Common use of EMERGENCY CARE BENEFITS Clause in Contracts

EMERGENCY CARE BENEFITS. This section of your Certificate explains your emergency care benefits. Notwithstanding anything in your Certificate to the contrary, for emergency care benefits rendered by Providers who are not part of your HMO's network or other­ wise contracted with your HMO, you will not be responsible for any charges that exceed the amount negotiated with Providers for emergency care benefits fur­ nished. This amount is calculated excluding any Copayment or Coinsurance imposed with respect to the participant. IN‐AREA TREATMENT OF AN EMERGENCY You are considered to be in your Participating IPA's/Participating Medical Group's treatment area if you are within 30 miles of your Participating IPA/Par­ ticipating Medical Group. Although you may go directly to the nearest Hospital emergency room to obtain treatment for an Emergency Condition, we recommend that you contact your Pri­ xxxx Care Physician or Woman's Principal Health Care Provider first if you are in your Participating IPA's/Participating Medical Group's treatment area. Benefits will be provided for the Hospital and Physician services that he/she authorizes. If you obtain emergency treatment in the Hospital emergency room, your Primary Care Physician or Woman's Principal Health Care Provider must be notified of your condition as soon as possible and benefits will be limited to the initial treat­ ment of your emergency unless further treatment is ordered by your Primary Care Physician or Woman's Principal Health Care Provider. If Inpatient Hospital care is required, it is especially important for you or your family to contact your Pri­ xxxx Care Physician or Woman's Principal Health Care Provider as soon as possible. All Participating IPA's/Participating Medical Groups have 24 hour phone service. Payment for In‐Area Emergency Treatment Benefits for emergency treatment received in your Participating IPA's/Participat­ ing Medical Group's treatment area will be paid at 100% of the Provider's Charge. However, each time you receive emergency treatment in a Hospital emergency room, you will be responsible for a Copayment of $150. The emergency room Copayment does not apply to services provided for the treatment of sexual as­ sault. Should you be admitted to the Hospital as an Inpatient, benefits will be paid as explained in the Hospital Benefits and Physician Benefits Sections of this Certi­ ficate.

EMERGENCY CARE BENEFITS. This section of your Certificate explains your emergency care benefits. Notwithstanding anything in your Certificate to the contrary, for emergency care benefits rendered by Providers who are not part of your HMO's network or other­ wise contracted with your HMO, you will not the Provider's Charge shall be responsible for any charges that exceed the amount negotiated with Providers for emergency care benefits fur­ nishedfurnished. This amount is calculated excluding any Copayment or Coinsurance imposed with respect to the participant. IN‐AREA TREATMENT OF AN EMERGENCY You are considered to be in your Participating IPA's/Participating Medical Group's treatment area if you are within 30 miles of your Participating IPA/Par­ ticipating Medical Group. Although you may go directly to the nearest Hospital emergency room to obtain treatment for an Emergency Condition, we recommend that you contact your Pri­ xxxx Care Physician or Woman's Principal Health Care Provider first if you are in your Participating IPA's/Participating Medical Group's treatment area. Benefits will be provided for the Hospital and Physician services that he/she authorizes. If you obtain emergency treatment in the Hospital emergency room, your Primary Care Physician or Woman's Principal Health Care Provider must be notified of your condition as soon as possible and benefits will be limited to the initial treat­ ment of your emergency unless further treatment is ordered by your Primary Care Physician or Woman's Principal Health Care Provider. If Inpatient Hospital care is required, it is especially important for you or your family to contact your Pri­ xxxx Care Physician or Woman's Principal Health Care Provider as soon as possible. All Participating IPA's/Participating Medical Groups have 24 hour phone service. Payment for In‐Area Emergency Treatment Benefits for emergency treatment received in your Participating IPA's/Participat­ ing Medical Group's treatment area will be paid at 100% of the Provider's Charge. However, each time you receive emergency treatment in a Hospital emergency room, you will be responsible for a Copayment of $150200. The emergency room Copayment does not apply to services provided for the treatment of sexual as­ sault. Should you be admitted to the Hospital as an Inpatient, benefits will be paid as explained in the Hospital Benefits and Physician Benefits Sections of this Certi­ ficate. If you are admitted to the Hospital as an Inpatient immediately following emergency treatment, the emergency room Copayment will be waived.

