Common use of Continuity of Care Clause in Contracts

Continuity of Care. If You are under the care of a Participating Provider who stops participating in HMO’s network, (for reasons other than failure to meet applicable quality standards, including medical incompetence or professional behavior, or for fraud), HMO will continue coverage for that Provider’s Covered Services if all the following conditions are met: • You are undergoing a course of treatment for a serious and complex condition, You are undergoing institutional or inpatient care, You are scheduled to undergo nonelective surgery from the Provider (including receipt of postoperative care from such Provider with respect to such surgery), You are pregnant or undergoing a course of treatment for the pregnancy, or You are determined to be terminally ill. A serious and complex condition is one that (1) for an acute illness, is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm care (for example, You are currently receiving chemotherapy, radiation therapy, or post-operative visits for a serious acute disease or condition), and (2) for a chronic illness or condition, is (i) life-threatening, degenerative, disabling or potentially disabling, or congenital, and (ii) requires specialized medical care over a prolonged period of time; • the Provider submits a request to HMO to continue coverage of Your care that identifies the condition for which You are being treated and, where required, indicates that the Provider reasonably believes that discontinuing treatment could cause You harm; and • the Provider agrees to continue accepting the same reimbursement that applied when participating in HMO’s network, and not to seek payment from You for any amounts for which You would not be responsible if the Provider were still participating in HMO’s network. Continuity coverage shall continue until the treatment is complete but shall not extend for more than ninety (90) days (or more than nine (9) months if You have been diagnosed with a terminal illness) beyond the date the Provider’s termination takes effect. If You are past the thirteenth (13th) week of pregnancy when the Provider’s termination takes effect, coverage may be extended through delivery, immediate postpartum care and the follow- up check-up within the first six (6) weeks of delivery. You have the right to appeal any decision made for a request for benefits under this subsection as explained in the

Continuity of Care. If You are under the care of a Participating Provider who stops participating in HMO’s network, (for reasons other than failure to meet applicable quality standards, including medical incompetence or professional behavior, or for fraud), HMO will continue coverage for that Provider’s Covered Services if all the following conditions are met: •  You are undergoing have a course of treatment for a serious and complex disability, acute condition, You are undergoing institutional or inpatient care, You are scheduled to undergo nonelective surgery from the Provider (including receipt of postoperative care from such Provider with respect to such surgery), You are pregnant or undergoing a course of treatment for the pregnancy, or You are determined to be terminally ill. A serious and complex condition is one that (1) for an acute illness, is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm care (for example, You are currently receiving chemotherapy, radiation therapy, or post-operative visits for a serious acute disease or condition), and (2) for a chronic life- threatening illness or condition, is are past the twenty- fourth (i24th) life-threatening, degenerative, disabling or potentially disabling, or congenital, week of pregnancy; and (ii) requires specialized medical care over a prolonged period of time; •  the Provider submits a written request to HMO to continue coverage of Your care that identifies the condition for which You are being treated and, where required, and indicates that the Provider reasonably believes that discontinuing treatment could cause You harm; and •  the Provider agrees to continue accepting the same reimbursement that applied when participating in HMO’s network, and not to seek payment from You for any amounts for which You would not be responsible if the Provider were still participating in HMO’s network. Continuity coverage shall continue until the treatment is complete but shall not extend for more than ninety (90) days (or more than nine (9) months if You have been diagnosed with a terminal illness) beyond the date the Provider’s termination takes effect. If You are past the thirteenth twenty- fourth (13th24th) week of pregnancy when the Provider’s termination takes effect, coverage may be extended through delivery, immediate postpartum care and the follow- up check-check- up within the first six (6) weeks of delivery. If You have been diagnosed with a chronic, disabling, or life- threatening illness, You may contact customer service at the right toll- free telephone number on Your identification card to get information to submit for approval from the HMO Medical Director to choose a Participating Specialist as Your PCP. The Medical Director will require both You and the Participating Specialist interested in serving as Your PCP to sign a certification of medical need, to submit along with all supporting documentation. The Participating Specialist must meet HMO’s requirements for PCP participation and be