Common use of Emergency Health Care Services - Outpatient Clause in Contracts

Emergency Health Care Services - Outpatient. Note: If you are confined in an out-of-Network Hospital after you receive outpatient Emergency Health Care Services, you must notify us within one business day or on the same day of admission if reasonably possible. We may elect to transfer you to a Network Hospital as soon as it is medically appropriate to do so. If you choose to stay in the out-of-Network Hospital after the date we decide a transfer is medically appropriate, Benefits will not be provided. If you are admitted as an inpatient to a Hospital directly from Emergent ER 40% Yes Yes Note: Your vPCP or PCP must submit an electronic referral before services are rendered by a Network Specialist or other Network Physician in order for benefits to be payable under this Policy. Covered Health Care Service What Is the Co- payment or Co- insurance You Pay? This May Include a Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply? Services, the Benefits provided as described under Hospital - Inpatient Stay will apply. You will not have to pay the Emergency Health Care Services Co-payment, Co-insurance and/or deductible. Allowed Amounts for Emergency Health Care Services provided by an Out-of-Network Provider will be determined as described below under Allowed Amounts in this Schedule of Benefits. Amounts paid toward the deductible or Out-of-Pocket Limit for Emergency Health Care Services provided by an Out-of-Network Provider will count towards any applicable deductibles and Out-of-Pocket Limits for Emergency Health Care Services provided by a Network Provider.

Emergency Health Care Services - Outpatient. Note: If you are confined in an out-of-Network Hospital after you receive outpatient Emergency Health Care Services, you must notify us within one business day or on the same day of admission if reasonably possible. We may elect to transfer you to a Network Hospital as soon as it is medically appropriate to do so. If you choose to stay in the out-of-Network Hospital after the date we decide a transfer is medically appropriate, Benefits will not be provided. If you are admitted as an inpatient to a Hospital directly from Emergent ER 40Services, the Benefits provided as described under Hospital - Inpatient Stay will apply. You will not have to pay the Emergency Health Care Services Co-payment, 50% Yes Yes Note: Your vPCP or PCP must submit an electronic referral before services are rendered by a Network Specialist or other Network Physician in order for benefits to be payable under this Policy. SAMPLE Covered Health Care Service What Is the Co- payment or Co- insurance You Pay? This May Include a Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply? Services, the Benefits provided as described under Hospital - Inpatient Stay will apply. You will not have to pay the Emergency Health Care Services Co-payment, Co-insurance and/or deductible. Allowed Amounts for Emergency Health Care Services provided by an Out-of-Network Provider will be determined as described below under Allowed Amounts in this Schedule of Benefits. Amounts paid toward the deductible or Out-of-Pocket Limit for Emergency Health Care Services provided by an Out-of-Network Provider will count towards any applicable deductibles and Out-of-Pocket Limits for Emergency Health Care Services provided by a Network Provider.

Emergency Health Care Services - Outpatient. Note: If you are confined in an out-of-Network Hospital after you receive outpatient Emergency Health Care Services, you must notify us within one business day or on the same day of admission if reasonably possible. We may elect to transfer you to a Network Hospital as soon as it is medically appropriate to do so. If you choose to stay in the out-of-Network Hospital after the date we decide a transfer is medically appropriate, Benefits will not be provided. If you are admitted as an inpatient to a Hospital directly from Emergent ER 40% $500 per visit Yes Yes Note: Your vPCP or PCP Primary Care Physician must submit an electronic referral before services are rendered by a Network Specialist or other Network Physician in order for benefits to be payable under this Policy. Covered Health Care Service What Is the Co- payment or Co- insurance You Pay? This May Include a Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply? Services, the Benefits provided as described under Hospital - Inpatient Stay will apply. You will not have to pay the Emergency Health Care Services Co-payment, Co-insurance and/or deductible. Allowed Amounts for Emergency Health Care Services provided by an Out-of-Network Provider will be determined as described below under Allowed Amounts in this Schedule of Benefits. Amounts paid toward the deductible or Out-of-Pocket Limit for Emergency Health Care Services provided by an Out-of-Network Provider will count towards any applicable deductibles and Out-of-Pocket Limits for Emergency Health Care Services provided by a Network Provider.

