COVENTRY HEALTH AND LIFE INSURANCE COMPANY. CoventryOne. PPO Plan INDIVIDUAL MEMBER CONTRACT AVAILABLE IN THE HEALTH INSURANCE MARKETPLACE

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1 COVENTRY HEALTH AND LIFE INSURANCE COMPANY CoventryOne PPO Plan INDIVIDUAL MEMBER CONTRACT AVAILABLE IN THE HEALTH INSURANCE MARKETPLACE Under ths PPO Plan, npatent, outpatent and other Covered Servces are avalable through both In-Network (Partcpatng) Provders and Out-of-Network (Non-Partcpatng) Provders. You have the full freedom of choce n the selecton of any duly lcensed health care professonal. Benefts under ths Plan are subject to Our Utlzaton Management Program. Keep n mnd that usng a Partcpatng Provder (Your In-Network benefts) wll usually cost You less than usng a Non-Partcpatng Provder (Your Out-of-Network benefts) because Partcpatng Provders are contracted wth Us to provde health care servces to Members for a lower fee, whereas Non-Partcpatng Provders are not contracted wth Us. Please see Secton 1 for more nformaton on how Your In-Network and Out-of-Network benefts work. You may return ths Polcy wthn (10) days of ts recept for a full refund of any Premum pad f, after examnng t, You are not satsfed for any reason. Any coverage returned for a refund of premum wll be null and vod from ts ncepton. If You have any questons, please wrte or call us at: Coventry Health and Lfe Insurance Company 550 Maryvlle Centre Drve, Sute 300 St. Lous, MO (855) Benefts underwrtten by Coventry Health & Lfe Insurance Company and Admnstered by Coventry Health Care of Mssour, Inc. CHLMOIVLPPOHIXCOC15 1

2 Dear New Member: Welcome to Coventry! We are extremely pleased that You have enrolled n Our CoventryOne Plan and look forward to servng You. Coventry s a subsdary of Coventry Health Care, Inc., a Fortune 500 company operatng Plans, nsurance companes, network rental, and workers' compensaton servces companes n all 50 states and Puerto Rco. We are one of the country s largest managed health care companes provdng a full range of rsk and fee-based health care products and servces. Coventry Health Care s Plans emphasze wellness and preventve care. You wll fnd that Our strong Network of area Physcans, Hosptals, and other Provders offers a broad range of servces to meet Your medcal needs. As a Coventry Health Care Member, t s mportant that You understand the way Your Plan operates. Ths Indvdual Member Contract s an mportant legal document and contans the nformaton You need to know about Your Coverage wth Us and how to get the care You need. Please keep t n a safe place where You can refer to t as needed. Please take a few mnutes to read these materals and to make Your covered famly Members aware of the provsons of Your Coverage. Our Customer Servces Department s avalable to answer any questons You may have about Your Coverage. You can reach them at (855) Monday through Frday, 8:00 a.m. to 8:00 p.m. CST. You may also access Your beneft nformaton 24 hours a day, seven days a week by regsterng and loggng n at We look forward to servng You and Your famly. Sncerely, Frank D Antono, Presdent Coventry Health and Lfe Insurance Company 2

3 Coventry Health and Lfe Insurance Company INDIVIDUAL MEMBER CONTRACT AVAILABLE IN THE HEALTH INSURANCE MARKET PLACE The ndvdual Contract (herenafter referred to as the Contract ) between Coventry Health and Lfe Insurance Company as the underwrter and Coventry Health Care of Mssour, Inc. as the admnstrator. (hereafter referred to as the Health Plan, CHL, We, Us, or Our ) and You s made up of the followng documents: Indvdual Member Contract and any Contract amendments; and Schedule of Benefts. Ths s to certfy that, n consderaton for and upon payment of the Premum rate, the ndvdual(s) covered under ths Contract are enttled to the benefts set forth under the terms and condtons n ths Contract. The laws of the State of Mssour govern ths Contract. Ths Contract s a legal document. The Covered Servces and provsons descrbed n ths Contract are effectve only whle You are elgble for Coverage under the Contract and whle the Contract s n effect. You may enroll and reman enrolled under the Contract f You meet the elgblty requrements descrbed n Secton 2 of ths Indvdual Member Contract. Ths Contract s renewable and may only be non-renewed and/or termnated) as set forth n Secton 3. You are subject to all terms, condtons, lmtatons, and exclusons n ths Contract and to all of the rules and regulatons of the Health Plan. By payng Premums or havng Premums pad on Your behalf, You accept the provsons of ths Contract. No person or entty has any authorty to wave any Contract provson or to make any changes or Amendments to ths Agreement unless approved n wrtng by an Offcer of the Health Plan, and the resultng waver, change, or Amendment s attached to the Contract. Ths Contract gves You access to both In-Network benefts, provded by Partcpatng Provders, and Out-of-Network benefts, provded by Non-Partcpatng Provders. Keep n mnd that usng Out-of- Network Benefts may cost You more than usng In-Network benefts. Please read Secton 1 to learn more about how Your In-Network and Out-of-Network benefts work, or call Our Customer Servce Department at (855) f You have any questons. THIS CONTRACT SHOULD BE READ AND RE-READ IN ITS ENTIRETY Many of the provsons of ths Contract are nterrelated. Therefore, readng just one or two provsons may gve You a msleadng mpresson. Many words used n ths Contract have specal meanngs. These words wll appear captalzed and are defned for You n Secton 11. By usng these defntons, You wll have a clearer understandng of Your Coverage. From tme to tme, the Contract may be amended, as requred by and n accordance wth Mssour state and federal law. When ths occurs, We wll provde an Amendment or new Contract to You. You should keep ths document n a safe place for Your future reference. HEALTH CARE REFORM Coventry Health and Lfe Insurance Company s n complance wth PPACA. If any provson of PPACA conflcts wth any of the provsons of ths Contract, the Contract wll be nterpreted to be complant wth PPACA. Coventry Health and Lfe Insurance Company 550 Maryvlle Centre Drve, Sute 300 St. Lous, MO (855) CHLMOIVLPPOHIXCOC15 3