willing to accept the coordination of all Your healthcare needs. If Your request is denied, You may appeal the decision as described in COMPLAINT AND APPEAL PROCEDURES. If Your request is approved, the Specialist’s designation as Your PCP will not be effective retroactively. As used herein, “life threatening,” means a disease or condition for which the likelihood of death is probable unless the course of the disease or condition is interrupted. HMO cannot guarantee the availability or continued participation of a particular Provider. Either HMO or any decision made Participating Provider may terminate the Provider contract or limit the number of Members that will be accepted as patients. If the PCP initially selected cannot accept additional patients, You will be given an opportunity to make another PCP selection. You must then cooperate with HMO to select another PCP. You may obtain Covered Services from Providers who are not part of HMO’s network of Participating Providers when receiving Emergency Care. Also, court- ordered Dependents living outside the Service Area may use non- Participating Providers. If Covered Services are not available from Participating Providers within the access requirements established by law and regulation, HMO will allow a Referral by Your PCP to a non- Participating Provider, if approved by HMO. If Your PCP is in a Limited Provider Network, in determining whether a Covered Service is available through Participating Providers, HMO will first consider Participating Providers in the PCP’s Limited Provider Network. If the Covered Service is not available in the Limited Provider Network, then HMO’s entire network will be considered. You will not be required to change Your PCP or Participating Specialist Providers to receive Covered Services that are not available from Participating Providers within the Limited Provider Network, but the following apply.  The request must be from a Participating Provider.  Reasonably requested documentation must be received by HMO.  The Referral will be provided within an appropriate time, not to exceed five business days, based on the circumstances and Your condition.  When HMO has allowed Referral to a non- Participating Provider, HMO will reimburse the non- Participating Provider at the usual and customary rate or otherwise agreed rate, less the applicable Copayment(s). You are responsible only for the Copayments for such Covered Services.  Before HMO denies a Referral, a review will be conducted by a Specialist of the same or similar specialty as the type of Provider to whom a Referral is requested. During an inpatient stay at a Participating Hospital, Skilled Nursing Facility or other Participating facility, it may be appropriate for a request for benefits Physician other than Your PCP to direct and oversee Your care, if Your PCP does not do so. However, upon discharge, You must return to the care of Your PCP or have Your PCP coordinate care that may be Medically Necessary. HMO will not prohibit, attempt to prohibit or discourage any Provider from discussing or communicating to You or Your designee any information or opinions regarding Your health care, any provisions of the Health Benefit Plan as it relates to Your medical needs or the fact that the Provider’s contract with HMO has terminated or that the Provider will no longer be providing services under HMO.  You shall complete and submit to HMO an application or other forms or statements that HMO may reasonably request. You agree that all information contained in the applications, forms and statements submitted to HMO due to enrollment under this subsection Certificate or the administration herein shall be true, correct, and complete to the best of Your knowledge and belief.  You shall notify HMO immediately of any change of address for You or any of Your covered Dependents.  You understand that HMO is acting in reliance upon all information You provided to HMO at time of enrollment and afterwards and represents that information so provided is true and accurate.  By electing coverage pursuant to this Certificate, or accepting benefits hereunder, all Members who are legally capable of contracting, and the legal representatives of all Members who are incapable of contracting, at time of enrollment and afterwards, represent that all information so provided is true and accurate and agree to all terms, conditions and provisions hereof.  You are subject to and shall abide by the rules and regulations of each Provider from which benefits are provided. You may, for personal reasons, refuse to accept procedures or treatment by a Participating Provider. Participating Providers may regard such refusal to accept their recommendations as explained incompatible with continuance of the Provider- patient relationship and as obstructing the provision of proper medical care. Participating Providers shall use their best efforts to render all necessary and appropriate Professional Services in thea manner compatible with Your wishes, insofar as this can be done consistent with the Participating Provider’s judgment as to the requirements of proper medical practice. If You refuse to follow a recommended treatment or procedure, and the Participating Provider informed You of his belief that no professionally acceptable alternative exists, neither HMO nor any Participating Provider shall have any further responsibility to provide care for the condition under treatment.

