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It explains the closed panel network structure, eligibility for covered services, and the agreement governing benefits, including definitions, provisions, limitations, and exclusions. The document describes guaranteed renewability rules, circumstances allowing non-renewal or cancellation, premium rate changes, advance notice requirements, prior authorization and referral requirements, and the ten-day right to return with premium refunds.","2025 EVIDENCE OF COVERAGE  \n[AmbetterofNorthCarolina.com](AmbetterofNorthCarolina.com)  \n77264NC001-2025  \nAmbetter of North Carolina Inc.  \nName of Product  \nHome Office: 1701 North Graham St. , Suite 101 , Charlotte, NC 28206 Individual Member HMO Policy  \nAmbetter of North Carolina Inc. is a health maintenance organization (HMO), organized under the laws of the State of North Carolina, providing health care coverage for members. In this policy, the terms\"you\" , or \"your\" , will refer to the member or any dependents enrolled in this policy. The terms \"we,\"\"our,\" or \"us\" will refer to Ambetter of North Carolina Inc.  \nThis policy is a closed panel network HMO. This means that services rendered by non-network providers will not be covered except in limited situations described in the eligible expense definition,  \nfound on page 19 of the policy.  \nThis policy is a legal contract between you and us. Read your policy carefully.  \nAGREEMENT AND CONSIDERATION  \nThis document along with the Schedule of Benefits and your application is your policy and it is a legal document. It is the agreement under which benefits will be provided and paid. In consideration of your application and the timely payment of premiums, we will provide benefits to you , the member, for covered services as outlined in this policy. Benefits are subject to policy definitions, provisions, limitations, and exclusions.  \nGUARANTEED RENEWABLE  \nAnnually, we must file this product, the cost share, and the rates associated with it for approval. Guaranteed renewable means that your plan will be renewed into the subsequent year’s approved product on the anniversary date unless terminated earlier in accordance with policy terms. You may keep this policy (or the new policy you are mapped to for the following year) in force by timely payment of the required premiums. In most cases, you will be moved to a new policy each year, however, we may decide not to renew the policy as of the renewal date if: (1) we decide not to renew all policies issued on this form, with a new policy at the same metal level with a similar type and level of benefits, to residents of the state where you then live; (2) we withdraw from the service area; or (3) there is fraud or an intentional material misrepresentation made by or with the knowledge of a member in filing a claim for policy benefits.  \nIn addition to the above, this guarantee for continuity of coverage shall not prevent us from cancelling or non-renewing this policy in the following events: (1) non-payment of premium; (2) a member fails to pay any deductible or copayment amount owed to us and not the provider of services; (3) a member is found to be in material breach of this policy; or (4) a change in federal or state law no longer permits the continued offering of such coverage, such as CMS guidance related to individuals who are Medicare eligible.  \nAnnually , we may change the rate table used for this policy form. Each premium will be based on the rate table in effect on that premium’s due date. The policy plan, and age of members, type and level of benefits, and place of residence on the premium due date are some of the factors used in determining your premium rates. We have the right to change premiums.  \nAt least 60 calendar days’ notice of any plan to take an action or make a change permitted by this clause will be delivered to you at your last address as shown in our records. We will make no change  \n77264NC001-2025 1  \nMember Services Department: 1-833-863-1310 Relay 711 [AmbetterofNorthCarolina.com](AmbetterofNorthCarolina.com)  \nin your premium solely because of claims made under this policy or a change in a member’s health. While this policy is in force, we will not restrict coverage already in force. If we discontinue offering and decide not to renew all policies issued on this form, with the same type and level of benefits, for all residents of the state where you reside, we will provide a written notice to you at lea","cbCaim7tBnD2FlYZ","https://ap.wps.com/l/cbCaim7tBnD2FlYZ","pdf",3142513,4,103,"English","en",105,"# Introduction\n## How to Contact Us\n## Interpreter Services\n## Member Rights and Responsibilities\n## Important Information","[{\"question\":\"What is the role of this 2025 Evidence of Coverage in the policy?\",\"answer\":\"It describes the legal agreement between the member and Ambetter of North Carolina Inc., outlining how benefits are provided and paid according to policy definitions and limitations.\"},{\"question\":\"What does guaranteed renewable mean for the member?\",\"answer\":\"The plan is renewed into the subsequent year’s approved product on the anniversary date unless terminated earlier under the policy’s terms and conditions.\"},{\"question\":\"When can coverage be canceled or a policy not renewed?\",\"answer\":\"Coverage may end for reasons such as non-payment of premium, failure to pay deductibles or copayments, material breach, or changes in federal/state law that no longer permit the offering.\"}]","Ambetter of North Carolina Inc. - Individual Member HMO Policy - 2025 Evidence of Coverage | PDF",1789798644,36,{"code":4,"msg":77,"data":78},"ok",{"site_id":70,"language":69,"slug":79,"title":59,"keywords":80,"description":60,"schema_data":81,"social_meta":136,"head_meta":138,"extra_data":140,"updated_unix":141},"ambetter-of-north-carolina-inc-individual-member-hmo-policy-2025-evidence-of-coverage","",{"@graph":82,"@context":135},[83,98,118],{"@type":84,"itemListElement":85},"BreadcrumbList",[86,90,93,96],{"item":87,"name":88,"@type":89,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":91,"name":10,"@type":89,"position":92},"https://docshare.wps.com/template/",2,{"item":94,"name":36,"@type":89,"position":95},"https://docshare.wps.com/template/forms/",3,{"item":97,"name":59,"@type":89,"position":66},"https://docshare.wps.com/template/ambetter-of-north-carolina-inc-individual-member-hmo-policy-2025-evidence-of-coverage/302928/",{"url":97,"name":59,"@type":99,"image":100,"author":105,"headline":59,"publisher":107,"fileFormat":110,"inLanguage":69,"description":60,"dateModified":111,"datePublished":112,"encodingFormat":110,"isAccessibleForFree":113,"interactionStatistic":114},"DigitalDocument",{"url":101,"@type":102,"width":103,"height":104},"https://docshare.wps.com/thumbnails/ambetter-of-north-carolina-inc-individual-member-hmo-policy-2025-evidence-of-coverage/302928.png","ImageObject",442,249,{"name":57,"@type":106},"Person",{"url":87,"name":108,"@type":109},"DocShare","Organization","application/pdf","2026-09-27","2026-09-19",true,{"@type":115,"interactionType":116,"userInteractionCount":92},"InteractionCounter",{"@type":117},"ViewAction",{"@type":119,"mainEntity":120},"FAQPage",[121,127,131],{"name":122,"@type":123,"acceptedAnswer":124},"What is the role of this 2025 Evidence of Coverage in the policy?","Question",{"text":125,"@type":126},"It describes the legal agreement between the member and Ambetter of North Carolina Inc., outlining how benefits are provided and paid according to policy definitions and limitations.","Answer",{"name":128,"@type":123,"acceptedAnswer":129},"What does guaranteed renewable mean for the member?",{"text":130,"@type":126},"The plan is renewed into the subsequent year’s approved product on the anniversary date unless terminated earlier under the policy’s terms and conditions.",{"name":132,"@type":123,"acceptedAnswer":133},"When can coverage be canceled or a policy not renewed?",{"text":134,"@type":126},"Coverage may end for reasons such as non-payment of premium, failure to pay deductibles or copayments, material breach, or changes in federal/state law that no longer permit the offering.","https://schema.org",{"og:url":97,"og:type":137,"og:title":59,"og:site_name":108,"og:description":60},"article",{"robots":139,"canonical":97},"index,follow",{"doc_id":55,"site_id":70},1790523299]