EMERGENCY CARE BENEFITS. This section of your Certificate explains your emergency care benefits. Notwithstanding anything in your Certificate to the contrary, for emergency care benefits rendered by Providers who are not part of your HMO's network or other­ wise contracted with your HMO, you will not be responsible for any charges that exceed the amount negotiated with Providers for emergency care benefits fur­ nished. This amount is calculated excluding any Copayment or Coinsurance imposed with respect to the participant. IN‐AREA TREATMENT OF AN EMERGENCY You are considered to be in your Participating IPA's/Participating Medical Group's treatment area if you are within 30 miles of your Participating IPA/Par­ ticipating Medical Group. Although you may go directly to the nearest Hospital emergency room to obtain treatment for an Emergency Condition, we recommend that you contact your Pri­ xxxx Primary Care Physician or Woman's Principal Health Care Provider first if you are in your Participating IPA's/Participating Medical Group's treatment area. Benefits Be­ nefits will be provided for the Hospital and Physician services that he/she authorizes. If you obtain emergency treatment in the Hospital emergency room, your Primary Care Physician or Woman's Principal Health Care Provider must be notified of your condition as soon as possible and benefits will be limited to the initial treat­ ment of your emergency unless further treatment is ordered by your Primary Care Physician or Woman's Principal Health Care Provider. If Inpatient Hospital care is required, it is especially important for you or your family to contact your Pri­ xxxx Care Physician or Woman's Principal Health Care Provider as soon as possible. All Participating IPA's/Participating Medical Groups have 24 hour phone service. Payment for In‐Area Emergency Treatment Benefits for emergency treatment received in your Participating IPA's/Participat­ ing Medical Group's treatment area will be paid at 100% as described in the BENEFIT HIGHLIGHTS section of the Provider's Chargethis Certificate. However, each time you receive emergency treatment in a Hospital emergency room, you will be responsible for a Copayment the deductible amount shown in the BENEFIT HIGHLIGHTS section of $150this Certificate. The Thereafter, you will be responsible for paying the Coinsurance amount shown in the BENEFIT HIGHLIGHTS section of this Certificate, after you have met your program deductible, if any is applic­ able. However, the emergency room Copayment deductible does not apply to services provided for the treatment of criminal sexual as­ saultassault. Should you be admitted to the Hospital as an Inpatient, benefits will be paid as explained in the Hospital Benefits and Physician Benefits Sections of this Certi­ ficate.IL‐G‐H‐OF‐2016 57

EMERGENCY CARE BENEFITS. This section of your Certificate explains your emergency care benefits. Notwithstanding anything in your Certificate to the contrary, for emergency care benefits rendered by Providers who are not part of your HMO's network or other­ wise contracted with your HMO, you will not the Provider's Charge shall be responsible for any charges that exceed the amount negotiated with Providers for emergency care benefits fur­ nishedfurnished. This amount is calculated excluding any Copayment or Coinsurance imposed with respect to the participant. IN‐AREA TREATMENT OF AN EMERGENCY You are considered to be in your Participating IPA's/Participating Medical Group's treatment area if you are within 30 miles of your Participating IPA/Par­ ticipating Medical Group. Although you may go directly to the nearest Hospital emergency room to obtain treatment for an Emergency Condition, we recommend that you contact your Pri­ xxxx Care Physician or Woman's Principal Health Care Provider first if you are in your Participating IPA's/Participating Medical Group's treatment area. Benefits will be provided for the Hospital and Physician services that he/she authorizes. If you obtain emergency treatment in the Hospital emergency room, your Primary Care Physician or Woman's Principal Health Care Provider must be notified of your condition as soon as possible and benefits will be limited to the initial treat­ ment of your emergency unless further treatment is ordered by your Primary Care Physician or Woman's Principal Health Care Provider. If Inpatient Hospital care is required, it is especially important for you or your family to contact your Pri­ xxxx Care Physician or Woman's Principal Health Care Provider as soon as possible. All Participating IPA's/Participating Medical Groups have 24 hour phone service. Payment for In‐Area Emergency Treatment Benefits for emergency treatment received in your Participating IPA's/Participat­ ing Medical Group's treatment area will be paid at 100% of the Provider's Charge. However, each time you receive emergency treatment in a Hospital emergency room, you will be responsible for a Copayment of $15075. The emergency room Copayment Co­ payment does not apply to services provided for the treatment of sexual as­ saultassault. Should you be admitted to the Hospital as an Inpatient, benefits will be paid as explained in the Hospital Benefits and Physician Benefits Sections of this Certi­ ficate. If you are admitted to the Hospital as an Inpatient immediately following emergency treatment, the emergency room Copayment will be waived.