or hospitals in your area.
• The ability of practitioners to meet our credentialing criteria, including a valid license to practice, applicable education and training, appropriate work history, etc.
• Assessment of facilities such as hospitals, to ensure they are appropriately licensed and accredited.
• Monitoring of the quality of care and service provided by individual practitioners and providers, which includes complaints from members and patient safety concerns.

Ambetter does not regularly use specific clinical performance, member experience, patient safety, or cost-related measures to select the practitioners and facilities in the network.