COVENTRY HEALTH AND LIFE INSURANCE COMPANY CERTIFICATE OF COVERAGE. GROUP PPO PLAN with Pediatric Dental

Transcription

1 COVENTRY HEALTH AND LIFE INSURANCE COMPANY CERTIFICATE OF COVERAGE GROUP PPO PLAN with Pediatric Dental AVAILABLE OUTSIDE OF THE HEALTH INSURANCE MARKETPLACE Under this Group PPO Plan, inpatient, outpatient and other Covered Services are available through both In- Network (Participating) Providers and Out-of-Network (Non-Participating) Providers. Benefits under this Group PPO Plan are subject to Our Utilization Management Program. Benefits are effective only while You are covered by the Group Insurance Contract. Keep in mind that using a Participating Provider (Your In-Network benefits) will usually cost You less than using a Non-Participating Provider (Your Out-of-Network benefits) because Participating Providers are contracted with Us to provide health care services to Members for a lower fee, whereas Non-Participating Providers are not contracted with Us. Please see Section 1 for more information on how Your In-Network and Out-of-Network benefits work. Coverage under this plan is non-occupational. Only non-occupational injuries and non-occupational illnesses are covered under this plan. If You have any questions, please write or call us at: Coventry Health and Life Insurance Company 550 Maryville Centre Drive, Suite 300 St. Louis, MO Benefits underwritten by Coventry Health & Life Insurance Company and Administered by Coventry Health Care of Missouri, Inc. CHLMOSMGRPPPOCOC16R2 1

2 Dear New Member: Welcome to Coventry! We are extremely pleased that You have enrolled in Our Group PPO Plan and look forward to serving You. Coventry Health Care s Plans emphasize wellness and preventive care. You will find that Our strong Network of area Physicians, Hospitals, and other Providers offers a broad range of services to meet Your medical needs. As a Coventry Health Care Member, it is important that You understand the way Your Plan operates. This Certificate of Coverage is an important legal document and contains the information You need to know about Your Coverage with Us and how to get the care You need. Please keep it in a safe place where You can refer to it as needed. Please take a few minutes to read these materials and to make Your covered family Members aware of the provisions of Your Coverage. Our Customer Services Department is available to answer any questions You may have about Your Coverage. You can reach them at Monday through Friday, 8:00 a.m. to 6:00 p.m. CST. You may also access Your benefit information 24 hours a day, seven days a week by registering and logging in at We look forward to serving You and Your family. Sincerely, Frank D Antonio, President Coventry Health and Life Insurance Company 2

3 Coventry Health and Life Insurance Company GROUP PPO PLAN AVAILABLE OUTSIDE OF THE HEALTH INSURANCE MARKET PLACE This Group PPO Certificate of Coverage (hereinafter referred to as the Certificate ) is part of the Group Contract between Coventry Health and Life Insurance Company as the underwriter and Coventry Health Care of Missouri, Inc. as the administrator. (hereafter referred to as the Health Plan, CHL, We, Us, or Our ) and the Group to provide benefits to Covered Persons ( You, Your ), subject to the terms, conditions, exclusions and limitations of this Certificate. We issue this Certificate based on the Group s application and payment of the required Premium. In addition to this Certificate, the Group Contract includes: The Group Enrollment Agreement; This Certificate and any amendment(s); Application Forms, and any supplemental application or change forms; Schedule of Benefits; and Any applicable Riders. This Certificate overrides and replaces any Certificate of Coverage previously issued to You. The coverage described in this Certificate is based upon the conditions of the Group Contract issued to Your employer, and is based upon the benefit plan that Your Group chose for You. The laws of the State of Missouri govern this Certificate. This Certificate is a legal document explaining Your Coverage. The Covered Services and provisions described in this Certificate are effective only while You are eligible for Coverage under the Certificate and while the Certificate is in effect. This Certificate of Coverage will continue in effect for the term agreed upon between the Group and the Plan. The Certificate will automatically renew as determined by the Group, unless it is non-renewed and/or terminated as described in Section 3. You are subject to all terms, conditions, limitations, and exclusions in this Certificate and to all of the rules and regulations of the Health Plan. This Certificate may require the Subscriber to contribute to the required Premiums. You can contact Your Group for information about any part of the Premium cost You are responsible for paying. By paying Premiums or having Premiums paid on Your behalf, You accept the provisions of this Certificate. We are delivering this Certificate in the State of Missouri. Unless otherwise prohibited by law, the Group intends this Certificate to be an employee welfare benefit plan as defined by ERISA. Except for a fraudulent misstatement or issues concerning non-payment of Premiums, the validity of this policy shall not be contested. PPACA prohibits rescission, except for non-payment of Premiums, or in cases where an individual has performed an act of practice that constitutes intentional fraud or makes an intentional misrepresentation of material fact as prohibited by the terms of the plan of coverage. No person or entity has any authority to waive any Certificate provision or to make any changes or Amendments to this Agreement unless approved in writing by an Officer of the Health Plan, and the resulting waiver, change, or Amendment is attached to the Certificate. This Certificate gives You access to both In-Network benefits, provided by Participating Providers, and Out-of-Network benefits, provided by Non-Participating Providers. Keep in mind that using Out-of- Network Benefits may cost You more than using In-Network benefits. Please read Section 1 to learn more about how Your In-Network and Out-of-Network benefits work, or call Our Customer Service Department at if You have any questions. THIS CERTIFICATE SHOULD BE READ AND RE-READ IN ITS ENTIRETY Many of the provisions of this Certificate are interrelated. Therefore, reading just one or two provisions may give You a misleading impression. Many words used in this Certificate have special meanings. These words will appear capitalized and are defined for You in Section 13. By using these definitions, You will have a clearer understanding of Your Coverage. From time to time, the Certificate may be amended, as required by and in accordance with Missouri state and federal law. When this occurs, We will provide an Amendment or new Certificate to You. You should keep this document in a safe place for Your future reference. CHLMOSMGRPPPOCOC16R2 3

4 HEALTH CARE REFORM Coventry Health and Life Insurance Company is in compliance with PPACA. If any provision of PPACA conflicts with any of the provisions of this Certificate, the Certificate will be interpreted to be compliant with PPACA. Coventry Health and Life Insurance Company 550 Maryville Centre Drive, Suite 300 St. Louis, MO CHLMOSMGRPPPOCOC16R2 4