Continuity of Care. If You are under the care of a Participating Provider who stops participating in HMO’s network, (for reasons other than failure to meet applicable quality standards, including medical incompetence or professional behavior, or for fraud), HMO will continue coverage for that Provider’s Covered Services if all the following conditions are met: • You are undergoing have a course of treatment for a serious and complex disability, acute condition, You are undergoing institutional or inpatient care, You are scheduled to undergo nonelective surgery from the Provider (including receipt of postoperative care from such Provider with respect to such surgery), You are pregnant or undergoing a course of treatment for the pregnancy, or You are determined to be terminally ill. A serious and complex condition is one that (1) for an acute illness, is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm care (for example, You are currently receiving chemotherapy, radiation therapy, or post-operative visits for a serious acute disease or condition), and (2) for a chronic life- threatening illness or condition, is are past the twenty- fourth (i24th) life-threatening, degenerative, disabling or potentially disabling, or congenital, week of pregnancy; and (ii) requires specialized medical care over a prolonged period of time; • the Provider submits a written request to HMO to continue coverage of Your care that identifies the condition for which You are being treated and, where required, and indicates that the Provider reasonably believes that discontinuing treatment could cause You harm; and • the Provider agrees to continue accepting the same reimbursement that applied when participating in HMO’s network, and not to seek payment from You for any amounts for which You would not be responsible if the Provider were still participating in HMO’s network. Continuity coverage shall continue until the treatment is complete but shall not extend for more than ninety (90) days (or more than nine (9) months if You have been diagnosed with a terminal illness) beyond the date the Provider’s termination takes effect. If You are past the thirteenth twenty- fourth (13th24th) week of pregnancy when the Provider’s termination takes effect, coverage may be extended through delivery, immediate postpartum care and the follow- up check-check- up within the first six (6) weeks of delivery. If You have been diagnosed with a chronic, disabling, or life- threatening illness, You may contact customer service at the right toll- free telephone number on Your identification card to get information to submit for approval from the HMO Medical Director to choose a Participating Specialist as Your PCP. The Medical Director will require both You and the Participating Specialist interested in serving as Your PCP to sign a certification of medical need, to submit along with all supporting documentation. The Participating Specialist must meet HMO’s requirements for PCP participation and be willing to accept the coordination of all Your healthcare needs. If Your request is denied, You may appeal the decision as described in Complaint and Appeal Procedures. If Your request is approved, the Specialist’s designation as Your PCP will not be effective retroactively. As used herein, “life threatening,” means a disease or condition for which the likelihood of death is probable unless the course of the disease or condition is interrupted. HMO cannot guarantee the availability or continued participation of a particular Provider. Either HMO or any decision made Participating Provider may terminate the Provider contract or limit the number of Members that will be accepted as patients. If the PCP initially selected cannot accept additional patients, You will be given an opportunity to make another PCP selection. You must then cooperate with HMO to select another PCP. You may obtain Covered Services from Providers who are not part of HMO’s network of Participating Providers when receiving Emergency Care. Also, court- ordered Dependents living outside the Service Area may use non- Participating Providers. If Covered Services are not available from Participating Providers within the access requirements established by law and regulation, HMO will allow a Referral by Your PCP to a non- Participating Provider, if approved by HMO. If Your PCP is in a Limited Provider Network, in determining whether a Covered Service is available through Participating Providers, HMO will first consider Participating Providers in the PCP’s Limited Provider Network. If the Covered Service is not available in the Limited Provider Network, then HMO’s entire network will be considered. You will not be required to change Your PCP or Participating Specialist Providers to receive Covered Services that are not available from Participating Providers within the Limited Provider Network, but the following apply. • The request must be from a Participating Provider. • Reasonably requested documentation must be received by HMO. • The Referral will be provided within an appropriate time, not to exceed five business days, based on the circumstances and Your condition. • When HMO has allowed Referral to a non- Participating Provider, HMO will reimburse the non- Participating Provider at the usual and customary rate or otherwise agreed rate, less the applicable Copayment(s). You are responsible only for the Copayments for such Covered Services. • Before HMO denies a Referral, a review will be conducted by a Specialist of the same or similar specialty as the type of Provider to whom a Referral is requested. During an inpatient stay at a Participating Hospital, Skilled Nursing Facility or other Participating facility, it may be appropriate for a request for benefits Physician other than Your PCP to direct and oversee Your care, if Your PCP does not do so. However, upon discharge, You must return to the care of Your PCP or have Your PCP coordinate care that may be Medically Necessary. HMO will not prohibit, attempt to prohibit or discourage any Provider from discussing or communicating to You or Your designee any information or opinions regarding Your health care, any provisions of the Health Benefit Plan as it relates to Your medical needs or the fact that the Provider’s contract with HMO has terminated or that the Provider will no longer be providing services under HMO. • You shall complete and submit to HMO an application or other forms or statements that HMO may reasonably request. You agree that all information contained in the applications, forms and statements submitted to HMO due to enrollment under this subsection Certificate or the administration herein shall be true, correct, and complete to the best of Your knowledge and belief. • You shall notify HMO immediately of any change of address for You or any of Your covered Dependents. • You understand that HMO is acting in reliance upon all information You provided to HMO at time of enrollment and afterwards and represents that information so provided is true and accurate. • By electing coverage pursuant to this Certificate, or accepting benefits hereunder, all Members who are legally capable of contracting, and the legal representatives of all Members who are incapable of contracting, at time of enrollment and afterwards, represent that all information so provided is true and accurate and agree to all terms, conditions and provisions hereof. • You are subject to and shall abide by the rules and regulations of each Provider from which benefits are provided. You may, for personal reasons, refuse to accept procedures or treatment by a Participating Provider. Participating Providers may regard such refusal to accept their recommendations as explained incompatible with continuance of the Provider- patient relationship and as obstructing the provision of proper medical care. Participating Providers shall use their best efforts to render all necessary and appropriate Professional Services in thea manner compatible with Your wishes, insofar as this can be done consistent with the Participating Provider’s judgment as to the requirements of proper medical practice. If You refuse to follow a recommended treatment or procedure, and the Participating Provider informed You of his belief that no professionally acceptable alternative exists, neither HMO nor any Participating Provider shall have any further responsibility to provide care for the condition under treatment.