4 SPECIAL NOTICES NOTICE TO QUALIFIED HIGH DEDUCTIBLE HEALTH PLAN MEMBERS (HSA NOTICE) If You enrolled n a qualfed Hgh Deductble Health Plan ( HDHP ) that s HSA-compatble, please read ths mportant notce: The Coventry Health and Lfe Insurance Company Hgh Deductble Plan s desgned to be a Federally qualfed Hgh Deductble Health Plan compatble wth Health Savngs Accounts ( HSA's ). Enrollment n an HDHP that s HSAcompatble s only one of the elgblty requrements for establshng and contrbutng to an HSA. Please note that f You have other health Coverage n addton to the Coverage under ths Contract, n most nstances You may not be elgble to establsh or contrbute to an HSA, unless both Coverages qualfy as Hgh Deductble Health Plans. Coventry Health and Lfe Insurance Company does not provde tax advce. The Mssour Department of Insurance does NOT n any way warrant that ths Plan meets the federal requrements. Please consult wth Your fnancal or legal advsor for nformaton about Your elgblty for an HSA. NOTICE OF NONDISCRIMINATION Coventry Health and Lfe Insurance Company does not dscrmnate on the bass of race, color, natonal orgn, dsablty, age, sex, gender dentty, sexual orentaton, or health status n the admnstraton of ths Polcy, ncludng enrollment and beneft determnatons. We also do not dscrmnate aganst any person based upon hs or her status as a vctm of famly volence, health care needs, prevous medcal nformaton, genetc nformaton, or recept of publc assstance. MASTECTOMY NOTICE Pursuant to the Women's Health and Cancer Act of 1998, a Member who has undergone a mastectomy receve coverage for: Reconstructon of the breast on whch a mastectomy has been performed; Surgery and reconstructon of the other breast to produce a symmetrcal appearance; Prostheses or prosthetcs necessary to restore symmetry; and Coverage for physcal complcatons for all states of a mastectomy, ncludng lymphedemas (swellng assocated wth the removal of lymph nodes). Coverage for breast reconstructon and related servces wll be subject to the cost-sharng amounts that are consstent wth those that apply to other benefts. There s no tme lmt for the recept of prosthetc devces or reconstructve surgery. NOTICE CONCERNING COVERAGE LIMITATIONS AND EXCLUSIONS UNDER THE MISSOURI LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION ACT Resdents of Mssour who purchase lfe nsurance, annutes or health nsurance should know that the nsurance companes lcensed n ths state to wrte these types of nsurance are members of the Mssour Lfe and Health Insurance Guaranty Assocaton. The purpose of ths assocaton s to assure that polcyholders wll be protected, wthn lmts, n the unlkely event that a member nsurer becomes fnancally unable to meet ts oblgatons. You wll receve a copy of ths notce n ts entrety upon Your enrollment. may CHLMOIVLPPOHIXCOC15 4

5 TABLE OF CONTENTS SECTION 1 USING YOUR BENEFITS... 6 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 GENERAL PROVISIONS SECTION 11 DEFINITIONS SECTION 12 MEMBERS RIGHTS AND RESPONSIBILITIES SECTION 13 SERVICE AREA DESCRIPTION SCHEDULE OF BENEFITS... A-1 CHLMOIVLPPOHIXCOC15 5

6 SECTION 1 USING YOUR BENEFITS CoventryOne s an Indvdual Preferred Provder Organzaton ( PPO ) Product. Under ths Product, We offer In-Network health care servces to You through a network of Partcpatng Provders, who have sgned a Contract wth Us, where they agree to provde health care servces to Members for a lower fee. Our Partcpatng Provder Network (hereafter referred to as the Network ) may change from tme to tme. Please vst Our webste at or You may call Our Customer Servce Department at (855) , n order to fnd out f a Provder s a Partcpatng Provder. If a Provder does not have a contractual agreement wth Us, the Provder s consdered to be a Non- Partcpatng Provder. Keep n mnd that usng a Partcpatng Provder (Your In-Network benefts) may cost You less than usng a Non-Partcpatng Provder (Your Out-of-Network benefts). If servces are provded to You by a Non- Partcpatng Provder, those servces wll be pad at the Out-of-Network level usng the Out-of-Network Rate ( ONR ); however, You wll be responsble for charges exceedng the Out-of-Network Rate, n addton to any Deductbles, Consurance, Copayments, and non-covered charges. Please see Secton for more nformaton on Out-of-Network Provders and the ONR. If You receve Covered Servces at an In-Network Hosptal or outpatent faclty, You mght nadvertently receve some servces from Non-Partcpatng Provders. In ths nstance, We wll pay the In-Network level for Covered Servces provded by a Non-Partcpatng Pathologst, Anesthesologst, Radologst, Lab or Emergency Room Physcan; however, f the Non-Partcpatng Provder balance blls You for Covered charges (above any applcable cost-share) prescrbed/ordered by a Partcpatng Physcan, please contact Our Customer Servces Department at the number on the back of Your ID card. 1.1 Membershp Identfcaton (ID) Card. Every Plan Member receves a Membershp ID card. Please carry Your Member ID card wth You at all tmes, and present t before health care servces are rendered. If Your Member ID card s mssng, lost, or stolen, contact Our Customer Servce Department at (855) or vst Our webste at to order a replacement free of charge. 1.2 Your Prmary Care Physcan (PCP). Although not requred, You are encouraged to select a Prmary Care Physcan ( PCP ) to assst You n coordnatng Your care. You may choose a PCP for Yourself and each Member of Your famly. You may select Your PCP by callng the Customer Servce phone number located on Your ID card or by vstng our webste at You have the rght to desgnate any Prmary Care Physcan, who partcpates n Our Network and s avalable to accept You or Your famly Members. Even f Your Plan does not requre the selecton of a PCP, We encourage You to select a PCP from the Drectory of Health Care Provders. The role of the PCP s mportant to the coordnaton of Your care, and You are encouraged to contact Your PCP when medcal care s needed. Ths may nclude preventve health servces, consultaton wth Specalsts and other Provders, and Urgent Care. You can select a PCP from one of the followng specaltes: Famly Practce, Internal Medcne, General Practce, OB/GYN or Pedatrcs. You may choose one PCP for the entre famly, or each Dependent may select a dfferent PCP. To locate the most current Drectory of Health Care Provders, please vst Our webste at Our onlne Provder drectory s updated at least monthly. If You wsh to change Your PCP, You must contact Our Customer Servce Department at (855) You may also vst Our webste at to make ths change. 1.3 Pror Authorzatons and Utlzaton Management. You must comply wth all of the Utlzaton Management Program polces and procedures noted n ths Secton. Our Utlzaton Management Program s desgned to help You receve Medcally Necessary health care n a tmely manner and at the most reasonable cost. It s an effectve measure n helpng to montor the qualty and cost- CHLMOIVLPPOHIXCOC15 6 DOI APPROVED