5 SPECIAL NOTICES NOTICE TO QUALIFIED HIGH DEDUCTIBLE HEALTH PLAN MEMBERS (HSA NOTICE) If You enrolled in a qualified High Deductible Health Plan ( HDHP ) that is HSA-compatible, please read this important notice: The Coventry Health and Life Insurance Company High Deductible Plan is designed to be a Federally qualified High Deductible Health Plan compatible with Health Savings Accounts ( HSA's ). Enrollment in an HDHP that is HSA-compatible is only one of the eligibility requirements for establishing and contributing to an HSA. Please note that if You have other health Coverage in addition to the Coverage under this Certificate, in most instances You may not be eligible to establish or contribute to an HSA, unless both Coverages qualify as High Deductible Health Plans. Coventry Health and Life Insurance Company does not provide tax advice. The Missouri Department of Insurance does NOT in any way warrant that this Plan meets the federal requirements. Please consult with Your financial or legal advisor for information about Your eligibility for an HSA. NOTICE OF NONDISCRIMINATION Coventry Health and Life Insurance Company does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status in the administration of this Policy, including enrollment and benefit determinations. We also do not discriminate against any person based upon his or her status as a victim of family violence, health status, health care needs, previous medical information, genetic information, or receipt of public assistance. MASTECTOMY NOTICE Pursuant to the Women's Health and Cancer Act of 1998, a Member who has undergone a mastectomy may also receive coverage for: Reconstruction of the breast on which a mastectomy has been performed; Surgery and reconstruction of the other breast to produce a symmetrical appearance; Prostheses or prosthetics necessary to restore symmetry; and Coverage for physical complications for all states of a mastectomy, including lymphedemas (swelling associated with the removal of lymph nodes). Coverage for breast reconstruction and related services will be subject to the cost-sharing amounts that are consistent with those that apply to other benefits. There is no time limit for the receipt of prosthetic devices or reconstructive surgery. NOTICE OF ERISA RIGHTS If You are a Member of an Employee Group Health Benefit Plan governed by the Employee Retirement Income Security Act of 1974 (ERISA), You are entitled to certain rights and protection under ERISA. As a participant in an Employer Group Benefit Health Plan, You are entitled to certain rights and protection under the Employee Retirement Income Security Act of 1974 (ERISA). Contact Your employer for Your rights under ERISA. NOTICE CONCERNING COVERAGE LIMITATIONS AND EXCLUSIONS UNDER THE MISSOURI LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION ACT Residents of Missouri who purchase life insurance, annuities or health insurance should know that the insurance companies licensed in this state to write these types of insurance are members of the Missouri Life and Health Insurance Guaranty Association. The purpose of this association is to assure that policyholders will be protected, within limits, in the unlikely event that a member insurer becomes financially unable to meet its obligations. You will receive a copy of this notice in its entirety upon Your enrollment. CHLMOSMGRPPPOCOC16R2 5

6 TABLE OF CONTENTS SECTION 1 USING YOUR BENEFITS... 7 SECTION 2 ENROLLMENT, ELIGIBILITY, AND EFFECTIVE DATES SECTION 3 TERMINATION OF COVERAGE SECTION 4 CLAIMS FOR REIMBURSEMENT OF SERVICES RENDERED BY NON-PARTICIPATING PROVIDERS SECTION 5 COVERED SERVICES SECTION 6 EXCLUSIONS AND LIMITATIONS SECTION 7 COMPLAINTS AND GRIEVANCES SECTION 8 CONFIDENTIALITY OF YOUR HEALTH INFORMATION SECTION 9 RIGHT OF RECOVERY SECTION 10 COORDINATION OF BENEFITS SECTION 11 CONTINUATION AND EXTENSION OF COVERAGE SECTION 12 GENERAL PROVISIONS SECTION 13 DEFINITIONS SECTION 14 MEMBERS RIGHTS AND RESPONSIBILITIES SECTION 15 SERVICE AREA DESCRIPTION SCHEDULE OF BENEFITS... A-1 CHLMOSMGRPPPOCOC16R2 6

7 SECTION 1 USING YOUR BENEFITS This Certificate describes Your benefits under a Group Preferred Provider Organization ( PPO ) Product. Under this Product, We offer In-Network health care services to You through a network of Participating Providers, who have signed a Certificate with Us, where they agree to provide health care services to Members for a lower fee. Our Participating Provider Network (hereafter referred to as the Network ) may change from time to time. Please visit Our website at or You may call Our Customer Service Department at , in order to find out if a Provider is a Participating Provider. If a Provider does not have a contractual agreement with Us, the Provider is considered to be a Non- Participating Provider. Keep in mind that using a Participating Provider (Your In-Network benefits) may cost You less than using a Non-Participating Provider (Your Out-of-Network benefits). If services are provided to You by a Non- Participating Provider, those services will be paid at the Out-of-Network level using the Out-of-Network Rate ( ONR ); however, You will be responsible for charges exceeding the Out-of-Network Rate, in addition to any Deductibles, Coinsurance, Copayments, and non-covered charges. Please see Section for more information on Out-of-Network Providers and the ONR. If You receive Covered Services at an In-Network Hospital or outpatient facility, You might inadvertently receive some services from Non-Participating Providers. In this instance, We will pay the In-Network level for Covered Services provided by a Non-Participating Pathologist, Anesthesiologist, Radiologist, Lab or Emergency Room Physician; however, if the Non-Participating Provider balance bills You for Covered charges (above any applicable cost-share) prescribed/ordered by a Participating Physician, please contact Our Customer Services Department at the number on the back of Your ID card. You will be held harmless for the Covered Health Services billed by the Non-Participating Provider, except for any applicable Copayment, Coinsurance and Deductible. 1.1 Membership Identification (ID) Card. Every Plan Member receives a Membership ID card. Please carry Your Member ID card with You at all times, and present it before health care services are rendered. If Your Member ID card is missing, lost, or stolen, contact Our Customer Service Department at or visit Our website at to order a replacement free of charge. 1.2 Your Primary Care Physician (PCP). Although not required, You are encouraged to select a Primary Care Physician ( PCP ) to assist You in coordinating Your care. You may choose a PCP for Yourself and each Member of Your family. You may select Your PCP by calling the Customer Service phone number located on Your ID card or by visiting our website at You have the right to designate any Primary Care Physician who participates in Our Network and is available to accept You or Your family Members. We encourage You to select a PCP from the Directory of Health Care Providers. The role of the PCP is important to the coordination of Your care, and You are encouraged to contact Your PCP when medical care is needed. This may include preventive health services, consultation with Specialists and other Providers, and Urgent Care. You can select a PCP from one of the following specialties: Family Practice, Internal Medicine, General Practice, OB/GYN or Pediatrics. You may choose one PCP for the entire family, or each Dependent may select a different PCP. To locate the most current Directory of Health Care Providers, please visit Our website at Our online Provider directory is updated at least monthly. If You wish to change Your PCP, You must contact Our Customer Service Department at You may also visit Our website at to make this change. 1.3 Prior Authorizations and Utilization Management. You must comply with all of the Utilization Management Program policies and procedures noted in this Section. Our Utilization Management 7