Continuity of Care. ‌ The CHC-MCO must provide continuity of care to Participants who are receiving LTSS as follows:‌  For a Participant who is a NF resident on his/her Effective Date of Enrollment and the First Enrollment Effective Date of any Enrollment into the CHC program in the zone in which the Participant resides, the continuity of care period will run from the Participant’s Effective Date of Enrollment into the CHC-MCO for the duration of the Participants’ residency in the Nursing Facility. The CHC-MCO must enter into a contract or payment arrangement with the resident’s NF to make payments for the Participant’s Nursing Facility services, whether or not the Nursing Facilities is in the CHC-MCO network The CHC-MCO must provide services and payment for all Participants who are in an NF on the date of Enrollment even if the NF does not enroll as a provider.Provider. The CHC-MCO is prohibited from interfering with a Participant’s choice of NF. This continuity of care period shall continue so long as the Participant remains a resident of the same NF and shall apply to each enrollment into a CHC-MCO, whether at the first effective date of enrollment or at some time later in the operation of the CHC program if the Participant chooses to transfer to a CHC-MCO.‌  For a Participant who is receiving LTSS through an HCBS Waiver program on his or her Effective Date of Enrollment, the continuity of care period for continuation of services provided under all existing PCSPs through all existing service Providers will run from the Effective Date of Enrollment into the CHC-MCO for 180 days or until a comprehensive needs assessment has been completed and a PCSP has been developed and implemented, whichever date is later. If You are under a Participant chooses to transfer to a different CHC-MCO, the care receiving CHC-MCO must continue to provide the previously authorized services for 60 days or until a comprehensive needs assessment has been completed and a PCSP been developed and implemented, whichever date is later.‌  For a Participant who is receiving LTSS but whose LTSS Provider leaves the CHC-MCO Provider Network, the CHC-MCO must continue to allow the Participant to receive services for a 60 day period and must pay that Provider until such time as an alternative Network Provider can be identified and begins to deliver the same LTSS services as the former Provider.‌  For all Participants, the Continuity of a Participating Provider who stops participating in HMO’s networkCare period for continuation of healthcare Providers, (for reasons other than failure to meet applicable quality standardsservices, including medical incompetence or professional behavior, or for fraud), HMO will continue coverage for that Provider’s Covered Services if all the following conditions are met: • You are undergoing a and any ongoing course of treatment is governed by the requirements outlined in Section 2117 of Article XXI of the Insurance Company Law of 1921, as amended, 40 P.S. §991.2117, regarding continuity of care requirements and 28 PACode §9.684 and 31 PA Code §154.15. The CHC-MCO must comply with the procedures outlined in Medical Assistance Bulletin 99-03-13, Continuity of Care for a serious Recipients Transferring Between and complex conditionAmong Fee-for-Service and Managed Care Organizations, You are undergoing institutional or inpatient care, You are scheduled to undergo nonelective surgery from the Provider (including receipt ensure continuity of postoperative care from such Provider with respect to such surgery), You are pregnant or undergoing a course of treatment Prior Authorized Services for the pregnancy, or You are determined to be terminally ill. A serious and complex condition is one that (1) for an acute illness, is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm care (for example, You are currently receiving chemotherapy, radiation therapy, or postindividuals age twenty-operative visits for a serious acute disease or condition), and (2) for a chronic illness or condition, is (i) life-threatening, degenerative, disabling or potentially disabling, or congenital, and (ii) requires specialized medical care over a prolonged period of time; • the Provider submits a request to HMO to continue coverage of Your care that identifies the condition for which You are being treated and, where required, indicates that the Provider reasonably believes that discontinuing treatment could cause You harm; and • the Provider agrees to continue accepting the same reimbursement that applied when participating in HMO’s network, and not to seek payment from You for any amounts for which You would not be responsible if the Provider were still participating in HMO’s network. Continuity coverage shall continue until the treatment is complete but shall not extend for more than ninety (90) days (or more than nine (9) months if You have been diagnosed with a terminal illness) beyond the date the Provider’s termination takes effect. If You are past the thirteenth (13th) week of pregnancy when the Provider’s termination takes effect, coverage may be extended through delivery, immediate postpartum care and the follow- up check-up within the first six (6) weeks of delivery. You have the right to appeal any decision made for a request for benefits under this subsection as explained in theone

