Common use of How to Use This Health Plan Clause in Contracts

How to Use This Health Plan. PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED. This Blue Shield health plan is designed for Members to obtain services from Blue Shield Participating Providers and MHSA Participating Providers. However, Members may choose to seek services from Non-Participating Providers for most services. Covered Services obtained from Non-Participating Providers will usually result in a higher share of cost for the Member. Some services are not covered unless rendered by a Participating Provider or MHSA Participating Provider. Please be aware that a provider’s status as a Participating Provider or an MHSA Participating Provider may change. It is the Member’s obligation to verify whether the provider chosen is a Participating Provider or an MHSA Participating Provider prior to obtaining coverage. Call Customer Service or visit xxx.xxxxxxxxxxxx.xxx to determine whether a provider is a Participating Provider. Call the MHSA to determine if a provider is an MHSA Participating Provider. See the sections below and the Summary of Benefits for more details. See the Out-of-Area Programs section for services outside of California. Blue Shield Participating Providers include primary care Physicians, specialists, Hospitals, Alternate Care Services Providers, and Other Providers that have a contractual relationship with Blue Shield. Participating Providers are listed in the Participating Provider directory.

How to Use This Health Plan. PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED. This Blue Shield health plan is designed for Members to obtain services from Blue Shield Participating Providers and MHSA Participating Providers. However, Members may choose to seek services from Non-Participating Providers for most services. Covered Services obtained from Non-Participating Providers will usually result in a higher share of cost for the Member. Some services are not covered unless rendered by a Participating Provider or MHSA Participating Provider. Please be aware that a provider’s status as a Participating Provider or an MHSA Participating Provider may change. It is the Member’s obligation to verify whether the provider chosen is a Participating Provider or an MHSA Participating Provider prior to obtaining coverage. Call Customer Service or visit xxx.xxxxxxxxxxxx.xxx to determine whether a provider is a Participating Provider. Call the MHSA to determine if a provider is an MHSA Participating Provider. See the sections below and the Summary of Benefits for more details. See the Out-of-Area Programs section for services outside of California. Blue Shield Participating Providers include primary care Physicians, specialists, Hospitals, and Alternate Care Services Providers, and Other Providers that have a contractual relationship with Blue ShieldShield to provide services to Members of this Plan. Participating Providers are listed in the Participating Provider directory.

How to Use This Health Plan. PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED. This Exclusive Provider Organization (EPO) benefit plan utilizes a network of Participating Providers. Except for Emergency Services or Urgent Services, or when authorized by Blue Shield health plan is designed for Shield, Members to must obtain services care from Blue Shield a Participating Providers Provider. Mental Health and Substance Abuse Services must be obtained from MHSA Participating Providers. However, Members may choose to seek services The EPO benefit plan does not provide benefits for non- Emergency or non-Urgent Services from Non-Participating Providers or Non-Preferred Providers. Also, the Plan provides no benefits for most services. Covered non-Emergency or non-Urgent Mental Health and Substance Abuse Services obtained from when rendered by MHSA Non-Participating Providers will usually result in a higher share of cost for the Member. Some services are not covered unless rendered by a Participating Provider or MHSA Participating ProviderProviders. Please be aware that a provider’s status as a Participating Provider or an MHSA Participating Provider may change. It is the Member’s obligation to verify whether the provider chosen is a Participating Provider or an MHSA Participating Provider prior to obtaining coverage. Call Customer Service or visit xxx.xxxxxxxxxxxx.xxx to determine whether a provider is a Participating Provider. Call the MHSA to determine if a provider is an MHSA Participating Provider. See the sections below and the Summary of Benefits for more details. See the Out-of-Area Programs section for services outside of California. Blue Shield Participating Providers include primary care Physicians, specialists, Hospitals, Alternate Care Services Providers, and Other Providers that have a contractual relationship with Blue Shield. Participating Providers are listed in the Participating Provider directory. Except for Emergency Services or Urgent Services or when authorized by Blue Shield, all Covered Services must be provided by a Participating Provider (or an MHSA Participating Provider for Mental Health Services or Substance Abuse Services). Participating Providers agree to accept Blue Shield’s