7 effectveness of Your health care. Our utlzaton management nurses revew requests for non-emergent Hosptal admssons, outpatent surgeres, and other outpatent procedures. Our nurses also montor the care You receve durng a Hosptal stay and post dscharge. Pror Authorzatons that have been ssued and approved by Us for Covered Servces cannot be retracted, except for materal msrepresentaton or omsson of Your health condton and/or the cause of the health condton, or If Your Coverage termnates before the Covered Servces are provded, regardless of the reason(s) for such termnaton. You do not need Pror Authorzaton from Us or from any other person (ncludng a PCP) n order to obtan access or make an appontment to receve obstetrcal or gynecologcal care from a health care professonal n Our Network who specalzes n obstetrcs or gynecology. The health care professonal, however, may recommend certan electve medcal procedures that may requre Pror Authorzaton. Preventve care servces do not requre Pror Authorzaton. For a lst of Partcpatng health care professonals who specalze n obstetrcs or gynecology, contact the telephone number on the back of Your Member ID Card or refer to Our webste, The fact that a Provder may prescrbe, order, recommend or approve a servce, treatment or supply does not make t Medcally Necessary or a Covered Servce and does not guarantee payment Health Care Management Utlzaton Revews. Utlzaton revew s performed under the followng crcumstances: Prospectve or Pre-Servce Revew - Conductng utlzaton revew for the purpose of Pror Authorzaton s called Prospectve or Pre-Servce Revew. Servces nclude, but are not lmted to, electve npatent admsson and outpatent surgeres that requre Pror Authorzaton. Concurrent Care Revew - Revew that occurs at the tme care s rendered. When You are Hosptalzed or Confned to a SNF, concurrent revew s conducted on ste or by telephone wth the utlzaton revew department at each faclty. Retrospectve or Post-Servce Revew - Retrospectve or Post-Servce revew s utlzaton revew that takes place for medcal servces that have not been Authorzed by Us, after the servce, treatment or admsson have been provded. Toll-Free Telephone Number Contact the Customer Servce Department at the number lsted on the back of Your ID card. Lack of Informaton Note that the Health Plan may deny precertfcaton of any admsson, procedure, or servce n cases where the You or the Provder wll not release the necessary nformaton to render a decson Tmng of Utlzaton Revew Decsons. As used n ths secton, the followng shall mean: Workng Day - Monday through Frday. It does not nclude Saturdays, Sundays and publc holdays, ncludng Chrstmas Day, Thanksgvng Day and the day after Thanksgvng Day. The tme-frames for makng utlzaton revew decsons are as follows: Prospectve or Pre-Servce Revew Thrty-sx (36) hours, whch shall nclude one workng day, from the date that We receve all necessary nformaton or ffteen (15) days after the request for servces, whchever s earler. Necessary nformaton" ncludes the results of any face- to-face clncal evaluaton or second opnon that may be requred. CHLMOIVLPPOHIXCOC15 7

8 1. Wthn twenty-four (24) hours of renderng a decson, We wll notfy Your Provder by telephone or electroncally of Our decson regardng the Pre-Servce request. 2. Wthn two (2) workng days of renderng a decson, We wll send You and Your Provder wrtten or electronc confrmaton of Our decson regardng the Pre- Servce request. 3. In the case of an Adverse Beneft Determnaton, You and Your Provder wll receve confrmaton of Our decson n wrtng or electroncally wthn one (1) workng day. Concurrent Care Revew - One (1) workng day from the date that We receve all necessary nformaton. 1. Wthn one (1) workng day after renderng a decson, We wll notfy Your Provder by telephone or electroncally of Our decson regardng the request for extended stay or addtonal servces. 2. Wthn one (1) workng day after the telephone or electronc notfcaton, We wll send You and Your Provder confrmaton of Our decson n wrtng or electroncally. The wrtten notfcaton wll nclude: a. The number of extended days or the next revew date; b. The new total number of days or servces approved; and c. The date of admsson or ntaton of servces. 3. In the case of a concurrent care Adverse Beneft Determnaton, We wll notfy Your Provder by telephone or electroncally wthn twenty-four (24) hours. Wrtten or electronc confrmaton of Our decson wll follow to You and Your Provder wthn one (1) workng day of the telephone or electronc notfcaton. When You receve Emergency Room Servces that requre mmedate post-evaluaton or post-stablzaton servces, the Health Plan wll provde authorzaton for poststablzaton and post-evaluaton servces wthn sxty (60) mnutes of recevng a request; f a decson s not made wthn thrty (30) mnutes, such servces wll be deemed approved. Retrospectve or Post-Servce Revew - Thrty (30) days from the date that We receve the request for servces. Wthn ten (10) workng days of renderng a decson, We wll notfy You n wrtng. Adverse Beneft Determnatons, In the event of any Adverse Beneft Determnaton, the Plan wll provde wrtten notfcaton that wll nclude: 1. The prncpal reason or reasons for the determnaton; 2. Instructons for submttng a Grevance or reconsderaton of the determnaton; and 3. The nstructons for requestng a wrtten statement of the clncal ratonale, ncludng the clncal revew crtera used to make the determnaton. Upon request, We wll provde n wrtng to You or Your Provder such clncal revew crtera and clncal ratonale used to make any Adverse Beneft Determnaton. Urgent Care Requests - Requests for precertfcaton or predetermnaton of medcal care or treatment that s Urgent, but that has not rsen to the level of an Emergency Medcal Condton. Precertfcaton or predetermnaton s not requred for Emergency Medcal Condtons; however, for predetermnaton or precertfcaton of Urgent Care requests, We wll make an ntal decson as soon as possble, takng nto account the medcal exgences, but no later than seventy-two (72) hours after recept of the requested servce. If there s nsuffcent nformaton to process the request, We wll notfy Your Provder of nsuffcency as soon as possble, but not later than twenty-four (24) hours. Your Provder then has forty-eght (48) hours to provde the specfed nformaton. We wll CHLMOIVLPPOHIXCOC15 8