Continuity of Care. If You are under the Continuity of care of with a Non-Participating Provider is available for the following Members: for Members who stops participating are currently seeing a provider who is no longer in HMO’s networkthe Blue Shield; or for newly- covered Members whose previous health plan was withdrawn from the market. Members who meet the eligibility requirements listed above may request continuity of care if they are being treated for acute conditions, serious chronic conditions, pregnancies (including imme- diate postpartum care), or terminal illness. Xxxxx- nuity of care may also be requested for reasons other than failure children who are up to meet applicable quality standards, including medical incompetence or professional behavior36 months old, or for fraud), HMO will continue coverage Members who have received authorization from a now-termi- nated provider for that Provider’s Covered Services if all the following conditions are met: • You are undergoing surgery or another procedure as part of a documented course of treatment treatment. To request continuity of care, visit xxx.xxxxxxxxxxxx.xxx and fill out the Continuity of Care Application. Blue Shield will review the request. The Non-Participating Provider must agree to accept Blue Shield’s Allowable Amount as payment in full for ongoing care. When autho- rized, the Member may continue to see the Non- Participating Provider for up to 12 months at the Participating Provider rate. Members who have questions about their diag- noses, or believe that additional information con- cerning their condition would be helpful in deter- mining the most appropriate plan of treatment, may make an appointment with another Physician for a serious and complex condition, You are undergoing institutional or inpatient care, You are scheduled second medical opinion. The Member’s at- tending Physician may also offer a referral to undergo nonelective surgery from the Provider (including receipt of postoperative care from such Provider with respect to such surgery), You are pregnant or undergoing a course of treatment for the pregnancy, or You are determined to be terminally ill. A serious and complex condition is one that (1) for an acute illness, is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm care (for example, You are currently receiving chemotherapy, radiation therapy, or post-operative visits an- other Physician for a serious acute disease or condition)second opinion. The second opinion visit is subject to the applica- ble Copayment, Coinsurance, Calendar Year De- ductible and (2) all Plan Contract Benefit limitations and exclusions. State law requires that health plans disclose to Members, upon request, the timelines for a chronic illness or condition, is (i) life-threatening, degenerative, disabling or potentially disabling, or congenital, and (ii) requires specialized medical care over a prolonged period of time; • the Provider submits a request respond- ing to HMO to continue coverage of Your care that identifies the condition for which You are being treated and, where required, indicates that the Provider reasonably believes that discontinuing treatment could cause You harm; and • the Provider agrees to continue accepting the same reimbursement that applied when participating in HMO’s network, and not to seek payment from You for any amounts for which You would not be responsible if the Provider were still participating in HMO’s network. Continuity coverage shall continue until the treatment is complete but shall not extend for more than ninety (90) days (or more than nine (9) months if You have been diagnosed with a terminal illness) beyond the date the Provider’s termination takes effect. If You are past the thirteenth (13th) week of pregnancy when the Provider’s termination takes effect, coverage may be extended through delivery, immediate postpartum care and the follow- up check-up within the first six (6) weeks of delivery. You have the right to appeal any decision made for a request for benefits under this subsection a second medical opinion. To request a copy of these timelines, you may call the Member is only responsible for the applicable De- ductible, Copayment or Coinsurance as explained shown in thethe Summary of Benefits, and is not responsible for any Allowable Amount Blue Shield is obli- gated to pay. Members who reasonably believe that they have an Emergency Medical Condition which requires an emergency response are encouraged to use the “911” emergency response system (where avail- able) or seek immediate care from the nearest Hos- pital. For the lowest out-of-pocket expenses, cov- ered non-Emergency Services or emergency room follow-up services (e.g., suture removal, wound check, etc.) should be received in a Participating Provider’s office. The NurseHelp 24/7 program offers Members ac- cess to registered nurses 24 hours a day, seven days a week. Registered nurses can provide assistance in answering many health-related questions, in- cluding concerns about:

Continuity of Care. If You are under the care of a Participating Provider who stops participating in HMO’s network, (for reasons other than failure to meet applicable quality standards, including medical incompetence or professional behavior, or for fraud), HMO will continue coverage for that Provider’s Covered Services if all the following conditions are met: • You are undergoing have a course of treatment for a serious and complex disability, acute condition, You are undergoing institutional or inpatient care, You are scheduled to undergo nonelective surgery from the Provider (including receipt of postoperative care from such Provider with respect to such surgery), You are pregnant or undergoing a course of treatment for the pregnancy, or You are determined to be terminally ill. A serious and complex condition is one that (1) for an acute illness, is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm care (for example, You are currently receiving chemotherapy, radiation therapy, or postlife-operative visits for a serious acute disease or condition), and (2) for a chronic threatening illness or condition, is are past the twenty-fourth (i24th) life-threatening, degenerative, disabling or potentially disabling, or congenital, week of pregnancy; and (ii) requires specialized medical care over a prolonged period of time; • the Provider submits a written request to HMO to continue coverage of Your care that identifies the condition for which You are being treated and, where required, and indicates that the Provider reasonably believes that discontinuing treatment could cause You harm; and • the Provider agrees to continue accepting the same reimbursement that applied when participating in HMO’s network, and not to seek payment from You for any amounts for which You would not be responsible if the Provider were still participating in HMO’s network. Continuity coverage shall continue until the treatment is complete but shall not extend for more than ninety (90) days (or more than nine (9) months if You have been diagnosed with a terminal illness) beyond the date the Provider’s termination takes effect. If You are past the thirteenth twenty-fourth (13th24th) week of pregnancy when the Provider’s termination takes effect, coverage may be extended through delivery, immediate postpartum care and the follow- follow-up check-up within the first six (6) weeks of delivery. If You have been diagnosed with a chronic, disabling, or life-threatening illness, You may contact customer service at the right toll-free telephone number on Your identification card to get information to submit for approval from the HMO Medical Director to choose a Participating Specialist as Your PCP. The Medical Director will require both You and the Participating Specialist interested in serving as Your PCP to sign a certification of medical need, to submit along with all supporting documentation. The Participating Specialist must meet HMO’s requirements for PCP participation and be willing to accept the coordination of all Your healthcare needs. If Your request is denied, You may appeal the decision as described in Complaint and Appeal Procedures. If Your request is approved, the Specialist’s designation as Your PCP will not be effective retroactively. As used herein, “life threatening,” means a disease or condition for which the likelihood of death is probable unless the course of the disease or condition is interrupted. HMO cannot guarantee the availability or continued participation of a particular Provider. Either HMO or any decision made Participating Provider may terminate the Provider contract or limit the number of Members that will be accepted as patients. If the PCP initially selected cannot accept additional patients, You will be given an opportunity to make another PCP selection. You must then cooperate with HMO to select another PCP. You may obtain Covered Services from Providers who are not part of HMO’s network of Participating Providers when receiving Emergency Care. Also, court-ordered Dependents living outside the Service Area may use non-Participating Providers. If Covered Services are not available from Participating Providers within the access requirements established by law and regulation, HMO will allow a Referral by Your PCP to a non-Participating Provider, if approved by HMO. If Your PCP is in a Limited Provider Network, in determining whether a Covered Service is available through Participating Providers, HMO will first consider Participating Providers in the PCP’s Limited Provider Network. If the Covered Service is not available in the Limited Provider Network, then HMO’s entire network will be considered. You will not be required to change Your PCP or Participating Specialist Providers to receive Covered Services that are not available from Participating Providers within the Limited Provider Network, but the following apply. • The request must be from a Participating Provider. • Reasonably requested documentation must be received by HMO. • The Referral will be provided within an appropriate time, not to exceed five business days, based on the circumstances and Your condition. • When HMO has allowed Referral to a non-Participating Provider, HMO will reimburse the non- Participating Provider at the usual and customary rate or otherwise agreed rate, less the applicable Copayment(s). You are responsible only for the Copayments for such Covered Services. • Before HMO denies a Referral, a review will be conducted by a Specialist of the same or similar specialty as the type of Provider to whom a Referral is requested. During an inpatient stay at a Participating Hospital, Skilled Nursing Facility or other Participating facility, it may be appropriate for a request for benefits Physician other than Your PCP to direct and oversee Your care, if Your PCP does not do so. However, upon discharge, You must return to the care of Your PCP or have Your PCP coordinate care that may be Medically Necessary. HMO will not prohibit, attempt to