payment, plus the Member’s payment of any applicable Deductibles, Copayments, and Coinsurance or amounts in excess of specified Benefit maximums as payment-in-full for Covered Services, except as provided under the Exception for Other Coverage and the Reductions-Third Party Liability sections. Payment for Emergency Services rendered by a Physician or Hospital that is not a Participating Provider will be based on Blue Shield’s Allowable Amount and will be paid at the Participating level of Benefits. The Member is responsible for notifying Blue Shield within 24 hours, or as soon as reasonably possible following medical stabilization of the emergency condition. The Member should contact Member Services if the Member needs assistance locating a provider in the Member’s Service Area. The Plan will review and consider a Member’s request for services that cannot be reasonably obtained in network. If a Member’s request for services from a Non-Participating Provider is approved at an in- network benefit level, the Plan will pay for Covered Services at a Participating Provider level. Please call Customer Service or visit xxx.xxxxxxxxxxxx.xxx to determine whether a provider is a Participating Provider. For Mental Health Services and Substance Abuse Services, Blue Shield has contracted with a Mental Health Service Administrator (MHSA). The MHSA is a specialized health care service plan licensed by the California Department of Managed Health Care, and will underwrite and deliver Blue Shield’s Mental Health and Substance Abuse Services through a separate network of MHSA Participating Providers. Except for Emergency Services or Urgent Services or when authorized by the MHSA, all covered Mental Health and Substance Abuse Services must be provided by an MHSA Participating Provider. MHSA Participating Providers are those providers who participate in the MHSA network and have contracted with the MHSA to provide Mental Health Services and Substance Abuse Services to Members. A Blue Shield Participating Provider may not be an MHSA Participating Provider. It is the Member’s responsibility to ensure that the provider selected for Mental Health and Substance Abuse Services is an MHSA Participating Provider. MHSA Participating Providers are identified in the Blue Shield Behavioral Health Provider Directory. Additionally, Members may contact the MHSA directly by calling 1-877- 000-0000.

How to Use This Health Plan. PLEASE READ THE FOLLOWING INFORMATION INFORMA- TION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED. This Blue Shield health plan Health Plan is designed for Members Mem- bers to obtain services from Blue Shield Participating Participat- ing Providers and MHSA Participating Providers. However, Members may choose to seek services from Non-Participating Providers for most servicesser- vices. Covered Services obtained from Non-Participating Par- ticipating Providers will usually result in a higher share of cost for the Member. Some services are not covered unless rendered by a Participating Provider or MHSA Participating Provider. Please be aware that a provider’s status as a Participating Partic- ipating Provider or an MHSA Participating Provider may change. It is the Member’s obligation obliga- tion to verify whether the provider chosen is a Participating Par- ticipating Provider or an MHSA Participating Provider prior to obtaining coverage. Call Customer Service or visit xxx.xxxxxxxxxxxx.xxx to determine whether a provider is a Participating Provider. Call the MHSA to determine if a provider is an MHSA Participating Par- ticipating Provider. See the sections below and the Summary of Benefits for more details. See the Out-of-Area Programs Services section for services outside of California. Blue Shield Participating Providers include primary pri- xxxx care Physicians, specialists, Hospitals, and Alternate Care Services Providers, and Other Providers that have a contractual con- tractual relationship with Blue Shield. Participating Participat- ing Providers are listed in the Participating Provider directory. Participating Providers agree to accept Blue Shield’s payment, plus the Member’s payment of any applicable Deductibles, Copayments, Coinsur- ance or amounts in excess of specified Benefit maximums as payment-in-full for Covered Ser- vices, except as provided under the Exception for Other Coverage and the Reductions – Third Party Liability sections. This is not true of Non-Partici- pating Providers. If a Member receives services from a Non-Partici- pating Provider, Blue Shield’s payment for that service may be substantially less than the amount billed. The Subscriber is responsible for the differ- ence between the amount Blue Shield pays and the amount billed by the Non-Participating Provider. If a Member receives services at a facility that is a Participating Provider, Blue Shield’s payment for Covered Services provided by a health profes- sional at the Participating Provider facility will be paid at the Participating Provider level of Benefits, whether the health professional is a Participating Provider or Non-Participating Provider. The Mem- ber’s share of cost will not exceed the Copayment or Coinsurance due to a participating Provider un- der similar