Emergency Health Care Services - Outpatient. Note: If you are confined in an out-of-Network Hospital after you receive outpatient Emergency Health Care Services, you must notify us within one business day or on the same day of admission if reasonably possible. We may elect to transfer you to a Network Hospital as soon as it is medically appropriate to do so. If you choose to stay in the out-of-Network Hospital after the date we decide a transfer is medically appropriate, Benefits will not be provided. If you are admitted as an inpatient to a Hospital directly from Emergent ER 4025% Yes Yes Note: Your vPCP or PCP must submit an electronic referral before services are rendered by a Network Specialist or other Network Physician in order for benefits to be payable under this Policy. Covered Health Care Service What Is the Co- payment or Co- insurance You Pay? This May Include a Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply? Services, the Benefits provided as described under Hospital - Inpatient Stay will apply. You will not have to pay the Emergency Health Care Services Co-payment, Co-insurance and/or deductible. Allowed Amounts for Emergency Health Care Services provided by an Out-of-Network Provider will be determined as described below under Allowed Amounts in this Schedule of Benefits. Amounts paid toward the deductible or Out-of-Pocket Limit for Emergency Health Care Services provided by an Out-of-Network Provider will count towards any applicable deductibles and Out-of-Pocket Limits for Emergency Health Care Services provided by a Network Provider.

Emergency Health Care Services - Outpatient. Note: If you are confined in an out-of-Network Hospital after you receive outpatient Emergency Health Care Services, you must notify us within one two business day or on days. Notification provided to us by the same day of admission if reasonably possibleattending physician will satisfy the requirement. We may elect to transfer you to a Network Hospital as soon as it is medically appropriate to do so. If you choose to stay in the out-of-Network Hospital after the date we decide a transfer is medically appropriate, Benefits will not be provided. If you are admitted as an inpatient to a Hospital directly from Emergent ER 40% the Emergency room, the Benefits provided as described under Hospital - Inpatient Stay will apply. You will not have to pay the Emergency Health Care Services Co-payment, Co- insurance and/or deductible. Allowed Amounts for $150 per visit. Yes Yes Note: Your vPCP or PCP must submit an electronic referral before services No Amounts which you are rendered by a Network Specialist or other Network Physician required to pay as shown below in order the Schedule of Benefits are based on Allowed Amounts. The Allowed Amounts provision near the end of this Schedule of Benefits will tell you when you are responsible for benefits to be payable under this Policyamounts that exceed the Allowed Amount. Covered Health Care Service What Is the Co- Co-payment or Co- Co-insurance You Pay? This May Include a Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply? Services, the Benefits provided as described under Hospital - Inpatient Stay will apply. You will not have to pay the Emergency Health Care Services Co-payment, Co-insurance and/or deductible. Allowed Amounts for Emergency Health Care Services provided by an Outout-of-of- Network Provider provider will be determined as described below under Allowed Amounts in this Schedule of Benefits. Amounts paid toward the deductible or Out-of-Pocket Limit for Emergency Health Care Services provided by an Out-of-Network Provider will count towards any applicable deductibles and Out-of-Pocket Limits for Emergency Health Care Services provided by a Network Provider.

Emergency Health Care Services - Outpatient. Note: If you are confined in an out-of-Network Hospital after you receive outpatient Emergency Health Care Services, you must notify us within one business day or on the same day of admission if reasonably possible. We may elect to transfer you to a Network Hospital as soon as it is medically appropriate to do so. If you choose to stay in the out-of-Network Hospital after the date we decide a transfer is medically appropriate, Benefits will not be provided. If you are admitted as an inpatient to a Hospital directly from Emergent ER 4020% Yes Yes Note: Your vPCP or PCP Primary Care Physician must submit an electronic referral before services are rendered by a Network Specialist or other Network Physician in order for benefits to be payable under this Policy. Covered Health Care Service What Is the Co- payment or Co- insurance You Pay? This May Include a Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply? admission if reasonably possible. We may elect to transfer you to a Network Hospital as soon as it is medically appropriate to do so. If you choose to stay in the out-of-Network Hospital after the date we decide a transfer is medically appropriate, Benefits will not be provided. If you are admitted as an inpatient to a Hospital directly from Emergent ER Services, the Benefits provided as described under Hospital - Inpatient Stay will apply. You will not have to pay the Emergency Health Care Services Co-payment, Co-insurance and/or deductible. Allowed Amounts for Emergency Health Care Services provided by an Out-of-Network Provider will be determined as described below under Allowed Amounts in this Schedule of Benefits. Amounts paid toward the deductible or Out-of-Pocket Limit for Emergency Health Care Services provided by an Out-of-Network Provider will count towards any applicable deductibles and Out-of-Pocket Limits for Emergency Health Care Services provided by a Network Provider.