8 Program is designed to help You receive Medically Necessary health care in a timely manner and at the most reasonable cost. It is an effective measure in helping to monitor the quality and costeffectiveness of Your health care. Our utilization management nurses review requests for non-emergent Hospital admissions, outpatient surgeries, and other outpatient procedures. Our nurses also monitor the care You receive during a Hospital stay and post discharge. Prior Authorizations that have been issued and approved by Us for Covered Services cannot be retracted, except for material misrepresentation or omission of Your health condition and/or the cause of the health condition, or If Your Coverage terminates before the Covered Services are provided, regardless of the reason(s) for such termination. You do not need Prior Authorization from Us or from any other person (including a PCP) in order to obtain access or make an appointment to receive obstetrical or gynecological care from a health care professional in Our Network who specializes in obstetrics or gynecology. The health care professional, however, may recommend certain elective medical procedures that may require Prior Authorization Preventive care services do not require Prior Authorization. For a list of Participating health care professionals who specialize in obstetrics or gynecology, contact the telephone number on the back of Your Member ID Card or refer to Our website, The fact that a Provider may prescribe, order, recommend or approve a service, treatment or supply does not make it Medically Necessary or a Covered Service and does not guarantee payment Special Note Regarding Medicare. If You are enrolled in Medicare on a primary basis (Medicare pays before We pay benefits under this Certificate), the Prior Authorization requirements described in this Certificate do not apply to You. Since Medicare is the primary payer, We will pay as secondary payer as described in Section 10 (Coordination of Benefits). You are required, however, to follow any Provider participation guidelines and Prior Authorization requirements of Your primary Medicare carrier in order for Us to pay benefits Health Care Management Utilization Reviews. Utilization review is performed under the following circumstances: Prospective or Pre-Service Review - Conducting utilization review for the purpose of Prior Authorization is called Prospective or Pre-Service Review. Services include, but are not limited to, elective inpatient admission and outpatient surgeries that require Prior Authorization. Concurrent Care Review - Review that occurs at the time care is rendered. When You are Hospitalized or Confined to a SNF, concurrent review is conducted on site or by telephone with the utilization review department at each facility. Retrospective or Post-Service Review - Retrospective or Post-Service review is utilization review that takes place for medical services that have not been Authorized by Us, after the service, treatment or admission have been provided. Toll-Free Telephone Number Contact the Customer Service Department at the number listed on the back of Your ID card. Lack of Information Note that the Health Plan may deny precertification of any admission, procedure, or service in cases where the You or the Provider will not release the necessary information to render a decision Timing of Utilization Review Decisions. As used in this section, the following shall mean: Working Day - Monday through Friday. It does not include Saturdays, Sundays and CHLMOSMGRPPPOCOC16R2 8

9 public holidays, including Christmas Day, Thanksgiving Day and the day after Thanksgiving Day, The time-frames for making utilization review decisions are as follows: Prospective or Pre-Service Review - Thirty-six (36) hours, which shall include one working day, from the date that We receive all necessary information. Necessary information" includes the results of any face- to-face clinical evaluation or second opinion that may be required. 1. Within twenty-four (24) hours of rendering a decision, We will notify Your Provider by telephone or electronically of Our decision regarding the Pre-Service request. 2. Within two (2) working days of rendering a decision, We will send You and Your Provider written or electronic confirmation of Our decision regarding the Pre- Service request. 3. In the case of an Adverse Benefit Determination, We will verbally notify Your Provider of Our decision within 24 hours of making a decision, and We will send You and Your Provider confirmation of Our decision in writing or electronically within one (1) working day. Concurrent Care Review - One (1) working day from the date that We receive all necessary information. 1. Within one (1) working day after rendering a decision, We will notify Your Provider by telephone or electronically of Our decision regarding the request for extended stay or additional services. 2. Within one (1) working day after the telephone or electronic notification, We will send You and Your Provider confirmation of Our decision in writing or electronically. The written notification will include: a. The number of extended days or the next review date; b. The new total number of days or services approved; and c. The date of admission or initiation of services. 3. In the case of a concurrent care Adverse Benefit Determination, We will notify Your Provider by telephone or electronically within twenty-four (24) hours. Written or electronic confirmation of Our decision will follow to You and Your Provider within one (1) working day of the telephone or electronic notification. Eligible Health Services will continue without any liability to You until You have been notified of our decision. When You receive Emergency Room Services that require immediate post-evaluation or post-stabilization services, the Health Plan will provide authorization for poststabilization and post-evaluation services within sixty (60) minutes of receiving a request; if a decision is not made within thirty (30) minutes, such services will be deemed approved. Retrospective or Post-Service Review - Thirty (30) days from the date that We receive all necessary information. Within ten (10) working days of rendering a decision, We will notify You in writing. Adverse Benefit Determinations - In the event of any Adverse Benefit Determination, the Plan will provide written notification that will include: 1. The principal reason or reasons for the determination; 2. Instructions for submitting a Grievance or reconsideration of the determination; and 3. Instructions for requesting a written statement of the clinical rationale, including the clinical review criteria used to make the determination. CHLMOSMGRPPPOCOC16R2 9