prohibit or discourage any Provider from discussing or communicating to You or Your designee any information or opinions regarding Your health care, any provisions of the Health Benefit Plan as it relates to Your medical needs or the fact that the Provider’s contract with HMO has terminated or that the Provider will no longer be providing services under HMO. • You shall complete and submit an application or other forms or statements that may be reasonably requested. You agree that all information contained in the applications, forms and statements submitted to HMO due to enrollment under this subsection Certificate or the administration herein shall be true, correct, and complete to the best of Your knowledge and belief. • You shall notify HMO immediately of any change of address for You or any of Your covered Dependents. • You understand that HMO is acting in reliance upon all information You provided at time of enrollment and afterwards and represents that information so provided is true and accurate. • By electing coverage pursuant to this Certificate, or accepting benefits hereunder, all Members who are legally capable of contracting, and the legal representatives of all Members who are incapable of contracting, at time of enrollment and afterwards, represent that all information so provided is true and accurate and agree to all terms, conditions and provisions hereof. • You are subject to and shall abide by the rules and regulations of each Provider from which benefits are provided. You may, for personal reasons, refuse to accept procedures or treatment by a Participating Provider. Participating Providers may regard such refusal to accept their recommendations as explained incompatible with continuance of the Provider-patient relationship and as obstructing the provision of proper medical care. Participating Providers shall use their best efforts to render all necessary and appropriate Professional Services in thea manner compatible with Your wishes, insofar as this can be done consistent with the Participating Provider’s judgment as to the requirements of proper medical practice. If You refuse to follow a recommended treatment or procedure, and the Participating Provider informed You of his belief that no professionally acceptable alternative exists, neither HMO nor any Participating Provider shall have any further responsibility to provide care for the condition under treatment.

Continuity of Care. If You are under the care of a Participating Provider who stops participating in HMO’s 's network, (for reasons other than failure to meet applicable quality standards, including medical incompetence or professional behavior, or for fraud), HMO will continue coverage for that Provider’s 's Covered Services if all the following conditions are met: • You are undergoing have a course of treatment for a serious and complex disability, acute condition, You are undergoing institutional or inpatient care, You are scheduled to undergo nonelective surgery from the Provider (including receipt of postoperative care from such Provider with respect to such surgery), You are pregnant or undergoing a course of treatment for the pregnancy, or You are determined to be terminally ill. A serious and complex condition is one that (1) for an acute illness, is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm care (for example, You are currently receiving chemotherapy, radiation therapy, or post-operative visits for a serious acute disease or condition), and (2) for a chronic life‐threatening illness or condition, is are past the thirteenth (i13th) life-threatening, degenerative, disabling or potentially disabling, or congenital, week of pregnancy; and (ii) requires specialized medical care over a prolonged period of time; • the Provider submits a written request to HMO to continue coverage of Your care that identifies the condition for which You are being treated and, where required, and indicates that the Provider reasonably believes that discontinuing treatment could cause You harm; and • the Provider agrees to continue accepting the same reimbursement that applied when participating in HMO’s 's network, and not to seek payment from You for any amounts for which You would not be responsible if the Provider were still participating in HMO’s 's network. Continuity coverage shall continue until the treatment is complete but shall not extend for more than ninety (90) days (or more than nine (9) months if You have been diagnosed with a terminal illness) beyond the date the Provider’s 's termination takes effect. If You are past the thirteenth (13th) week of pregnancy when the Provider’s 's termination takes effect, coverage may be extended through delivery, immediate postpartum care and the follow- up check-up follow‐up check‐up within the first six (6) weeks of delivery. If You have been diagnosed with a chronic, disabling, or life‐threatening illness, You may contact customer service at the right toll‐free telephone number on Your identification card to get information to submit for approval from the HMO Medical Director to choose a Participating Specialist as Your PCP. The Medical Director will require both You and the Participating Specialist interested in serving as Your PCP to sign a certification of medical need, to submit along with all supporting documentation. The Participating Specialist must meet HMO's requirements for PCP participation and be willing to accept the coordination of