9 make a determnaton on the Urgent Care request as soon as possble, but no later than forty-eght (48) hours after the earler of: (a) Our recept of specfed nformaton; or (b) the end of the 48-hour perod afforded Your Provder to submt the addtonal nformaton., In the event of an Urgent Care request to precertfy an mmedate post evaluaton or poststablzaton servce, We wll provde an authorzaton decson wthn sxty (60) mnutes of recevng the request; f the authorzaton decson s not made wthn thrty (30) mnutes, such servces shall be deemed approved. NOTE: Tmeframes and requrements lsted are based on state and federal regulatons. Where state regulatons are strcter than federal regulatons, we wll abde by state regulatons Reconsderaton You or Your Provder have the rght to request reconsderaton of any Adverse Beneft Determnaton nvolvng a Prospectve or Pre-Servce Revew, as well as any Concurrent Care Revew determnaton. Such reconsderaton wll occur wthn one (1) workng day of the recept of the request and wll be conducted between the Provder renderng the servce and the revewer who made the Adverse Beneft Determnaton, or a clncal peer desgnated by the revewer f the revewer who made the adverse determnaton s not avalable wthn one (1) workng day. If the reconsderaton process does not resolve the dfference of opnon, You, Your authorzed representatve, or Your Provder actng on Your behalf, may Appeal the Adverse Beneft Determnaton. General Polces. The followng polces apply to both In-Network and Out-of-Network servces: Except for emergences, all Hosptalzatons and most outpatent procedures requre Pror Authorzaton. You must ask Your Provder to contact Us at least two (2) workng days pror to a scheduled Hosptal admsson, outpatent surgery, or other outpatent procedure (except for emergences) to obtan Pror Authorzaton. If You are admtted to a faclty pror to the date Authorzed by Us, then You wll be responsble for all charges related to the unauthorzed days. We wll Authorze only Medcally Necessary Covered Servces. If You obtan servces that are not Medcally Necessary or the servces are not Authorzed by Us, then You wll be responsble for all charges for those servces Emergency Servces, however, are not subject to any Medcally Necessary determnatons or Pror Authorzaton. Intentonal materal msrepresentaton: If We Authorze a servce that We later determne was based on an ntentonal materal msrepresentaton about Your health status, payment of the servce wll be dened. You wll be responsble for all charges related to that servce. Notfcaton letter: When We approve or deny a Pror Authorzaton request, We wll send a notfcaton letter to You and Your Provder. Rght to Appeal: You have the rght to Appeal any denal for any reason, ncludng any Adverse Beneft Determnatons or denal regardng Medcal Necessty. Please see the Complants and Grevance procedures n Secton 7. Attendng Physcan responsblty: Under all crcumstances, the attendng Physcan bears the ultmate responsblty for the medcal decsons regardng Your treatment. Pror Authorzaton requrements are subject to change from tme to tme. Please ask Your Provder to call Customer Servce at (855) to determne whether a Covered Servce requres Pror Authorzaton. The Pror Authorzaton phone number s CHLMOIVLPPOHIXCOC15 9

10 located on the back of Your Member ID Card. It s Your responsblty to ensure that Your Provder contacts us to obtan Pror Authorzaton. Please call Our Customer Servce Department at (855) to determne whether a Covered Servce requres Pror Authorzaton. 1.4 Access to Servces. We make every effort to ensure that Your access to Covered Servces s quck and easy and the servces are reasonably avalable. If You wsh to see a partcular Provder that s not acceptng new patents or s no longer partcpatng n Our Network, please call Our Customer Servce Department at (855) We can help You fnd another Partcpatng Provder that meets Your needs. You may also nomnate Your Non-Partcpatng Provder to become a Partcpatng Provder wth Coventry, or You may nomnate Your Non-Partcpatng Provder under the Consumer Choce Opton. Please call Our Customer Servce Department for more nformaton. A Partcpatng Provder or the Health Plan may termnate the Provder s contract wthout cause by gvng proper notce under applcable law. In such case, the Health Plan wll notfy Members of a Provder s contractual termnaton wthn thrty-one (31) days, when the Member s seen on a regular bass by the Provder or the Provder s the Prmary Care Physcan. Contnuty of care s especally mportant to Us. If Your Partcpatng Provder unexpectedly stops partcpatng wth Us whle You are n the mddle of treatment, please call Us so We can help You contnue treatment wth another Partcpatng Provder. If You are sufferng from a termnal or chronc llness or are an npatent, or where the contnuaton of care s Medcally Necessary and n accordance wth reasonable medcal prudence, ncludng crcumstances such as dsablty, pregnancy, or lfe-threatenng Illness, We wll allow You to contnue Your treatment wth Your Non- Partcpatng Provder. In ths case, We wll contnue to pay for the Covered Servces You receve from Your Non-Partcpatng Provder for nnety (90) days followng the Provder s termnaton from Our Network. To locate the most current Drectory of Health Care Provders, please vst Our webste at Covered Servces Rendered by Out-Of-Network Provders You may choose to receve servces from an Out-of-Network Provder; however, keep n mnd that usng Out-of-Network Benefts may cost You more than usng In-Network benefts. Please see Secton for more nformaton on Out-of-Network Provders. If, however, You have a medcal condton that We beleve needs specal servces, We may drect You to a Desgnated Faclty or other Provder chosen by Us; or, f You requre certan complex Covered Servces for whch expertse s lmted or equally effectve treatments cannot be provded by or through a Partcpatng Provder, We may Authorze the Network cost share amounts (Deductble, Copayment, and/or Consurance) to apply to a clam for a Covered Servce You receve from an Out-Of-Network Provder. In such crcumstance, You must contact Us n advance of obtanng the Covered Servce. If You contact Us pror to recevng the servce, Your out-ofpocket costs wll be no greater than f servces were provded n-network. Coverage s subject to the provsons and exclusons of ths Contract Emergency Servces When an Emergency Medcal Condton occurs, You should seek medcal attenton mmedately from a Hosptal or other Emergency faclty. Emergency Care rendered by a Non-Network Provder wll be covered as a Network servce; however the Member may be responsble for the dfference between the Non-Network Provder s charge and the Allowed Amount, n addton to CHLMOIVLPPOHIXCOC15 10