10 Upon request, We will provide in writing to You or Your Provider such clinical review criteria and clinical rationale used to make any Adverse Benefit Determination. Urgent Care Requests - Requests for precertification or predetermination of medical care or treatment that is Urgent, but that has not risen to the level of an Emergency Medical Condition. Precertification or predetermination is not required for Emergency Medical Conditions; however, for predetermination or precertification of Urgent Care requests, We will make an initial decision as soon as possible, taking into account the medical exigencies, but no later than seventy-two (72) hours after receipt of the requested service. If there is insufficient information to process the request, We will notify Your Provider of insufficiency as soon as possible, but not later than twenty-four (24) hours. Your Provider then has forty-eight (48) hours to provide the specified information. We will make a determination on the Urgent Care request as soon as possible, but no later than forty-eight (48) hours after the earlier of: (a) Our receipt of specified information; or (b) the end of the 48-hour period afforded Your Provider to submit the additional information. In the event of an Urgent Care request to precertify an immediate post-evaluation or poststabilization service, We will provide an authorization decision within sixty (60) minutes of receiving the request; if the authorization decision is not made within thirty (30) minutes, such services shall be deemed approved. NOTE: Timeframes and requirements listed are based on state and federal regulations. Where state regulations are stricter than federal regulations, we will abide by state regulations Reconsideration. You or Your Provider have the right to request reconsideration of any Adverse Benefit Determination involving a Prospective or Pre-Service Review, as well as any Concurrent Care Review determination. Such reconsideration will occur within one (1) working day of the receipt of the request and will be conducted between the Provider rendering the service and the reviewer who made the Adverse Benefit Determination, or a clinical peer designated by the reviewer if the reviewer who made the adverse determination is not available within one (1) working day. If the reconsideration process does not resolve the difference of opinion, You, Your authorized representative, or Your Provider acting on Your behalf, may Appeal the Adverse Benefit Determination. General Policies. The following policies apply to both In-Network and Out-of-Network services: Except for emergencies, all Hospitalizations and most outpatient procedures require Prior Authorization. You must ask Your Provider to contact Us at least two (2) working days prior to a scheduled Hospital admission, outpatient surgery, or other outpatient procedure (except for emergencies) to obtain Prior Authorization. If You are admitted to a facility prior to the date Authorized by Us, then You will be responsible for all charges related to the unauthorized days. We will Authorize only Medically Necessary Covered Services. If You obtain services, that are not Medically Necessary or the services are not Authorized by Us, then You will be responsible for all charges for those services. Emergency Services, however, are not subject to any Medically Necessary determinations or Prior Authorization. Second Opinion. You may seek a second opinion or consultation from any Provider within the Network. You may select any Network Physician in the same or a similar specialty for a second opinion. If, however, a Physician of the same or a similar specialty is not available within the Network, We will arrange for a referral to a Non-Participating Physician with the necessary expertise to provide a second opinion or consultation. With approval of a Prior Authorization request in advance of the service, Your cost-share will be the same as if You obtained services from a Provider within Our Network. CHLMOSMGRPPPOCOC16R2 10

11 Intentional material misrepresentation: If We Authorize a service that We later determine was based on an intentional material misrepresentation about Your health status, payment of the service will be denied. You will be responsible for all charges related to that service. Notification letter: When We approve or deny a Prior Authorization request, We will send a notification letter to You and Your Provider. Right to Appeal: You have the right to Appeal any denial for any reason, including any Adverse Benefit Determinations or denial regarding Medical Necessity. Please see the Complaints and Grievances procedures in Section 7. Attending Physician responsibility: Under all circumstances, the attending Physician bears the ultimate responsibility for the medical decisions regarding Your treatment. Prior Authorization requirements are subject to change from time to time. Please ask Your Provider to call Customer Service at to determine whether a Covered Service requires Prior Authorization. The Prior Authorization phone number is located on the back of Your Member ID Card. It is Your responsibility to ensure that Your Provider contacts us to obtain Prior Authorization. Please call Our Customer Service Department at to determine whether a Covered Service requires Prior Authorization. 1.4 Access to Services. We make every effort to ensure that Your access to Covered Services is quick and easy and the services are reasonably available. If You wish to see a particular Provider that is not accepting new patients or is no longer participating in Our Network, please call Our Customer Service Department at We can help You find another Participating Provider that meets Your needs. You may also nominate Your Non-Participating Provider to become a Participating Provider with Coventry. Please call Our Customer Service Department for more information. A Participating Provider or the Health Plan may terminate the Provider s contract without cause by giving proper notice under applicable law. In such case, the Health Plan will notify Members of a Provider s contractual termination within thirty-one (31) days, when the Member is seen on a regular basis by the Provider or the Provider is the Primary Care Physician. Continuity of care is especially important to Us. If Your Participating Provider unexpectedly stops participating with Us while You are in the middle of treatment, please call Us so We can help You continue treatment with another Participating Provider. If You are suffering from a terminal or chronic illness or are an inpatient, or where the continuation of care is Medically Necessary and in accordance with reasonable medical prudence, including circumstances such as disability, pregnancy, or life-threatening Illness, We will allow You to continue Your treatment with Your Non- Participating Provider. In this case, We will continue to pay for the Covered Services You receive from Your Non-Participating Provider for ninety (90) days following the Provider s termination from Our Network. This continuation of care section shall not be construed to require the Plan to provide coverage for benefits otherwise not Covered under this Contract. To locate the most current Directory of Health Care Providers, please visit Our website at Covered Services Rendered by Out-Of-Network Providers. You may choose to receive services from an Out-of-Network Provider; however, keep in mind that using Out-of- Network Benefits may cost You more than using In-Network benefits. Please see Section for more information on Out-of-Network Providers. CHLMOSMGRPPPOCOC16R2 11

