Common use of For non-network providers Clause in Contracts

For non-network providers. a. When a covered service is received from a non-network provider as a result of an emergency and there is not a network provider reasonably accessible to render the covered service, the eligible service expense is the lesser of (1) the negotiated fee, if any, that has been mutually agreed upon by us and the provider as payment in full (you will not be billed for the difference between the negotiated fee and the provider’s charge), or (2) the provider’s billed charge.; b. When a covered service is received from a non-network provider as a result of an emergency and there is a network provider reasonably accessible to render the covered service, the eligible service expense is the negotiated fee, if any, that the provider has agreed to accept as payment in full (you will not be billed for the difference between the negotiated fee and the provider’s charge). However, if the provider has not agreed to accept a negotiated fee as payment in full, the eligible expense is the greatest of the following: i. the amount that would be paid under Medicare, ii. the amount for the covered service calculated using the same method we generally use to determine payments for out-of-network services, or iii. the contracted amount paid to network providers for the covered service. If there is more than one contracted amount with network providers for the covered service, the amount is the median of these amounts. c. When a covered service is received from a non-network provider as approved or authorized by us, the eligible service expense is the negotiated fee, if any, that the provider has agreed to accept as payment in full (you will not be billed for the difference between the negotiated fee and the provider’s charge). ). If there is no negotiated fee agreed to by the provider with us, the eligible service expense is the greater of (1) the amount that would be paid by Medicare, or (2) the contracted amount paid to network providers for the covered service. If there is more than one contracted amount with network providers for the covered service, the amount is the median of these amounts. You may be billed for the difference between the amount paid and the provider’s charge. d. When a covered service expense is received from a non-network provider because the service or supply is not of a type provided by any network provider, the eligible service expense is the negotiated fee, if any, that the provider has agreed to accept as payment in full (you will not be billed for the difference between the negotiated fee and the provider’s charge). If there is no negotiated fee agreed to by the provider with us, the eligible service expense is the amount that would be paid by Medicare. You may be billed for the difference between the amount paid and the provider’s charge. law. 1. Placing the health of the member (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; 2. Serious impairment to bodily functions; or 3. Serious dysfunction of any bodily organ or part. With Respect to a pregnant woman: 1. that there is inadequate time to effect a safe transfer to another hospital prior to delivery; 2. that the transfer may pose a threat to the health and safety of the patient or fetus; or 3. that there is evidence of the onset and persistence of uterine contractions or rupture of the membranes. Essential health benefits are defined by federal and state law and refer to benefits in at least the following categories: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management and pediatric services, including oral and vision care. Essential health benefits provided within this contract are not subject to lifetime or annual dollar maximums. Certain non-essential health benefits, however, are subject to either a lifetime and/or annual dollar maximum Expedited grievance means a grievance where any of the following applies: 1. The duration of the standard resolution process will result in serious jeopardy to the life or health of the claimant or the ability of the claimant to regain maximum function. 2. In the opinion of a physician with knowledge of the claimant’s medical condition, the claimant is subject to severe pain that cannot be adequately managed without the care or treatment that is the subject of the grievance.