11 any applcable Consurance, Copayment or Deductble. Servces provded by an Emergency faclty for condtons that are not an Emergency Medcal Condton are not covered. Whenever You are admtted as an npatent drectly from a Hosptal Emergency Room, the Emergency Room servces Copayment/Consurance for that Emergency Room vst wll be waved. For an npatent admsson followng Emergency Care, You are responsble to notfy Us, or verfy that Your Physcan has notfed Us wthn forty-eght (48) hours of Your admsson, or wthn a reasonable perod as dctated by the crcumstances. When We are contacted, You wll be notfed whether the npatent settng s approprate, and f approprate, the number of days consdered Medcally Necessary. By callng Us, You may avod fnancal responsblty for any npatent care that s determned to be not Medcally Necessary under ths Contract. If Your Provder does not have a contract wth Us, You wll be fnancally responsble for any care that s determned to be not Medcally Necessary. When You receve Emergency Room Servces that requre mmedate post-evaluaton or poststablzaton servces, the Health Plan wll provde authorzaton for post-stablzaton and postevaluaton servces wthn sxty (60) mnutes of recevng a request; f a decson s not made wthn thrty (30) mnutes, such servces wll be deemed approved. If You are admtted as an npatent to a Non-Partcpatng Hosptal after You receve Emergency Room Care, We may elect to transfer You to a Partcpatng Hosptal as soon as t s medcally approprate to do so for contnued medcal management of an Emergency Medcal Condton. If the Non-Partcpatng Hosptal determnes that You are stablzed, the Hosptal and Medcal Drector (or Medcal Drector s desgnee) may confer regardng a decson to transfer You to a Partcpatng faclty. Ar or ground ambulance transportaton to return a Member to a Partcpatng Provder s covered when Authorzed by Us. If You choose to stay n the Non-Partcpatng Hosptal after the date We decde a transfer s medcally approprate, servces rendered by Non- Partcpatng Provders or n Non-Partcpatng facltes wll be covered at Your Out-of-Network beneft level. Follow-up care and treatment provded once You have been released from the Hosptal s not consdered Emergency Care. Follow-up care from a Non-Network Provder wll be covered at Your Non-Network beneft. 1.5 Copayments, Consurance, Deductbles. Your Copayment, Consurance, and Deductble amounts are lsted n Your Schedule of Benefts. You are responsble for payng Copayments to Your Provder at the tme of servce. Consurance and Deductble amounts, based on the Health Plan s rembursement to the Provder, may be due to the Provder before or at the tme of servce. You must satsfy any applcable Deductble lsted n Your Schedule of Benefts before We begn payng for Covered Servces. Any applcable Consurance wll be appled after You meet Your Deductble. You wll be responsble for any applcable cost-share for Covered Servces that You ncur. You wll be responsble for Your cost-share up to the maxmum Out-Of-Pocket lmt applcable to Your plan. The Schedule of Benefts s a summary of the Deductbles, Consurance, Copayments, maxmums and other lmts that apply when You receve Covered Servces from a Provder. Please refer to Secton 5, "Covered Servces", n ths Contract for a more complete explanaton of the specfc servces covered by the Plan. In-Network. If You receve In-Network Covered Servces, You are responsble only for the applcable Copayment, Deductble, and/or Consurance amounts noted n Your Schedule of Benefts. Out-of-Network. If You receve Out-of-Network Covered Servces, You are responsble for the applcable Copayment, Deductble, and/or Consurance amounts noted n Your Schedule of Benefts, plus any amount n excess of the Out-of-Network Rate ( ONR ). Please see Secton 1.7 CHLMOIVLPPOHIXCOC15 11

12 for more nformaton on the Out-of Network Rate and Your potental Out-of-Network lablty. Indvdual Deductble. For servces subject to the Deductble, You must satsfy Your calendar year Indvdual Deductble before the Health Plan wll pay for Your Covered Servces, unless the calendar year Famly Deductble s satsfed frst. After You satsfy Your calendar year Indvdual Deductble or the calendar year Famly Deductble s satsfed, the Health Plan wll pay for Your Covered Servces, mnus any applcable Copayments or Consurance. Prescrpton benefts may be subject to a separate Deductble. Please refer to the Schedule of Benefts for detals on your Indvdual Deductble. Famly Deductble. The Famly Deductble apples when two or more Members are enrolled n Your Plan. The Famly Deductble s met by any combnaton of Members meetng the total Famly Deductble. After the calendar year Famly Deductble s satsfed, the Health Plan wll pay for Covered Servces, mnus any applcable Copayments or Consurance, for each Member; provded, however, that f a Member satsfes the calendar year Indvdual Deductble pror to the calendar year Famly Deductble beng satsfed, the Health Plan wll pay for Covered Servces, mnus any applcable Copayments or Consurance, for that Member. Please refer to the Schedule of Benefts for detals on your Famly Deductble. We have contractual arrangements wth Partcpatng Provders and other health care Provders, Provder Networks, pharmacy beneft managers, and other vendors of health care servces and supples ( Provders ). In accordance wth these arrangements, certan Provders have agreed to Dscounted Charges. A Dscounted Charge s the amount that a Provder has agreed to accept as payment n full for Covered Servces. A Dscounted Charge does not nclude pharmaceutcal rebates or any other reductons, fees or credts a Provder may perodcally gve Us. We wll retan those amounts that are not Dscounted Charges. However, We have taken those nto consderaton n settng the fees charged to provde servces under ths Plan. Clams under the Plan and any Deductble, Copayment, Consurance and the Out-of-Pocket Maxmums as descrbed n ths Contract wll be determned based on the Dscounted Charge. 1.6 Out-of-Pocket Maxmum (OOP). The ndvdual OOP s the total amount each Member must pay out of hs or her pocket annually for Covered Servces, unless the famly OOP s satsfed frst. The famly OOP s the total out-of-pocket amount famly Members must pay together annually for Covered Servces, regardless of whether each Member satsfes hs or her ndvdual OOP. Generally speakng, out-of-pocket expenses that accumulate to the OOP nclude Deductbles, Consurance, or Copayments. The Out-of-Pocket Maxmum amounts are lsted n Your Schedule of Benefts. 1.7 Payment to Provders In Network Provders (Partcpatng Provders). For In-Network Covered Servces, the Partcpatng Provder wll bll the Health Plan drectly for the servces. You do not have to fle any clams for these servces. You are responsble for payment of: A. The applcable In-Network Copayment, Deductble, and/or Consurance amounts; B. Servces that requre Pror Authorzaton, whch were not Pror Authorzed; C. Servces that are not Medcally Necessary, except for Emergency Servces; and D. Servces that are not Covered Servces Out of Network Provders (Non-Partcpatng Provders). For Out-of-Network Covered Servces, the Non-Partcpatng Provder typcally expects CHLMOIVLPPOHIXCOC15 12