12 If, however, You have a medical condition that We believe needs special services, We may refer You to a Designated Facility or other Provider within Our Network; or, if You require certain complex Covered Services for which expertise is limited or equally effective treatments cannot be provided by or through a Participating Provider, We may Authorize the Network cost share amounts to apply to a claim for a Covered Service You receive from an Out-Of-Network Provider. In such circumstance, You must contact Us in advance of obtaining the Covered Service. If You contact Us prior to receiving the service, Your out-of-pocket costs will be no greater than if services were provided in-network. Coverage is subject to the provisions and exclusions of this Certificate Emergency Services. When an Emergency Medical Condition occurs, You should seek medical attention immediately from a Hospital or other Emergency facility. Emergency Care rendered by a Non-Network Provider will be covered as a Network service; however the Member may be responsible for the difference between the Non-Network Provider s charge and the Allowed Amount, in addition to any applicable Coinsurance, Copayment or Deductible. Services provided by an Emergency facility for conditions that are not an Emergency Medical Condition are not covered. Whenever You are admitted as an inpatient directly from a Hospital Emergency Room, the Emergency Room services Copayment/Coinsurance for that Emergency Room visit will be waived. For an inpatient admission following Emergency Care, You are responsible to notify Us, or verify that Your Physician has notified Us within forty-eight (48) hours of Your admission, or within a reasonable period as dictated by the circumstances. When We are contacted, You will be notified whether the inpatient setting is appropriate, and if appropriate, the number of days considered Medically Necessary. By calling Us, You may avoid financial responsibility for any inpatient care that is determined to be not Medically Necessary under this Certificate. If Your Provider does not have a contract with Us, You will be financially responsible for any care that is determined to be not Medically Necessary. When You receive Emergency Room Services that require immediate post-evaluation or poststabilization services, the Health Plan will provide authorization for post-stabilization and postevaluation services within sixty (60) minutes of receiving a request; if a decision is not made within thirty (30) minutes, such services will be deemed approved. If You are admitted as an inpatient to a Non-Participating Hospital after You receive Emergency Room Care, We may elect to transfer You to a Participating Hospital as soon as it is medically appropriate to do so for continued medical management of an Emergency Medical Condition. If the Non-Participating Hospital determines that You are stabilized, the Hospital and Medical Director (or Medical Director s designee) may confer regarding a decision to transfer You to a Participating facility. Air or ground ambulance transportation to return a Member to a Participating Provider is covered when Authorized by Us. If You choose to stay in the Non-Participating Hospital after the date We decide a transfer is medically appropriate, services rendered by Non- Participating Providers or in Non-Participating facilities will be covered at Your Out-of-Network benefit level. Follow-up care and treatment provided once You are stabilized or released from the Hospital is no longer considered Emergency Care. Continuation of care from a Non-Network Provider beyond that needed to evaluate or stabilize Your condition after an Emergency will be covered at Your Non-Network benefit. Follow-up care is not considered Emergency Care. 1.5 Copayments, Coinsurance, Deductibles. Your Copayment, Coinsurance, and Deductible amounts are listed in Your Schedule of Benefits. You are responsible for paying Copayments to Your Provider at the time of service. Coinsurance and Deductible amounts, based on the Health Plan s reimbursement to the Provider, may be due to the Provider before or at the time of service. You must satisfy any applicable Deductible listed in Your Schedule of Benefits before We begin paying for Covered Services. Any applicable Coinsurance will be applied after You meet Your Deductible. You will be responsible for any applicable cost-share for Covered Services that You CHLMOSMGRPPPOCOC16R2 12

13 incur. You will be responsible for Your cost-share up to the maximum Out-Of-Pocket limit applicable to Your plan. The Schedule of Benefits is a summary of the Deductibles, Coinsurance, Copayments, maximums and other limits that apply when You receive Covered Services from a Provider. Please refer to Section 5, "Covered Services", in this Contract for a more complete explanation of the specific services covered by the Plan. In-Network. If You receive In-Network Covered Services, You are responsible only for the applicable Copayment, Deductible, and/or Coinsurance amounts noted in Your Schedule of Benefits. Out-of-Network. If You receive Out-of-Network Covered Services, You are responsible for the applicable Copayment, Deductible, and/or Coinsurance amounts noted in Your Schedule of Benefits, plus any amount in excess of the Out-of-Network Rate ( ONR ). Please see Section 1.7 for more information on the Out-of Network Rate and Your potential Out-of-Network liability. Individual Deductible. For services subject to the Deductible, You must satisfy Your calendar year Individual Deductible before the Health Plan will pay for Your Covered Services, unless the calendar year Family Deductible is satisfied first. After You satisfy Your calendar year Individual Deductible or the calendar year Family Deductible is satisfied, the Health Plan will pay for Your Covered Services, minus any applicable Copayments or Coinsurance. Prescription benefits may be subject to a separate Deductible. Please refer to the Schedule of Benefits for details on your Individual Deductible. Family Deductible. The Family Deductible applies when two or more Members are enrolled in Your Plan. The Family Deductible is met by any combination of Members meeting the total Family Deductible. After the benefit year Family Deductible is satisfied, the Health Plan will pay for Covered Services, minus any applicable Copayments or Coinsurance, for each Member; provided, however, that if a Member satisfies the benefit year Individual Deductible prior to the benefit year Family Deductible being satisfied, the Health Plan will pay for Covered Services, minus any applicable Copayments or Coinsurance, for that Member. Please refer to the Schedule of Benefits for details on your Family Deductible. We have contractual arrangements with Participating Providers and other health care Providers, Provider Networks, pharmacy benefit managers, and other vendors of health care services and supplies ( Providers ). In accordance with these arrangements, certain Providers have agreed to Discounted Charges. A Discounted Charge is the amount that a Provider has agreed to accept as payment in full for Covered Services. A Discounted Charge does not include pharmaceutical rebates or any other reductions, fees or credits a Provider may periodically give Us. We will retain those amounts that are not Discounted Charges. However, We have taken those into consideration in setting the fees charged to provide services under this Plan. Claims under the Plan and any Deductible, Copayment, Coinsurance and Out-of-Pocket Maximums as described in this Certificate will be determined based on the Discounted Charge. 1.6 Out-of-Pocket Maximum (OOP). The individual OOP is the total amount each Member must pay out of his or her pocket annually for In-Network Covered Services, unless the family OOP is satisfied first. The family OOP is the total out-of-pocket amount family Members must pay together annually for In-Network Covered Services, regardless of whether each Member satisfies his or her individual OOP. Generally speaking, out-of-pocket expenses that accumulate to the OOP include Deductibles, Coinsurance, or Copayments. The Out-of-Pocket Maximum amounts are listed in Your Schedule of Benefits. CHLMOSMGRPPPOCOC16R2 13