For non-network providers. When a covered service is received from a non-network provider, the eligible service expense is the minimum amount required by applicable federal or state law to be paid to the non-network provider for the service. If and only if there is no minimum amount required by applicable federal or state law, then the eligible service expense for a non-network provider shall be as determined below. a. When a covered service is received from a non-network provider as a result of an emergency and there is not a network provider reasonably accessible to render the covered service, the eligible service expense is the lesser of (1) the negotiated fee, if any, that has been mutually agreed upon by us and the non-network provider as payment in full (you will not be billed for the difference between the negotiated fee and the provider’s charge), or (2) the amount reasonably accepted by the provider (not to exceed the provider’s charge). You will not be billed for the difference between the amount paid and the non- network provider’s charge, but will remain responsible for payment of applicable copayments, coinsurance, and deductible.; b. When a covered service is received from a non-network provider as a result of an emergency and there is a network provider reasonably accessible to render the covered service, the eligible service expense is the least of (1) the negotiated fee, if any, that has been mutually agreed upon by us and the non-network provider as payment in full, (2) the amount reasonably accepted by the non-network provider (not to exceed the non-network provider’s charge), or (3) the usual and customary charge for similar services in the community where the covered services were provided. You will not be billed for the difference between the amount paid and the non-network provider’s charge, but will remain responsible for payment of applicable copayments, coinsurance, and deductible. c. When a covered service is received from a non-network provider as approved or authorized by us that is not the result of an emergency, the eligible service expense is the negotiated fee, if any, that has been mutually agreed to accept upon by us and the non- network provider as payment in full (you will not be billed for the difference between the negotiated fee and the provider’s charge). However, if the provider has not agreed to accept a negotiated fee as payment in full, the eligible expense is the greatest of the following: i. the amount that would be paid under Medicare, ii. the amount for the covered service calculated using the same method we generally use to determine payments for out-of-network services, or iii. the contracted amount paid to network providers for the covered service. If there is more than one contracted amount with network providers for the covered service, the amount is the median of these amounts. c. When a covered service is received from a non-network provider as approved or authorized by us, the eligible service expense is the negotiated fee, if any, that the provider has agreed to accept as payment in full (you will not be billed for the difference between the negotiated fee and the provider’s charge). ). If there is no negotiated fee agreed to by the non- network provider with us, the eligible service expense is the greater of (1) the amount that would be paid by Medicare, or (2) the contracted amount paid to network providers for the covered service. If there is more than one contracted amount with network providers for the covered service, the amount is the median of these amounts. You may be billed for the difference between the amount paid and the non-network provider’s charge, and will also be responsible for payment of applicable copayments, coinsurance, and deductible. d. When a covered service expense that is not the result of an emergency is received from a non-network provider because at a facility that is a network provider and you do not have the ability and opportunity to choose an available network provider at such facility, the eligible service expense is the least of (1) the negotiated fee, if any, that has been mutually agreed upon by us and the non-network provider as payment in full, (2) the amount reasonably accepted by the non-network provider (not to exceed the non-network provider’s charge), or supply (3) the usual and customary charge for similar services in the community where the covered services were provided(not to exceed the non-network provider’s charge). You will not be billed for the difference between the amount paid and the non-network provider’s charge but will remain responsible for payment of applicable copayments, coinsurance, and deductible. e. When a covered service is received from a non-network provider that is not the result of a type an emergency and is not approved or authorized by us, and is not within the scope of services provided by any network provider, the eligible service expense is the negotiated fee, if any, that has been mutually agreed upon by us and the non-network provider has agreed to accept as payment in full (you will not be billed for the difference between the negotiated fee and the non-network provider’s charge). If there is no negotiated fee agreed to by the non-network provider with us, the eligible service expense is the will be an amount that would is no less than ten percentage points lower than the percentage rate paid to network providers. This reimbursement rate will be paid by Medicareapplied to the usual and customary charge in the area. You may be billed for the difference between the amount paid and the non-network provider’s charge. law. 1. Placing the health charge and will also be responsible for payment of the member (orapplicable copayments, with respect to a pregnant womancoinsurance, the health of the woman or her unborn child) in serious jeopardy; 2. Serious impairment to bodily functions; or 3. Serious dysfunction of any bodily organ or part. With Respect to a pregnant woman: 1. that there is inadequate time to effect a safe transfer to another hospital prior to delivery; 2. that the transfer may pose a threat to the health and safety of the patient or fetus; or 3. that there is evidence of the onset and persistence of uterine contractions or rupture of the membranes. Essential health benefits are defined by federal and state law and refer to benefits in at least the following categories: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management and pediatric services, including oral and vision care. Essential health benefits provided within this contract are not subject to lifetime or annual dollar maximums. Certain non-essential health benefits, however, are subject to either a lifetime and/or annual dollar maximum Expedited grievance means a grievance where any of the following applies: 1. The duration of the standard resolution process will result in serious jeopardy to the life or health of the claimant or the ability of the claimant to regain maximum function. 2deductible. In the opinion all cases covered by 2(a) and (b) above, your responsibility for payment of a physician with knowledge of the claimant’s medical conditionapplicable copayments, the claimant is subject to severe pain that cannot be adequately managed without the care or treatment that coinsurance, and deductible is the subject of same as your responsibility would have been had the grievancecovered emergency service been provided by a network provider.