13 You to pay for the servces. If so, You should submt a clam to Us for rembursement wthn twelve (12) months and We wll send the payment drectly to You. However, falure to submt a clam to Us wthn the specfed perod shall not nvaldate nor reduce the clam, f t was not reasonably possble to furnsh proof wthn the tme. Please refer to Secton 4, Notce of Clam and Tmely Submsson of Clam for more nformaton. Note that f You assgn payment of the servces to the Non-Partcpatng Provder, We wll send the payment to the Non-Partcpatng Provder. Our payment for Out-of-Network Covered Servces s lmted to the Out-of-Network Rate, less the applcable Out-of-Network Copayment, Deductble, and/or Consurance amounts You are requred to pay under Your Plan. Out-of-Network Rate (ONR). The ONR s the Allowed Amount for charges blled by Non-Partcpatng Provders. The ONR s based upon what Medcare would pay the same Provder for the same servce. If the amount You are blled by a Non-Partcpatng Provder s equal to or less than the ONR amount, the charges should be completely Covered by Us, except for any Out-of- Network Copayment, Deductble, and/or Consurance amounts You are requred to pay under Your Plan. However, f the amount You are blled by the Out-of-Network Provder s greater than the ONR amount, You must pay the amount n excess of the ONR amount, n addton to Your Copayment, Deductble, and/or Consurance amounts. Important Note for Emergency Servces: Please note that as Non-Partcpatng Provders are not Partcpatng Provders and do not have a contract wth Us, the Provder may not accept payment of Your cost share (Your Deductble and Consurance) as payment n full. You may receve a bll for the dfference between the amount blled by the Provder and the amount pad by Us. If the emergency room faclty or Physcan blls You for an amount above Your cost share, You are not responsble for payng that amount. Please send Us the bll at the address lsted on Your Member ID card and We wll resolve any payment dspute wth the Provder over that amount. Make sure Your Member ID number s on the bll. Please Remember In addton to the Out-of-Network Copayment, Deductble, and/or Consurance amounts that You are requred to pay for Out-of-Network Covered Servces, You are also responsble for payng the blled charges that exceed the ONR amount We allow. Ths excess amount may be substantal. CHLMOIVLPPOHIXCOC15 13

14 Here s an example of what Your costs could be usng an In-Network Partcpatng Provder under the scenaro detaled below. IN-NETWORK RULES IN-NETWORK AMOUNTS (A) Total amount blled by the Partcpatng Provder for a $12,000 procedure: (B) Our Allowed Amount for the procedure, as ndcated $10,000 n the In-Network Provder s contract wth Us: Your In-Network Deductble: $2,000 (C) We subtract Your Deductble from (B): $10,000 - $2,000 = $8,000 Your In-Network Consurance: 30% (D) We apply Your Consurance to (C): 30% of $8,000 = $2,400 Dfference between (A) and (B): PLEASE NOTE: Because We have a contract wth the Partcpatng Provder, You are not responsble for payng the dfference between the total blled 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 requred to pay ths amount) $10,000 (Our Allowed Amount) $2,000 (Your Deductble) $2,400 (Your Consurance) $5,600 $2,000 (Your Deductble) +$2,400 (Your Consurance) $4,400 CHLMOIVLPPOHIXCOC15 14

15 By contrast, here s an example of what Your costs could be usng an Out-of-Network Non-Partcpatng Provder under a smlar scenaro detaled below. OUT-OF-NETWORK RULES OUT-OF-NETWORK AMOUNTS (A) Total amount blled by Non-Partcpatng Provder for $12,000 a procedure: (B) Our Out-of-Network Rate (ONR) for the procedure. $10,000 Ths s the amount We allow all Non-Partcpatng Provders for ths procedure: Your Out-of-Network Deductble: $4,000 (C) We subtract Your Deductble from (B): $10,000 - $4,000 = $6,000 Your Out-of-Network Consurance: 40% (D) We apply Your Consurance to (C): 40% of $6,000 = $2,400 Dfference Between (A) and (B): $12,000 - $10,000= $2,000 (You are requred to pay ths amount n excess of the ONR) PLEASE NOTE: Because We do not have a contract wth the Non-Partcpatng Provder, You are requred to pay the dfference between the total blled amount and the ONR. Total amount We pay for procedure: Total amount You pay for procedure: $10,000 (Our Allowed Amount) $4,000 (Your Deductble) $2,400 (Your Consurance) $3,600 $4,000 (Your Deductble) + $2,400 (Your Consurance) + $2,000 (Amount n excess of ONR) $8, Premum Payment and Grace Perod. The monthly Premum s due on the frst (1 st ) day of each month. There s a 31 day grace perod for Premum payments. In other words, f the requred Premum payment s not pad on or before the frst (1 st ) day of the month (.e., the due date), t may be pad durng the grace perod. Ths Contract wll stay n force durng the grace perod. If the Premum payment s not receved by the end of the grace perod, Your Coverage under the Contract wll be termnated at the end of the grace perod. IF THE HEALTH INSURANCE MARKETPLACE HAS DETERMINED THAT YOU ARE A PERSON ELIGIBLE TO RECEIVE ADVANCE PAYMENT OF THE PREMIUM TAX CREDIT THE FOLLOWING APPLIES TO YOUR COVERAGE RATHER THAN THE ABOVE PARAGRAPH Premum Payment and Grace Perod for Persons Recevng Advance Payment of the Premum Tax Credt, as requred by the Health Insurance Marketplace. The monthly Premum s due on the frst (1 st ) day of each month. There s a three (3) month grace perod for Premum payments. If the requred Premum payment s not pad on or before the frst (1 st ) day of the month (.e., the due date), t may be pad durng the grace perod. Durng the frst month of the grace perod, We wll contnue to pay clams for Covered Servces Durng the second and thrd months of the grace perod, We wll suspend payment of any clams untl We receve the past due Premums. If payment s not receved for outstandng Premum by the end of the grace perod, Your Coverage under the Contract wll be termnated effectve at 11:59 p.m. on the last day of the frst month of the grace perod. You wll be responsble for the cost of any health care servces You receve after the last day of the frst month of the grace perod. 1.9 Changes n Premum or Benefts. Your rates that begn on Your Member Effectve Date wll not change untl January frst (1 st ) of each year. Upon renewal and n accordance wth applcable law, We may ncrease or decrease the Premum and/or Covered Servces for all Members covered under an Indvdual Contract n the event that any state or federal laws or regulatons requre Us to cover addtonal servces, reduce Consurance or Deductbles, or otherwse expand Coverage n CHLMOIVLPPOHIXCOC15 15