all Your healthcare needs. If Your request is denied, You may appeal the decision as described in Complaint and Appeal Procedures. If Your request is approved, the Specialist's designation as Your PCP will not be effective retroactively. As used herein, “life threatening,” means a disease or condition for which the likelihood of death is probable unless the course of the disease or condition is interrupted. HMO cannot guarantee the availability or continued participation of a particular Provider. Either HMO or any decision made Participating Provider may terminate the Provider contract or limit the number of Members that will be accepted as patients. If the PCP initially selected cannot accept additional patients, You will be given an opportunity to make another PCP selection. You must then cooperate with HMO to select another PCP. Out‐of‐Network Services You may obtain Covered Services from Providers who are not part of HMO's network of Participating Providers when receiving Emergency Care. Also, court‐ordered Dependents living outside the Service Area may use non‐Participating Providers. If Covered Services are not available from Participating Providers within the access requirements established by law and regulation, HMO will allow a Referral by Your PCP to a non‐Participating Provider, if approved by HMO. If Your PCP is in a Limited Provider Network, in determining whether a Covered Service is available through Participating Providers, HMO will first consider Participating Providers in the PCP's Limited Provider Network. If the Covered Service is not available in the Limited Provider Network, then HMO's entire network will be considered. You will not be required to change Your PCP or Participating Specialist Providers to receive Covered Services that are not available from Participating Providers within the Limited Provider Network, but the following apply. • The request must be from a Participating Provider. • Reasonably requested documentation must be received by HMO. • The Referral will be provided within an appropriate time, not to exceed five business days, based on the circumstances and Your condition. • When HMO has allowed Referral to a non‐Participating Provider, HMO will reimburse the non‐Participating Provider at the usual and customary rate or otherwise agreed rate, less the applicable Copayment(s). You are responsible only for the Copayments for such Covered Services. • Before HMO denies a Referral, a review will be conducted by a Specialist of the same or similar specialty as the type of Provider to whom a Referral is requested. Inpatient Care by Non‐PCP During an inpatient stay at a Participating Hospital, Skilled Nursing Facility or other Participating facility, it may be appropriate for a request for benefits Physician other than Your PCP to direct and oversee Your care, if Your PCP does not do so. However, upon discharge, You must return to the care of Your PCP or have Your PCP coordinate care that may be Medically Necessary. HMO will not prohibit, attempt to prohibit or discourage any Provider from discussing or communicating to You or Your designee any information or opinions regarding Your health care, any provisions of the Health Benefit Plan as it relates to Your medical needs or the fact that the Provider's contract with HMO has terminated or that the Provider will no longer be providing services under HMO. • You shall complete and submit to HMO an application or other forms or statements that HMO may reasonably request. You agree that all information contained in the applications, forms and statements submitted to HMO due to enrollment under this subsection Certificate or the administration herein shall be true, correct, and complete to the best of Your knowledge and belief. • You shall notify HMO immediately of any change of address for You or any of Your covered Dependents. • You understand that HMO is acting in reliance upon all information You provided to HMO at time of enrollment and afterwards and represents that information so provided is true and accurate. • By electing coverage pursuant to this Certificate, or accepting benefits hereunder, all Members who are legally capable of contracting, and the legal representatives of all Members who are incapable of contracting, at time of enrollment and afterwards, represent that all information so provided is true and accurate and agree to all terms, conditions and provisions hereof. • You are subject to and shall abide by the rules and regulations of each Provider from which benefits are provided. You may, for personal reasons, refuse to accept procedures or treatment by a Participating Provider. Participating Providers may regard such refusal to accept their recommendations as explained incompatible with continuance of the Provider‐patient relationship and as obstructing the provision of proper medical care. Participating Providers shall use their best efforts to render all necessary and appropriate Professional Services in thea manner compatible with Your wishes, insofar as this can be done consistent with the Participating Provider's judgment as to the requirements of proper medical practice. If You refuse to follow a recommended treatment or procedure, and the Participating Provider informed You of his belief that no professionally acceptable alternative exists, neither HMO nor any Participating Provider shall have any further responsibility to provide care for the condition under treatment.