14 1.7 Payment to Providers In Network Providers (Participating Providers). For In-Network Covered Services, the Participating Provider will bill the Health Plan directly for the services. You do not have to file any claims for these services. You are responsible for payment of: A. The applicable In-Network Copayment, Deductible, and/or Coinsurance amounts; B. Services that require Prior Authorization, which were not Prior Authorized; C. Services that are not Medically Necessary; and D. Services that are not Covered Services Out of Network Providers (Non-Participating Providers). For Out-of-Network Covered Services, the Non-Participating Provider typically expects You to pay for the services. If so, You should submit a claim to Us for reimbursement within twelve (12) months from the date of service and We will send the payment directly to You. However, failure to submit a claim to Us within the specified period shall not invalidate nor reduce the claim, if it was not reasonably possible to furnish proof within the time. Please refer to Section 4, Notice of Claim and Timely Submission of Claim for more information. Note that if You assign payment of the services to the Non- Participating Provider, We will send the payment to the Non-Participating Provider. Our payment for Out-of-Network Covered Services is limited to the Out-of-Network Rate, less the applicable Out-of-Network Copayment, Deductible, and/or Coinsurance amounts You are required to pay under Your Plan. Out-of-Network Rate (ONR). The ONR is the Allowed Amount for charges billed by Non-Participating Providers. The ONR is based upon what Medicare would pay the same Provider for the same service. If the amount You are billed by a Non-Participating Provider is equal to or less than the ONR amount, the charges should be completely Covered by Us, except for any Out-of- Network Copayment, Deductible, and/or Coinsurance amounts You are required to pay under Your Plan. However, if the amount You are billed by the Out-of-Network Provider is greater than the ONR amount, You must pay the amount in excess of the ONR amount, in addition to Your Copayment, Deductible, and/or Coinsurance amounts. *Important Note for Emergency Services: Please note that as Non-Participating Providers are not Participating Providers and do not have a contract with Us, the Provider may not accept payment of Your cost share (Your Deductible and Coinsurance) as payment in full. You may receive a bill for the difference between the amount billed by the Provider and the amount paid by Us. If the emergency room facility or Physician bills You for an amount above Your cost share, You are not responsible for paying that amount. Please send Us the bill at the address listed on Your Member ID card and We will resolve any payment dispute with the Provider over that amount. Make sure Your Member ID number is on the bill. Please Remember In addition to the Out-of-Network Copayment, Deductible, and/or Coinsurance amounts that You are required to pay for Out-of-Network Covered Services, You are also responsible for paying the billed charges that exceed the ONR amount We allow. This excess amount may be substantial. CHLMOSMGRPPPOCOC16R2 14

15 Here is an example of what Your costs could be using an In-Network Participating Provider under the scenario detailed below. IN-NETWORK RULES IN-NETWORK AMOUNTS (A) Total amount billed by the Participating Provider for a $12,000 procedure: (B) Our Allowed Amount for the procedure, as indicated $10,000 in the In-Network Provider s contract with Us: Your In-Network Deductible: $2,000 (C) We subtract Your Deductible from (B): $10,000 - $2,000 = $8,000 Your In-Network Coinsurance: 30% (D) We apply Your Coinsurance to (C): 30% of $8,000 = $2,400 Difference between (A) and (B): PLEASE NOTE: Because We have a contract with the Participating Provider, You are not responsible for paying the difference between the total billed amount and the Allowed Amount. Total amount We pay for procedure: Total amount You pay for procedure: $12,000 - $10,000 = $2,000 (You are not required to pay this amount) $10,000 (Our Allowed Amount) $2,000 (Your Deductible) $2,400 (Your Coinsurance) $5,600 $2,000 (Your Deductible) +$2,400 (Your Coinsurance) $4,400 By contrast, here is an example of what Your costs could be using an Out-of-Network Non-Participating Provider under a similar scenario detailed below. OUT-OF-NETWORK RULES OUT-OF-NETWORK AMOUNTS (A) Total amount billed by Non-Participating Provider for $12,000 a procedure: (B) Our Out-of-Network Rate (ONR) for the procedure. $10,000 This is the amount We allow all Non-Participating Providers for this procedure: Your Out-of-Network Deductible: $4,000 (C) We subtract Your Deductible from (B): $10,000 - $4,000 = $6,000 Your Out-of-Network Coinsurance: 40% (D) We apply Your Coinsurance to (C): 40% of $6,000 = $2,400 Difference Between (A) and (B): $12,000 - $10,000= $2,000 (You are required to pay this amount in excess of the ONR) PLEASE NOTE: Because We do not have a contract with the Non-Participating Provider, You are required to pay the difference between the total billed amount and the ONR. Total amount We pay for procedure: Total amount You pay for procedure: $10,000 (Our Allowed Amount) $4,000 (Your Deductible) $2,400 (Your Coinsurance) $3,600 $4,000 (Your Deductible) + $2,400 (Your Coinsurance) + $2,000 (Amount in excess of ONR) $8,400 CHLMOSMGRPPPOCOC16R2 15