16 order to meet new mnmum standards. In the event of such change, You wll receve a notce va U.S. mal at Your last known address but only after approval by applcable regulatory agences ncludng the Mssour Department of Insurance. Any such change wll take effect on the frst (1 st ) of the month followng approval from the Mssour Department of Insurance. In the event of materal modfcatons to Your Covered Servces, and as, as requred under PPACA, such change wll take effect followng the requred sxty (60) day notfcaton perod. Renewals occur the followng year and are effectve on the frst (1 st ) day of January. We do not have a duty to accept premum payments from thrd partes other than from those thrd partes who are related to you or as requred by law, ncludng but not lmted to, hosptals and healthcare provders. The fact that we may have prevously accepted a premum payment from a thrd party descrbed above does not mean that we wll accept premums from these partes n the future How to Contact the Health Plan. Whenever You have a queston or concern, please call Our Customer Servce Department at the telephone number lsted on Your Member ID card, or vst Our webste at Our contact nformaton s lsted as follows. For Customer Servce Department and To Submt Clams Hours Monday-Frday: 8:00 am to 8:00 pm CST Toll Free Telephone Number (855) Address Coventry Health and Lfe Insurance Company PO Box 7374 London, KY To Request a Revew of Dened Clams or to Appeal a Denal of Authorzaton of Servces Hours Monday-Frday: 8:00 am to 8:00 pm CST Toll Free Telephone Number (855) Address Coventry Health and Lfe Insurance Company 550 Maryvlle Centre Drve, Sute 300 St. Lous, MO (855) Attn: Appeals Department To Regster a Complant Hours Monday-Frday: 8:00 am to 8:00 pm CST Toll Free Telephone Number (855) Address Coventry Health and Lfe Insurance Company PO Box 7374 London, KY Attn: Customer Servce 1.11 Verfcaton of Benefts. When We provde nformaton about whch health care servces are covered under Your Plan that nformaton s referred to as verfcaton of benefts. When You or Your Provder call Our Customer Servce Department at (855) durng regular busness hours to request verfcaton of benefts, a Health Plan representatve wll be mmedately avalable to provde assstance. If the health care servces are verfed as a covered beneft, the Customer Servce representatve wll advse whether Pror Authorzaton s requred. Please be aware that verfcaton of benefts s not a guarantee of payment for servces. CHLMOIVLPPOHIXCOC15 16

17 SECTION 2 ENROLLMENT, ELIGIBILITY, AND EFFECTIVE DATES 2.1 Elgblty Subscrber Elgblty. To enroll as a Subscrber n ths Polcy, You must apply to the Health Insurance Marketplace. The Health Insurance Marketplace wll notfy Us f You are a Qualfed Indvdual. Indvduals who wsh to enroll n plans outsde of the Health Insurance Marketplace, may enroll drectly through the Health Plan, Dependent Elgblty. You may enroll Your spouse, or Domestc Partner; or. a chld who s: A chld under age twenty-sx (26): Who s the brth chld of the Subscrber, the Subscrber s spouse, or Domestc Partner; or Who s legally adopted by or placed for adopton wth the Subscrber, the Subscrber s spouse, or Domestc Partner; or For whom the Subscrber, the Subscrber s spouse, or Domestc Partner s the courtapponted legal guardan; Enrollment of a Dependent chld wll not be dened for any of the followng reasons: o The chld was born out of wedlock. o The chld s not clamed as a Dependent on Your Federal ncome tax return. o The chld does not resde wth You Or a chld age twenty-sx (26) or older, f the followng crtera s met: The chld s the brth or adopted chld of the Subscrber, the Subscrber s spouse, or Domestc Partner; or The Subscrber, the Subscrber s spouse, or Domestc Partner s the court-apponted legal guardan; and The chld s mentally or physcally ncapable of earnng a lvng, and the chld s chefly dependent upon the Subscrber for support and mantenance, provded that the onset of such ncapacty occurred before the chld was twenty-sx (26). Note: Proof of ncapacty and dependency must be furnshed to Us upon enrollment of Your Dependent chld, or wthn thrty-one (31) days after the Dependent s twenty-sxth (26 th ) brthday and subsequently thereafter at reasonable ntervals, but not more frequently than annually after the two (2) year perod followng the Dependent s attanng age twenty-sx (26). Coverage wll contnue as long as the Dependent chld s dsabled and contnues to satsfy the qualfyng condtons lsted above, unless Coverage s otherwse termnated n accordance wth the terms of ths Contract. 2.2 Enrollment and Effectve Dates. A. Enrollment/Effectve Date. You are elgble to enroll under the Plan durng the open enrollment and specal enrollment perods as descrbed n B. and C. below. If Your completed applcaton s receved before the 20 th of the month, Your enrollment wll be effectve the frst day of the followng month. However, f Your completed applcaton s receved after the 20 th of the month, Your enrollment wll be effectve the frst (1 st ) day of the second month. B. Open Enrollment. The annual open enrollment perod wll be from November 15 through February 15, C. Specal Enrollment. Elgble ndvduals may request enrollment n the Plan wthn sxty (60) days after these trggerng events: CHLMOIVLPPOHIXCOC15 17

18 Brth Legal adopton/placement for adopton Marrage/Dvorce Legal permanent general guardanshp Court or admnstratve order Loss of employer coverage Loss of mnmum essental coverage COBRA contnuaton coverage expred Change n elgblty for the Health Insurance Exchange subsdy Release from ncarceraton Return from actve mltary servce Pror health beneft plan volated a materal provson of ther polcy Gan of legal U.S. ctzenshp or lawful present status Permanent change of resdency nto the Mssour Servce Area Change of a qualfed health plan once per month by a Natve Amercan Indan Termnaton of Medcad or CHIP Coverage. D. Newborns. A newborn chld of the Subscrber or the Subscrber s spouse shall be covered for the frst thrty-one (31) days from the date of brth. If Dependent Coverage s already n force, enrollment s automatc and there s no addtonal Premum. In the event that no other members of the Subscrber s mmedate famly are Covered, mmedate coverage for the frst newborn nfant shall be provded only f the Subscrber apples for Dependent s Coverage and pays the applcable addtonal Premum wthn thrty-one (31) days of the newborn s brth. For Coverage to contnue beyond the frst thrty-one (31) days, You must notfy Us of the brth, ether orally or n wrtng. Upon notfcaton, the Plan wll provde You wth all forms and nstructons necessary to enroll Your newborn chld. We must receve Your applcaton form to add the chld as a Dependent and a payment of Premum wthn (31) days after the brth of the chld, or wthn ten (10) addtonal days from the date the forms and nstructons were provded.. Newborn Coverage wll nclude necessary care and treatment of medcally dagnosed congental defects and brth abnormaltes. E. Adopted Chldren. A newly adopted chld shall be covered for the frst thrty-one (31) days from the date of placement for adopton n Your home or the date of an entry of an order grantng custody of the chld to You. Coverage wll contnue unless the placement s dsrupted pror to legal adopton and the chld s removed from placement. Coverage wll nclude the necessary care and treatment of medcal condtons exstng pror to the day of placement. Placement means n the physcal custody of the adoptve parent. For Coverage to contnue beyond the frst thrty-one (31) days, an applcaton form to add the chld as a Dependent and a payment of Premum must be receved by Us wthn thrty-one (31) days from the date of placement for adopton, or the fnal decree of adopton, whchever s earlest. 2.3 Notfcaton of Change n Status. You must notfy Us, n wrtng, of any changes n Your status or the status of any Dependent wthn sxty (60) days after the date of the status change. Events that qualfy as a change n status nclude, but are not lmted to, changes n address, dvorce, marrage, death, dependency status, ncarceraton, Medcare elgblty, or Coverage by another nsurance polcy. Coventry requres notce of Medcare elgblty or Coverage by another payer for purposes of coordnatng benefts. We should be notfed wthn a reasonable tme of the death of any Member. For more nformaton, call Customer Servce at (855) CHLMOIVLPPOHIXCOC15 18