circumstances. Some services are covered only if rendered by a Participating Provider. In these instances, using a Non-Participating Provider could result in a higher share of cost to the Member or no payment by Blue Shield for the services received. Payment for Emergency Services rendered by x Please call Customer Service or visit xxx.xxxxxxxxxxxx.xxx to determine whether a provider is a Participating Provider. For Mental Health Services and Substance Use Disorder Services, Blue Shield has contracted with a Mental Health Service Administrator (MHSA). The MHSA is a specialized health care service plan licensed by the California Department of Managed Health Care, and will underwrite and de- liver Blue Shield’s Mental Health Services and Substance Use Disorder Services through a sepa- rate network of MHSA Participating Providers. MHSA Participating Providers are those providers who participate in the MHSA network and have contracted with the MHSA to provide Mental Health and Substance Use Disorder Services to Blue Shield Members. A Blue Shield Participating Provider may not be an MHSA Participating Provider. It is the Member’s responsibility to en- sure that the provider selected for Mental Health and Substance Use Disorder Services is an MHSA Participating Provider. MHSA Participating Providers are identified in the Blue Shield Behav- ioral Health Provider Directory. Additionally, Members may contact the MHSA directly by call- ing 0-000-000-0000. If a Member receives services at a facility that is an MHSA Participating Provider, MHSA’s pay- ment for Mental Health and Substance Use Disor- der Services provided by a health professional at the MHSA Participating Provider facility will be paid at the MHSA Participating Provider level of Benefits, whether the health professional is an MHSA Participating Provider or MHSA Non-Par- ticipating Provider. The Member’s share of cost will not exceed the Copayment or Coinsurance due to an MHSA Participating Provider under similar circumstances. Physician or Hospital that is not a Participating Provider will be based on Blue Shield’s Allowable Amount and will be paid at the Participating level of Benefits. The Member is responsible for notify- ing Blue Shield within 24 hours, or as soon as rea- sonably possible following medical stabilization of the emergency condition.

How to Use This Health Plan. PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED. This Exclusive Provider Organization (EPO) benefit plan utilizes a network of Participating Providers. Except for Emergency Services or Urgent Services, or when authorized by Blue Shield health plan is designed for Shield, Members to must obtain services care from Blue Shield a Participating Providers Provider. Mental Health and Substance Abuse Services must be obtained from MHSA Participating Providers. However, Members may choose to seek services The EPO benefit plan does not provide benefits for non- Emergency or non-Urgent Services from Non-Participating Providers or Non-Preferred Providers. Also, the Plan provides no benefits for most services. Covered non-Emergency or non-Urgent Mental Health and Substance Abuse Services obtained from when rendered by MHSA Non-Participating Providers will usually result in a higher share of cost for the Member. Some services are not covered unless rendered by a Participating Provider or MHSA Participating ProviderProviders. Please be aware that a provider’s status as a Participating Provider or an MHSA Participating Provider may change. It is the Member’s obligation to verify whether the provider chosen is a Participating Provider or an MHSA Participating Provider prior to obtaining coverage. Call Customer Service or visit xxx.xxxxxxxxxxxx.xxx to determine whether a provider is a Participating Provider. Call the MHSA to determine if a provider is an MHSA Participating Provider. See the sections below and the Summary of Benefits for more details. See the Out-of-Area Programs section for services outside of California. Blue Shield Participating Providers include primary care Physicians, specialists, Hospitals, Alternate Care Services Providers, and Other Providers that have a contractual relationship with Blue Shield. Participating Providers are listed in the Participating Provider directory. Except for Emergency Services or urgent services or when authorized by Blue Shield, all Covered Services must be provided by a Participating Provider (or an MHSA Participating Provider for Mental Health Services or Substance Abuse Services). Participating Providers agree to accept Blue Shield’s payment, plus the Member’s payment of any applicable Deductibles, Copayments, and Coinsurance or amounts in excess of specified Benefit maximums as payment-in-full for Covered Services, except as provided under the Exception for Other Coverage and the Reductions-Third Party Liability sections. Payment for Emergency Services rendered by a Physician or Hospital that is not a Participating Provider will be based on Blue Shield’s Allowable Amount and will be paid at the Participating level of Benefits. The Member is responsible for notifying Blue Shield within 24 hours, or as soon as reasonably possible following medical stabilization of the emergency