For non-network providers. When a covered service is received from a non-network provider, the eligible service expense is the minimum amount required by applicable federal or state law to be paid to the non-network provider for the service. If and only if there is no minimum amount required by applicable federal or state law, then the eligible service expense for a non-network provider shall be as determined below. a. When a covered service is received from a non-network provider as a result of an emergency and there is not a network provider reasonably accessible to render the covered service, the eligible service expense is the lesser of (1) the negotiated fee, if any, that has been mutually agreed upon by us and the provider as payment in full (you will not be billed for the difference between the negotiated fee and the provider’s charge), or (2) the amount accepted by the provider (not to exceed the provider’s billed charge).; b. When a covered service is received from a non-network provider as a result of an emergency and there is a network provider reasonably accessible to render the covered service, the eligible service expense is the least of (1) the negotiated fee, if any, that has been mutually agreed upon by us and the provider as payment in full, (2) the amount accepted by the provider (not to exceed the provider’s charge), or (3) the usual and customary charge for similar services in the community where the covered services were provided. You will not be billed for the difference between the amount paid and the provider’s charge. c. When a covered service is received from a non-network provider as approved or authorized by us that is not the result of an emergency, the eligible service expense is the negotiated fee, if any, that has been mutually agreed to accept upon by us and the provider as payment in full (you will not be billed for the difference between the negotiated fee and the provider’s charge). However, if the provider has not agreed to accept a negotiated fee as payment in full, the eligible expense is the greatest of the following: i. the amount that would be paid under Medicare, ii. the amount for the covered service calculated using the same method we generally use to determine payments for out-of-network services, or iii. the contracted amount paid to network providers for the covered service. If there is more than one contracted amount with network providers for the covered service, the amount is the median of these amounts. c. When a covered service is received from a non-network provider as approved or authorized by us, the eligible service expense is the negotiated fee, if any, that the provider has agreed to accept as payment in full (you will not be billed for the difference between the negotiated fee and the provider’s charge). ). If there is no negotiated fee agreed to by the provider with us, the eligible service expense is the greater of (1) the amount that would be paid by Medicare, or (2) the contracted amount paid to network providers for the covered service. If there is more than one contracted amount with network providers for the covered service, the amount is the median of these amounts. You may be billed for the difference between the amount paid and the provider’s charge. d. When a covered service expense that is not the result of an emergency is received from a non-network provider because at a facility that is a network provider and you do not have the ability and opportunity to choose an available network provider at such facility, the eligible service expense is the least of (1) the negotiated fee, if any, that has been mutually agreed upon by us and the provider as payment in full, (2) the amount accepted by the provider (not to exceed the provider’s charge), or supply (3) the usual and customary charge for similar services in the community where the covered services were provided. You will not be billed for the difference between the amount paid and the provider’s charge. e. When a covered service is received from a non-network provider that is not the result of a type an emergency and is not approved or authorized by us, and is not within the scope of services provided by any network provider, the eligible service expense is the negotiated fee, if any, that has been mutually agreed upon by us and the provider has agreed to accept as payment in full (you will not be billed for the difference between the negotiated fee and the provider’s charge). If there is no negotiated fee agreed to by the provider with us, the eligible service expense is the will be an amount that would be is no less than ten percentage points lower than the usual and customary percentage rate paid by Medicareto network providers. You may be billed for the difference between the amount paid and the provider’s charge. law. 1. Placing the health of the member (or, with respect to a pregnant womanpregnancy, the health of the woman member or her the unborn child) in serious jeopardy; 2. Serious impairment to bodily functions; or 3. Serious dysfunction of any bodily organ or part. With Respect to a pregnant womanpregnancy: 1. that there is inadequate time to effect a safe transfer to another hospital