16 1.8 Premium Payment and Grace Period. If In the event any required Premium is not timely paid by You or on Your behalf, Your coverage may be canceled after not less than a 31-day grace period. The Group shall remain liable for all Premiums not paid prior to termination. This Certificate will stay in force during the grace period. If the Premium payment is not received by the end of the grace period, Your Coverage under the Certificate will be terminated effective at 11:59 p.m. on the last day of the grace period. If Your Coverage is terminated on the last day of the grace period, please be aware that you will be responsible for the Premium payment owed during the grace period. 1.9 Changes in Premium or Benefits. Your Coverage that begins on Your Member Effective Date will not change until the anniversary date of the Group Contract. While Coverage is renewable, Premium rates may change. Upon renewal and in accordance with applicable law, We may increase or decrease the Premium and/or Covered Services for all Members covered under this Certificate in the event that any state or federal laws or regulations require Us to cover additional services, reduce Coinsurance or Deductibles, or otherwise expand Coverage in order to meet new minimum standards. Information regarding the Premium and any portion of the Premium cost that a Member must pay can be obtained from the Group. In the event of material modifications to Your Covered Services, We will send You written notice via U.S. mail at Your last known address, but only after approval by applicable regulatory agencies including the Missouri Department of Insurance. Any such change will take effect after approval from the Missouri Department of Insurance and, as required under PPACA, after a required sixty (60) day notification period How to Contact the Health Plan. Whenever You have a question or concern, please call Our Customer Service Department at the telephone number listed on Your Member ID card, or visit Our website at Our contact information is listed as follows. For Customer Service Department and To Submit Claims Hours Monday-Friday: 8:00 am to 6:00 pm CST Toll Free Telephone Number Address Coventry Health and Life Insurance Company PO Box 7374 London, KY To Request a Review of Denied Claims or to Appeal a Denial of Authorization of Services Hours Monday-Friday: 8:00 am to 6:00 pm CST Toll Free Telephone Number Address Coventry Health and Life Insurance Company 550 Maryville Centre Drive, Suite 300 St. Louis, MO Attn: Appeals Department To Register a Complaint Hours Monday-Friday: 8:00 am to 6:00 pm CST Toll Free Telephone Number Address Coventry Health and Life Insurance Company PO Box 7374 London, KY Attn: Customer Services 1.11 Verification of Benefits. When We provide information about which health care services are covered under Your Plan that information is referred to as verification of benefits. When You or Your Provider call Our Customer Service Department at during regular business hours to request verification of benefits, a Health Plan representative will be immediately available CHLMOSMGRPPPOCOC16R2 16

17 to provide assistance. If the health care services are verified as a covered benefit, the Customer Service representative will advise whether Prior Authorization is required. Please be aware that verification of benefits is not a guarantee of payment for services. SECTION 2 ENROLLMENT, ELIGIBILITY, AND EFFECTIVE DATES 2.1 Eligibility. You have coverage provided under this Certificate because of the Subscriber s employment with/membership with/retirement from the Group. The Subscriber must satisfy certain requirements to participate in the Group s benefit plan. These requirements may include waiting periods (that are not greater than 90 days) and Actively At Work standards as determined by the Group or state and/or federal law. So long as this Contract is in effect, any change in the Group s eligibility requirements must be approved in advance by the Plan. Eligibility requirements are described in general terms below. For Group specific eligibility requirements, contact the Group s Human Resources or Benefits Department Subscriber Eligibility. To be eligible to be enrolled as a Subscriber, You must meet all of the criteria listed below: A. Be an Eligible Employee of the Group; B. Be eligible to participate equally in any alternate health benefits plan offered by the Group by virtue of his or her own status with the Group, and not by virtue of dependency; C. Meet all eligibility requirements specified by Your Group and approved by the Plan, including, without limitation, the criteria set forth in the Group Enrollment Agreement; D. Live or work in the Service Area (which may not include all Missouri counties) at least twelve (12) months out of the calendar year unless on temporary work assignment of six (6) months or less; and E. Complete and submit to Us such enrollment forms or other documents that We may reasonably request Dependent Eligibility. To be eligible to be enrolled as a Dependent, You must be listed on the enrollment form completed by the Subscriber, meet all Dependent eligibility criteria established by the Group, and be: A. The lawful spouse of the Subscriber and reside in Our Missouri Service Area, (which may not include all Missouri counties); or B. A child of the Subscriber who is: A child under age twenty-six (26): Who is the birth child of the Subscriber or the Subscriber s spouse; or Who is legally adopted by or placed for adoption with the Subscriber or the Subscriber s spouse; or For whom the Subscriber or the Subscriber s spouse is the court-appointed legal guardian; or For whom the Group has determined is covered under a Qualified Medical Child Support Order as defined by ERISA or any applicable state law; Or, a child age twenty-six (26) or older, if the following criteria is met: The child is the birth or adopted child of the Subscriber or the Subscriber s spouse; or The Subscriber or the Subscriber s spouse is the court-appointed legal guardian; and The child is mentally or physically incapable of earning a living, and the child is CHLMOSMGRPPPOCOC16R2 17

18 chiefly dependent upon the Subscriber for support and maintenance, provided that the onset of such incapacity occurred before the child was twenty-six (26). Note: Proof of incapacity and dependency must be furnished to Us upon enrollment of Your Dependent child, or within thirty-one (31) days after the Dependent s twenty-sixth (26 th ) birthday and subsequently thereafter at reasonable intervals, but not more frequently than annually after the two (2) year period following the Dependent s attaining age twenty-six (26). Coverage will continue as long as the Dependent child is disabled and continues to satisfy the qualifying conditions listed above, unless Coverage is otherwise terminated in accordance with the terms of this Contract. Enrollment of a Dependent child will not be denied for any of the following reasons: o The child was born out of wedlock. o The child is not claimed as a Dependent on Your Federal income tax return. o The child does not reside with You Dependent children are not required to live in the Service Area to be enrolled under this Group Plan. 2.2 Persons Not Eligible to Enroll. A. A person who fails to meet the eligibility requirements specified in this Certificate shall not be eligible to enroll under this Certificate; B. A person whose Coverage under a prior CHL Certificate was terminated due to fraud shall not be eligible to enroll under this Certificate; C. A child born to or adopted by a Dependent child shall not be eligible to enroll under this Certificate; D. Late Enrollees are not eligible to enroll except during the next Open Enrollment or Special Enrollment Period. 2.3 Enrollment and Effective Dates. You are eligible to enroll under the Plan during the Group s Open Enrollment Period and Special Enrollment Periods and as described below. The effective date will be a future first (1st) day of the month effective date specified in the Group Enrollment Agreement, based on the date of receipt of a completed application, and assigned by the Health Plan. Coverage under this Certificate will begin at 12:01 a.m. on the Member Effective Date. For information on Your specific Member Effective Date of Coverage under this Certificate, please contact the Group s Human Resources or Benefits Department. You can also contact Us by calling the number located on the back of Your Identification (ID) Card Initial Enrollment Period. When Your Group purchases coverage under this Certificate from Us, the Initial Enrollment Period is the first period of time when an Eligible Employee can enroll. Coverage begins on the effective date identified in this Certificate, when We receive Your completed enrollment form and any required Premium within thirty-one (31) days of the date You are eligible to enroll. We will not provide Benefits for health services that You receive before Your effective date of coverage. Any newly Eligible Employee or Eligible employee who transfers into the Plan s Service Area may enroll with the Plan for Coverage under this Certificate within thirty-one (31) days after becoming eligible. If the Eligible Employee fails to submit an Enrollment/Change Form within thirty-one (31) days after becoming eligible, s/he is not eligible to enroll until the next Open Enrollment Period, unless there is a qualifying event under the Special Enrollment Period Open Enrollment. An Eligible Employee or Dependent who did not request enrollment for Coverage during the initial enrollment period, or during a Special Enrollment Period, may apply for Coverage at any time; however, s/he will not be enrolled until the Group s next annual enrollment. Open Enrollment means a period of time (at least 31 days prior the CHLMOSMGRPPPOCOC16R2 18