19 SECTION 3 TERMINATION OF COVERAGE 3.1 Termnaton. A. Termnaton by Subscrber. The Subscrber may termnate Coverage for hmself/herself and any enrolled Dependents under the Contract for any reason by provdng fourteen (14) days advance wrtten notce to the Health Insurance Marketplace. For notces receved on the 1 st through 15 th day of the month, termnaton wll take effect on the frst day of the month n whch the notce was receved. For notces receved on the 16 th through 31 st day of the month, termnaton wll take effect on the frst day of the month followng the month n whch the notce was receved, unless the Health Plan agrees to an earler termnaton. To termnate Coverage You may call the Health Insurance Marketplace at , or f You have an onlne account through B. Termnaton by Us. In the event of a rescsson (retroactve cancellaton) due to ntentonal msrepresentaton of a materal fact, or fraud, the Plan wll notfy You n wrtng at least thrty (30) days pror to the rescsson. In the event of termnaton for non-payment of Premum, the Plan wll notfy You n wrtng at least thrty (30) days pror to the termnaton, whch shall be effectve as of the last date of the grace perod. 1. Non-Payment of Premum. a. Non-Payment of Premums. In the event that We do not receve payment of Premums by the end of the 31-day grace perod, Your Coverage under the Contract wll be termnated at 11:59 p.m. on the last date of the grace perod. If Your Coverage s termnated for non-payment of the Premum, You wll be responsble for the cost of any health care servces You receve after the grace perod. IF THE HEALTH INSURANCE MARKETPLACE HAS DETERMINED THAT YOU ARE A PERSON ELIGIBLE TO RECEIVE ADVANCE PAYMENT OF THE PREMIUM TAX CREDIT THE FOLLOWING APPLIES TO TERMINATION OF YOUR COVERAGE RATHER THAN THE ABOVE SECTION B. In the event that We do not receve payment of outstandng Premums by the end of the three (3) month grace perod, Your Coverage under the Contract wll be termnated at 11:59 p.m. on the last day of the frst month of the grace perod. If Your Coverage s termnated for non-payment of the Premum, You wll be responsble for the cost of any health care servces You receve after the last day of the frst month of the grace perod. b. Renstatement. If ths polcy s termnated for nonpayment of Premum, coverage may only be renstated as provded n ths secton. You must request renstatement usng a form and wth nstructons that We wll provde CHLMOIVLPPOHIXCOC15 19

20 upon request, and You must pay all Premums owed wth submsson of the form. Coverage wll be renstated as confrmed by Us n wrtng; f not so confrmed by Us n wrtng, Coverage wll be renstated upon the 45 th day followng Our recept of the premum owed. The renstated polcy shall cover Covered expenses ncurred after the date of renstatement and shall nclude the same rghts You had under the polcy pror to termnaton. Any Premum accepted n connecton wth a renstatement shall be appled to a perod for whch Premum has not been prevously pad, but not to any perod more than 60 days pror to the date of renstatement. 2. Fraud. If You or Your enrolled Dependents partcpate n fraudulent or crmnal behavor n connecton wth enrollment or Coverage under the Contract, Coverage for You and Your enrolled Dependents shall end at 11:59 p.m. upon the date set forth n Our notce of termnaton to the Subscrber. Examples of fraud nclude, but are not lmted to the followng: a. Performng an act or practce that consttutes fraud or ntentonally msrepresentng materal facts, ncludng usng Your Member ID card to obtan goods or servces that are not prescrbed or ordered for You or to whch You are otherwse not legally enttled. In ths nstance, Coverage for the Subscrber and all Dependents wll be termnated. b. Knowngly allowng any other person to use Your Member ID card to obtan servces. If a Dependent allows any other person to use hs/her Member ID card to obtan servces, the Coverage of the Dependent that allowed the msuse of the card wll be termnated. If the Subscrber allows any other person to use hs/her Member ID card to obtan servces, the Coverage of the Subscrber and hs/her Dependents wll be termnated. c. Intentonally msrepresentng or gvng false nformaton n Your applcaton for coverage to the Health Insurance Marketplace that s materal to Our acceptance of You enrollment. d. Engagng n fraudulent actvty wth respect to obtanng health servces, ncludng but not lmted to obtanng medcatons n a fraudulent manner. 3. Dependent Elgblty Ends Due to Attanment of Lmtng Age, Unless Dsabled. When the Dependent attans the age of twenty-sx (26), unless dsabled, the Dependent shall no longer meet the elgblty requrements for Dependents, as set forth n ths Contract. The Dependent s enttled to apply to the Health Insurance Marketplace for coverage f the Dependent s a Qualfed Indvdual. 4. Dependent Elgblty Ends Due to Subscrber Termnaton. If a Subscrber requests to termnate the Contract and the termnaton results n only chldren under the age of nneteen (19) remanng on the Contract, the Dependent(s) Coverage under the Contract wll also termnate on the same termnaton date as the Subscrber. The Dependent(s) are enttled to apply to the Health Insurance Marketplace for coverage f the Dependent s a Qualfed Indvdual. CHLMOIVLPPOHIXCOC15 20