prior to delivery; 2. that the transfer may pose a threat to the health and safety of the patient or fetus; or 3. that there is evidence of the onset and persistence of uterine contractions or rupture of the membranes. Emergency services and care shall mean medical screening, examination, and evaluation by a physician, or, to the extent permitted by applicable law, by other appropriate personnel under the supervision of a physician, to determine if any emergency medical condition exists and, if it does, the care, treatment, or surgery for a covered service by a physician necessary to relieve or eliminate the emergency medical condition, within the service capability of a hospital. Follow-up care is not considered emergency Care. Benefits are provided for treatment of emergency medical conditions and emergency screening and stabilization services without prior authorization. Benefits for emergency care include facility costs and physician services, and supplies and prescription drugs charged by that facility. You must notify us or verify that your physician has notified us of your admission to a hospital within 48 hours or as soon as possible within a reasonable period of time. When we are contacted, you will be notified whether the inpatient setting is appropriate, and if appropriate, the number of days considered medically necessary. By contacting us, you may avoid financial responsibility for any inpatient care that is determined to be not medically necessary under your plan. If your provider does not contract with us you will be financially responsible for any care we determine is not medically necessary. Care and treatment provided once you are medically stabilized is no longer considered emergency care. Continuation of care from a non- participating provider beyond that needed to evaluate or stabilize your condition in an emergency will be covered as a non-network service unless we authorize the continuation of care and it is medically necessary. Essential health benefits are defined by federal and state law and refer to benefits in at least the following categories: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management and pediatric services, including oral and vision care. Essential health benefits provided within this contract are not subject to lifetime or annual dollar maximums. Certain non-essential health benefits, however, are subject to either a lifetime and/or or annual dollar maximum Expedited grievance means a grievance where any of the following applies: 1. The duration of the standard resolution process will result in serious jeopardy to the life or health of the claimant or the ability of the claimant to regain maximum functionmaximum. 2. In the opinion of a physician with knowledge of the claimant’s medical condition, the claimant is subject to severe pain that cannot be adequately managed without the care or treatment that is the subject of the grievance.

For non-network providers. When a covered service is received from a non-network provider, the eligible service expense is the minimum amount required by applicable federal or state law to be paid to the non-network provider for the service. If and only if there is no minimum amount required by applicable federal or state law, then the eligible service expense for a non-network provider shall be as determined below. a. When a covered service is received from a non-network provider as a result of an emergency and there is not a network provider reasonably accessible to render the covered service, the eligible service expense is the lesser of (1) the negotiated fee, if any, that has been mutually agreed upon by us and the non-network provider as payment in full (you will not be billed for the difference between the negotiated fee and the provider’s charge), or (2) the amount reasonably accepted by the non-network provider (not to exceed the provider’s charge). You will not be billed for the difference between the amount paid and the non-network provider’s charge, but will remain responsible for payment of applicable copayments, coinsurance, and deductible.; b. When a covered service is received from a non-network provider as a result of an emergency and there is a network provider reasonably accessible to render the covered service, the eligible service expense is the least of (1) the negotiated fee, if any, that has been mutually agreed upon by us and the non-network provider as payment in full, (2) the amount reasonably accepted by the non-network provider (not to exceed the non-network provider’s charge), or (3) the usual and customary charge for similar services in the community where the covered services were provided. You will not be billed for the difference between the amount paid and the non-network provider’s charge, but will remain responsible for payment of applicable copayments, coinsurance, and deductible. c. When a covered service is received from a non-network provider as approved or authorized by us that is not the result of an emergency, the eligible service expense is the negotiated fee, if any, that has been mutually agreed to accept upon by us and the non- network provider as payment in full (you will not be billed for the