19 Group s renewal date and 31 days following) which is held no less frequently than once in any 12 consecutive months Special Enrollment. A. A Special Enrollment Period applies to an Eligible Employee and/or Dependent who did not enroll during the Initial Enrollment Period or Open Enrollment Period, if the following are true: The Eligible Employee and/or Dependent had existing health coverage under another Plan at the time they had an opportunity to enroll during the Initial Enrollment Period or Open Enrollment Period; and Coverage under the prior plan ended because of any of the following: o o o Loss of eligibility (The term loss of eligibility includes a loss of coverage due to legal separation, divorce, death, termination of employment, or reduction in the number of hours of employment. This term does not include loss of coverage due to failure to timely pay required contributions or premiums or loss of coverage for cause (i.e., fraud or intentional misrepresentation); The employer stopped paying the contributions; In the case of COBRA continuation Coverage, the Coverage ended. If We receive the completed enrollment form and any required Premium within thirty-one (31) days of the date coverage under the prior plan ended, Coverage under the Plan will become effective no later than the first (1st) day of the 1st calendar month after the date the completed request for Special Enrollment is received. B. A Special Enrollment Period also applies when one of the following qualifying events described below occurs and provided that the Subscriber requests enrollment within thirty (30) days after the marriage, birth, adoption, or placement for adoption. Subscribers may enroll Dependents who join their family because of any of the following qualifying events: Birth Legal adoption Placement for adoption Marriage Legal permanent general guardianship Court or administrative order C. Termination of Medicaid or CHIP Coverage. An Eligible Employee and/or Dependent may enroll during a Special Enrollment Period within sixty (60) days of the date s/he Loses eligibility for coverage under Medicaid or the Children s Health Insurance Program (CHIP), or Becomes eligible for premium assistance under Medicaid or CHIP. An Eligible Employee and/or his or her Dependents must request Special Enrollment in writing no later than sixty (60) days from the date of termination of the Medicaid/CHIP eligibility or the date the Eligible Employee or Dependent is determined to be eligible for the premium assistance Newborns. A newborn child born to, or adopted by the Subscriber or the Subscriber s spouse shall be covered for the first thirty-one (31) days from the date of birth. If CHLMOSMGRPPPOCOC16R2 19

20 Dependent Coverage is already in force, coverage is automatic and there is no additional Premium. If the Subscriber does not have family Coverage, immediate Coverage for the first newborn infant shall be provided when the Subscriber applies for family Coverage and pays any applicable Premium within thirty-one (31) days of the newborn s birth. For Coverage to continue beyond the first thirty-one (31) days, You must notify Us of the birth, either orally or in writing. Upon notification, the Plan will provide You with all forms and instructions necessary to enroll Your newborn child. We must receive Your Application Form to add the child as a Dependent and a payment of Premium must be received by Us within thirty-one (31) days from the date of birth. We will allow You ten (10) additional days after You receive the Application form to enroll Your newborn. Newborn Coverage will include necessary care and treatment of medically diagnosed congenital defects and birth abnormalities Adopted Children. A newly adopted child shall be covered for the first thirty-one (31) days from the date of placement for adoption in Your home or the date of an entry of an order granting custody of the child to You. Coverage will continue unless the placement is disrupted prior to legal adoption and the child is removed from placement. Coverage will include the necessary care and treatment of medical conditions existing prior to the day of placement. Placement means in the physical custody of the adoptive parent. If Dependent Coverage is already in force, Coverage is automatic and there is no additional Premium. If Dependent Coverage is not in force, You will need to apply for Dependent Coverage, pay the applicable additional Premium and enroll the child within the first thirtyone (31) days from the date of placement for adoption or the final decree of adoption, whichever is earliest. For Coverage to continue beyond the first thirty-one (31) days, an Application Form to add the child as a Dependent and a payment of Premium must be received by Us within thirty-one (31) days from the date of placement for adoption or the final decree of adoption, whichever is earliest. 2.4 Notification of Change in Status. The Subscriber is responsible for notifying the Group of any changes that will affect his or her eligibility or that of Dependents for services or benefits under this Certificate. The Group must notify Us, in writing, of any changes in Your status or the status of any Dependent(s) within thirty-one (31) days after the date of the status change. This notification must be submitted to Us on a Change Form. Events that qualify as a change in status include, but are not limited to, changes in address, divorce, marriage, death, dependency status, Medicare eligibility, or Coverage by another insurance Plan. Coventry requires notice of Coverage by another payer for purposes of coordinating benefits. We should be notified within a reasonable time of the death of any Member. For more information, call Customer Service at Failure to notify Us of persons no longer eligible for services will not obligate Us to pay for such services. Acceptance of payments from the Group for persons no longer eligible for services will not obligate Us to pay for such services. The Group and/or You will be responsible for payment for any services incurred by you after you cease to meet eligibility requirements. 2.5 If You Become Eligible for Medicare While Covered Under this Plan. In the event that You are eligible for Medicare Parts A, B, and/or D, We will calculate benefits under this Plan as if You had enrolled in the applicable Medicare Part, and regardless of whether You are actually enrolled. Please direct any questions regarding Medicare eligibility and enrollment to Your local Social Security Administration office. 2.6 Delivery of Documents We will provide an Identification Card for each Member and a Certificate for each Subscriber. The Group, however, is responsible for issuing a Certificate to each Member. CHLMOSMGRPPPOCOC16R2 20