Emergency Health Care Services - Outpatient. Note: If you are confined in an out-of-Network Hospital after you receive outpatient Emergency Health Care Services, you must notify us within one business day or on the same day of admission if reasonably possible. We may elect to transfer you to a Network Hospital as soon as it is medically appropriate to do so. If you choose to stay in the out-of-Network Hospital after the date we decide a transfer is medically appropriate, Benefits will not be provided. If you are admitted as an inpatient to a Hospital directly from Emergent ER 40% Yes Yes Note: Your vPCP or PCP must submit an electronic referral before services are rendered by a Network Specialist or other Network Physician in order for benefits to be payable under this Policy. Covered Health Care Service What Is the Co- payment or Co- insurance You Pay? This May Include a Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply? Services, the Benefits provided as described under Hospital - Inpatient Stay will apply. You will not have to pay the Emergency Health Care Services Co-payment, Co-Co- insurance and/or deductible. Allowed Amounts for Emergency Health Care Services provided by an Out-out- of-Network Provider provider will be determined as described below under Allowed Amounts in this Schedule of Benefits. 40% Yes Yes Enteral Nutrition 40% Yes Yes Habilitative Services Inpatient SAMPLE Amounts paid toward which you are required to pay as shown below in the deductible or Out-of-Pocket Limit Schedule of Benefits are based on Allowed Amounts or, for Emergency specific Covered Health Care Services provided by an Out-of-Network Provider as described in the definition of Recognized Amount in the Policy, Recognized Amounts. The Allowed Amounts provision near the end of this Schedule of Benefits will count towards any applicable deductibles and Out-of-Pocket Limits tell you when you are responsible for Emergency Health Care Services provided by a Network Provideramounts that exceed the Allowed Amount.

Emergency Health Care Services - Outpatient. Note: If you are confined in an out-of-Network Hospital after you receive outpatient Emergency Health Care Services, you must notify us within one business day or on the same day of admission if reasonably possible. We may elect to transfer you to a Network Hospital as soon as it is medically appropriate to do so. If you choose to stay in the out-of-Network Hospital after the date we decide a transfer is medically appropriate, Benefits will not be provided. If you are admitted as an inpatient to a Hospital directly from Emergent ER 40% $1,500 per visit Yes Yes No Note: Your vPCP or PCP Primary Care Physician must submit an electronic referral before services are rendered by a Network Specialist or other Network Physician in order for benefits to be payable under this Policy. Covered Health Care Service What Is the Co- payment or Co- insurance You Pay? This May Include a Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply? If you are admitted as an inpatient to a Hospital directly from Emergent ER Services, the Benefits provided as described under Hospital - Inpatient Stay will apply. You will not have to pay the Emergency Health Care Services Co-payment, Co-insurance and/or deductible. Allowed Amounts for Emergency Health Care Services provided by an Out-of-Network Provider will be determined as described below under Allowed Amounts in this Schedule of Benefits. Amounts paid toward the deductible or Out-of-Pocket Limit for Emergency Health Care Services provided by an Out-of-Network Provider will count towards any applicable deductibles and Out-of-Pocket Limits for Emergency Health Care Services provided by a Network Provider.

Emergency Health Care Services - Outpatient. Note: If you are confined in an out-of-Network Hospital after you receive outpatient Emergency Health Care Services, you must notify us within one business day or on the same day of admission if reasonably possible. We may elect to transfer you to a Network Hospital as soon as it is medically appropriate to do so. If you choose to stay in the out-of-Network Hospital after the date we decide a transfer is medically appropriate, Benefits will not be provided. If you are admitted as an inpatient to a Hospital directly from Emergent ER 40Services, the Benefits provided as described under Hospital - Inpatient Stay will apply. You will not have to pay the Emergency Health Care Services Co-payment, 50% Yes Yes Note: Your vPCP or PCP must submit an electronic referral before services are rendered by a Network Specialist or other Network Physician in order for benefits to be payable under this Policy. Covered Health Care Service What Is the Co- payment or Co- insurance You Pay? This May Include a Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply? Services, the Benefits provided as described under Hospital - Inpatient Stay will apply. You will not have to pay the Emergency Health Care Services Co-payment, Co-insurance and/or deductible. Allowed Amounts for Emergency Health Care Services provided by an Out-of-Network Provider will be determined as described below under Allowed Amounts in this Schedule of Benefits. Amounts paid toward the deductible or Out-of-Pocket Limit for Emergency Health Care Services provided by an Out-of-Network Provider will count towards any applicable deductibles and Out-of-Pocket Limits for Emergency Health Care Services provided by a Network Provider.