difference between the negotiated fee and the provider’s charge). However, if the provider has not agreed to accept a negotiated fee as payment in full, the eligible expense is the greatest of the following: i. the amount that would be paid under Medicare, ii. the amount for the covered service calculated using the same method we generally use to determine payments for out-of-network services, or iii. the contracted amount paid to network providers for the covered service. If there is more than one contracted amount with network providers for the covered service, the amount is the median of these amounts. c. When a covered service is received from a non-network provider as approved or authorized by us, the eligible service expense is the negotiated fee, if any, that the provider has agreed to accept as payment in full (you will not be billed for the difference between the negotiated fee and the provider’s charge). ). If there is no negotiated fee agreed to by the non- network provider with us, the eligible service expense is the greater of (1) the amount that would be paid by Medicare, or (2) the contracted amount paid to network providers for the covered service. If there is more than one contracted amount with network providers for the covered service, the amount is the median of these amounts. You may be billed for the difference between the amount paid and the non-network provider’s charge, and will also be responsible for payment of applicable copayments, coinsurance, and deductible. d. When a covered service expense that is not the result of an emergency is received from a non-network provider because at a facility that is a network provider and you do not have the ability and opportunity to choose an available network provider at such facility, the eligible service expense is the least of (1) the negotiated fee, if any, that has been mutually agreed upon by us and the non-network provider as payment in full, (2) the amount reasonably accepted by the non-network provider (not to exceed the non-network provider’s charge), or supply (3) the usual and customary charge for similar services in the community where the covered services were provided (not to exceed the non-network provider’s charge). You will not be billed for the difference between the amount paid and the non-network provider’s charge, but will remain responsible for payment of applicable copayments, coinsurance, and deductible. e. When a covered service is received from a non-network provider that is not the result of a type an emergency and is not approved or authorized by us, and is not within the scope of services provided by any network provider, the eligible service expense is the negotiated fee, if any, that has been mutually agreed upon by us and the non-network provider has agreed to accept as payment in full (you will not be billed for the difference between the negotiated fee and the non-network provider’s charge). If there is no negotiated fee agreed to by the non-network provider with us, the eligible service expense is the will be an amount that would is no less than ten percentage points lower than the percentage rate paid to network providers. This reimbursement rate will be paid by Medicareapplied to the usual and customary charge in the area. You may be billed for the difference between the amount paid and the non-network provider’s charge. law. 1. Placing the health , and will also be responsible for payment of the member (orapplicable copayments, with respect to a pregnant womancoinsurance, the health of the woman or her unborn child) in serious jeopardy; 2. Serious impairment to bodily functions; or 3. Serious dysfunction of any bodily organ or part. With Respect to a pregnant woman: 1. that there is inadequate time to effect a safe transfer to another hospital prior to delivery; 2. that the transfer may pose a threat to the health and safety of the patient or fetus; or 3. that there is evidence of the onset and persistence of uterine contractions or rupture of the membranes. Essential health benefits are defined by federal and state law and refer to benefits in at least the following categories: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management and pediatric services, including oral and vision care. Essential health benefits provided within this contract are not subject to lifetime or annual dollar maximums. Certain non-essential health benefits, however, are subject to either a lifetime and/or annual dollar maximum Expedited grievance means a grievance where any of the following applies: 1. The duration of the standard resolution process will result in serious jeopardy to the life or health of the claimant or the ability of the claimant to regain maximum function. 2deductible. In the opinion all cases covered by 2(a) and (b) above, your responsibility for payment of a physician with knowledge of the claimant’s medical conditionapplicable copayments, the claimant is subject to severe pain that cannot be adequately managed without the care or treatment that coinsurance, and deductible is the subject of same as your responsibility would have been had the grievancecovered emergency service been provided by a network provider.

For non-network providers. When a covered service is received from a non-network provider, the eligible service expense is the minimum amount required by applicable federal or state law to be paid to the non-network provider for the service. If and only if there is no minimum amount required by applicable federal or state law, then the eligible service expense for a non-network provider shall be as determined below. a. When a covered service is received from a non-network provider as a result of an emergency and there is not a network provider reasonably accessible to render the covered service, the eligible service expense is the lesser of (1) the negotiated fee, if any, that has been mutually agreed upon by us and the provider as payment in full (you will not be billed for the difference between the negotiated fee and the provider’s charge), or (2) the amount accepted by the provider (not to exceed the provider’s billed charge).; b. When a covered service is received from a non-network provider as a result of an emergency and there is a network provider reasonably accessible to render the covered service, the eligible service expense is the least of (1) the negotiated fee, if any, that has been mutually agreed upon by us and the provider as payment in full, (2) the amount accepted by the provider (not to exceed the provider’s charge), or (3) the usual and customary charge for similar services in the community where the covered services were provided. You will not be billed for the difference between the amount paid and the provider’s charge. c. When a covered service is received from a non-network provider as approved or authorized by us that is not the result of an emergency, the eligible service expense is the negotiated fee, if any, that has been mutually agreed to accept upon by us and the provider as payment in full (you will not be billed for the difference between the negotiated fee and the provider’s charge). However, if the provider has not agreed to accept a negotiated fee as payment in full, the eligible expense is the greatest of the following: i. the amount that would be paid under Medicare, ii. the amount for the covered service calculated using the same method we generally use to determine payments for out-of-network services, or iii. the contracted amount paid to network providers for the covered service. If there is more than one contracted amount with network providers for the covered service, the amount is the median of these amounts. c. When a covered service is received from a non-network provider as approved or authorized by us, the eligible service expense is the negotiated fee, if any, that the provider has agreed to accept as payment in full (you will not be billed for the difference between the negotiated fee and the provider’s charge). ). If there is no negotiated fee agreed to by the provider with us, the eligible service expense is the greater of (1) the amount that would be paid by Medicare, or (2) the contracted amount paid to network providers for the covered service. If there is more than one contracted amount with network providers for the covered service, the amount is the median of these amounts. You may be billed for the difference between the amount paid and the provider’s charge. d. When a covered service expense that is not the result of an emergency is received from a non-network provider because at a facility that is a network provider and you do not have the ability and opportunity to choose an available network provider at such facility, the eligible service expense is the least of (1) the negotiated fee, if any, that has been mutually agreed upon by us and the provider as payment in full, (2) the amount accepted by the provider (not to exceed the provider’s charge), or supply (3) the usual and customary charge for similar services in the community where the covered services were provided. You will not be billed for the difference between the amount paid and the provider’s charge. e. When a covered service is received from a non-network provider that is not the result of a type an emergency and is not approved or authorized by us, and is not within the scope of services provided by any network provider, the eligible service expense is the negotiated fee, if any, that has been mutually agreed upon by us and the provider has agreed to accept as payment in full (you will not be billed for the difference between the negotiated fee and the provider’s charge). If there is no negotiated fee agreed to by the provider with us, the eligible service expense is the will be an amount that would be is no less than ten percentage points lower than the usual and customary percentage rate paid by Medicareto network providers. You may be billed for the difference between the amount paid and the provider’s charge. law. 1. Placing the health of the member (or, with respect to a pregnant womanpregnancy, the health of the woman member or her the unborn child) in serious jeopardy; 2. Serious impairment to bodily functions; or 3. Serious dysfunction of any bodily organ or part. With Respect to a pregnant womanpregnancy: 1. that there is inadequate time to effect a safe transfer to another hospital prior to delivery; 2. that the transfer may pose a threat to the health and safety of the patient or fetus; or 3. that there is evidence of the onset and persistence of uterine contractions or rupture of the membranes. Emergency services and care shall mean medical screening, examination, and evaluation by a physician, or, to the extent permitted by applicable law, by other appropriate personnel under the supervision of a physician, to determine if any emergency medical condition exists and, if it does, the care, treatment, or surgery for a covered service by a physician necessary to relieve or eliminate the emergency medical condition, within the service capability of a hospital. Follow-up care is not considered emergency care. Benefits are provided for treatment of emergency medical conditions and emergency screening and stabilization services without prior authorization. Benefits for emergency care include facility costs and physician services, and supplies and prescription drugs charged by that facility. You must notify us or verify that your physician has notified us of your admission to a hospital within 48 hours or as soon as possible within a reasonable period of time. When we are contacted, you will be notified whether the inpatient setting is appropriate, and if appropriate, the number of days considered medically necessary. By contacting us, you may avoid financial responsibility for any inpatient care that is determined to be not medically necessary under your plan. If your provider does not contract with us you will be financially responsible for any care we determine is not medically necessary. Care and treatment provided once you are medically stabilized is no longer considered emergency care. Continuation of care from a non- participating provider beyond that needed to evaluate or stabilize your condition in an emergency will be covered as a non-network service unless we authorize the continuation of care and it is medically necessary. Essential health benefits are defined by federal and state law and refer to benefits in at least the following categories: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management and pediatric services, including oral and vision care. Essential health benefits provided within this contract are not subject to lifetime or annual dollar maximums. Certain non-essential health benefits, however, are subject to either a lifetime and/or or annual dollar maximum Expedited grievance means a grievance where any of the following applies: 1. The duration of the standard resolution process will result in serious jeopardy to the life or health of the claimant or the ability of the claimant to regain maximum functionmaximum. 2. In the opinion of a physician with knowledge of the claimant’s medical condition, the claimant is subject to severe pain that cannot be adequately managed without the care or treatment that is the subject of the grievance.

For non-network providers. When a covered service is received from a non-network provider, the eligible service expense is the minimum amount required by applicable federal or state law to be paid to the non-network provider for the service. If and only if there is no minimum amount required by applicable federal or state law, then the eligible service expense for a non-network provider shall be as determined below. a. When a covered service is received from a non-network provider as a result of an emergency and there is not a network provider reasonably accessible to render the covered service, the eligible service expense is the lesser of (1) the negotiated fee, if any, that has been mutually agreed upon by us and the provider as payment in full (you will not be billed for the difference between the negotiated fee and the provider’s charge), or (2) the amount accepted by the provider (not to exceed the provider’s billed charge).; b. When a covered service is received from a non-network provider as a result of an emergency and there is a network provider reasonably accessible to render the covered service, the eligible service expense is the least of (1) the negotiated fee, if any, that has been mutually agreed upon by us and the provider as payment in full, (2) the amount accepted by the provider (not to exceed the provider’s charge), or (3) the usual and customary charge for similar services in the community where the covered services were provided. You will not be billed for the difference between the amount paid and the provider’s charge. c. When a covered service is received from a non-network provider as approved or authorized by us that is not the result of an emergency, the eligible service expense is the negotiated fee, if any, that has been mutually agreed to accept upon by us and the provider as payment in full (you will not be billed for the difference between the negotiated fee and the provider’s charge). However, if the provider has not agreed to accept a negotiated fee as payment in full, the eligible expense is the greatest of the following: i. the amount that would be paid under Medicare, ii. the amount for the covered service calculated using the same method we generally use to determine payments for out-of-network services, or iii. the contracted amount paid to network providers for the covered service. If there is more than one contracted amount with network providers for the covered service, the amount is the median of these amounts. c. When a covered service is received from a non-network provider as approved or authorized by us, the eligible service expense is the negotiated fee, if any, that the provider has agreed to accept as payment in full (you will not be billed for the difference between the negotiated fee and the provider’s charge). ). If there is no negotiated fee agreed to by the provider with us, the eligible service expense is the greater of (1) the amount that would be paid by Medicare, or (2) the contracted amount paid to network providers for the covered service. If there is more than one contracted amount with network providers for the covered service, the amount is the median of these amounts. You may be billed for the difference between the amount paid and the provider’s charge. d. When a covered service expense that is not the result of an emergency is received from a non-network provider because at a facility that is a network provider and you do not have the ability and opportunity to choose an available network provider at such facility, the eligible service expense is the least of (1) the negotiated fee, if any, that has been mutually agreed upon by us and the provider as payment in full, (2) the amount accepted by the provider (not to exceed the provider’s charge), or supply (3) the usual and customary charge for similar services in the community where the covered services were provided. You will not be billed for the difference between the amount paid and the provider’s charge. e. When a covered service is received from a non-network provider that is not the result of a type an emergency and is not approved or authorized by us, and is not within the scope of services provided by any network provider, the eligible service expense is the negotiated fee, if any, that has been mutually agreed upon by us and the provider has agreed to accept as payment in full (you will not be billed for the difference between the negotiated fee and the provider’s charge). If there is no negotiated fee agreed to by the provider with us, the eligible service expense is the will be an amount that would be is no less than ten percentage points lower than the usual and customary percentage rate paid by Medicareto network providers. You may be billed for the difference between the amount paid and the provider’s charge. law. 1. Placing the health of the member (or, with respect to a pregnant womanpregnancy, the health of the woman member or her the unborn child) in serious jeopardy; 2. Serious impairment to bodily functions; or 3. Serious dysfunction of any bodily organ or part. With Respect to a pregnant womanpregnancy: 1. that there is inadequate time to effect a safe transfer to another hospital prior to delivery; 2. that the transfer may pose a threat to the health and safety of the patient or fetus; or 3. that there is evidence of the onset and persistence of uterine contractions or rupture of the membranes. Emergency services and care shall mean medical screening, examination, and evaluation by a physician, or, to the extent permitted by applicable law, by other appropriate personnel under the supervision of a physician, to determine if any emergency medical condition exists and, if it does, the care, treatment, or surgery for a covered service by a physician necessary to relieve or eliminate the emergency medical condition, within the service capability of a hospital. Follow-up care is not considered emergency care. Benefits are provided for treatment of emergency medical conditions and emergency screening and stabilization services without prior authorization. Benefits for emergency care include facility costs and physician services, and supplies and prescription drugs charged by that facility. You must notify us or verify that your physician has notified us of your admission to a hospital within 48 hours or as soon as possible within a reasonable period of time. When we are contacted, you will be notified whether the inpatient setting is appropriate, and if appropriate, the number of days considered medically necessary. By contacting us, you may avoid financial responsibility for any inpatient care that is determined to be not medically necessary under your plan. If your provider does not contract with us you will be financially responsible for any care we determine is not medically necessary. Care and treatment provided once you are medically stabilized is no longer considered emergency care. Continuation of care from a non- participating provider beyond that needed to evaluate or stabilize your condition in an emergency will be covered as a non-network service unless we authorize the continuation of care and it is medically necessary. Essential health benefits are defined by federal and state law and refer to benefits in at least the following categories: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management and pediatric services, including oral and vision care. Essential health benefits provided within this contract are not subject to lifetime or annual dollar maximums. Certain non-essential health benefits, however, are subject to either a lifetime and/or annual dollar maximum Expedited grievance means a grievance where any of the following applies: 1. The duration of the standard resolution process will result in serious jeopardy to the life or health of the claimant or the ability of the claimant to regain maximum functionmaximum. 2. In the opinion of a physician with knowledge of the claimant’s medical condition, the claimant is subject to severe pain that cannot be adequately managed without the care or treatment that is the subject of the grievance.