condition. The Member should contact Member Services if the Member needs assistance locating a provider in the Member’s Service Area. The Plan will review and consider a Member’s request for services that cannot be reasonably obtained in network. If a Member’s request for services from a Non-Participating Provider is approved at an in- network benefit level, the Plan will pay for Covered Services at a Participating Provider level. Please call Customer Service or visit xxx.xxxxxxxxxxxx.xxx to determine whether a provider is a Participating Provider. For Mental Health Services and Substance Abuse Services, Blue Shield has contracted with a Mental Health Service Administrator (MHSA). The MHSA is a specialized health care service plan licensed by the California Department of Managed Health Care, and will underwrite and deliver Blue Shield’s Mental Health and Substance Abuse Services through a separate network of MHSA Participating Providers. Except for Emergency Services or urgent services or when authorized by the MHSA, all covered Mental Health and Substance Abuse Services must be provided by an MHSA Participating Provider. MHSA Participating Providers are those providers who participate in the MHSA network and have contracted with the MHSA to provide Mental Health Services and Substance Abuse Services to Blue Shield Members. A Blue Shield Participating Provider may not be an MHSA Participating Provider. It is the Member’s responsibility to ensure that the provider selected for Mental Health and Substance Abuse Services is an MHSA Participating Provider. MHSA Participating Providers are identified in the Blue Shield Behavioral Health Provider Directory. Additionally, Members may contact the MHSA directly by calling 0-000-000-0000.

How to Use This Health Plan. PLEASE READ THE FOLLOWING INFORMATION INFORMA- TION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED. This Blue Shield health plan Health Plan is designed for Members Mem- bers to obtain services from Blue Shield Participating Participat- ing Providers and MHSA Participating Providers. However, Members may choose to seek services from Non-Participating Providers for most servicesser- vices. Covered Services obtained from Non-Participating Par- ticipating Providers will usually result in a higher share of cost for the Member. Some services are not covered unless rendered by a Participating Provider or MHSA Participating Provider. Please be aware that a provider’s status as a Participating Partic- ipating Provider or an MHSA Participating Provider may change. It is the Member’s obligation obliga- tion to verify whether the provider chosen is a Participating Par- ticipating Provider or an MHSA Participating Provider prior to obtaining coverage. Call Customer Service or visit xxx.xxxxxxxxxxxx.xxx to determine whether a provider is a Participating Provider. Call the MHSA to determine if a provider is an MHSA Participating Par- ticipating Provider. See the sections below and the Summary of Benefits for more details. See the Out-of-Area Programs Services section for services outside of California. Blue Shield Participating Providers include primary pri- xxxx care Physicians, specialists, Hospitals, and Alternate Care Services Providers, and Other Providers that have a contractual con- tractual relationship with Blue Shield. Participating Participat- ing Providers are listed in the Participating Provider directory. Participating Providers agree to accept Blue Shield’s payment, plus the Member’s payment of any applicable Deductibles, Copayments, Coinsur- ance or amounts in excess of specified Benefit maximums as payment-in-full for Covered Ser- vices, except as provided under the Exception for Other Coverage and the Reductions – Third Party Liability sections. This is not true of Non-Partici- pating Providers. If a Member receives services from a Non-Partici- pating Provider, Blue Shield’s payment for that service may be substantially less than the amount billed. The Subscriber is responsible for the differ- ence between the amount Blue Shield pays and the amount billed by the Non-Participating Provider. If a Member receives services at a facility that is a Participating Provider, Blue Shield’s payment for Covered Services provided by a health profes- sional at the Participating Provider facility will be paid at the Participating Provider level of Benefits, whether the health professional is a Participating Provider or Non-Participating Provider. The Mem- ber’s share of cost will not exceed the Copayment or Coinsurance due to a participating Provider un- der similar circumstances. Some services are covered only if rendered by a Participating Provider. In these instances, using a Non-Participating Provider could result in a higher share of cost to the Member or no payment by Blue Shield for the services received. Payment for Emergency Services rendered by a Physician or Hospital that is not a Participating Provider will be based on Blue Shield’s Allowable Amount and will be paid at the Participating level of Benefits. The Member is responsible for notify- ing Blue Shield within 24 hours, or as soon as rea- sonably possible following medical stabilization of the emergency condition. Please call Customer Service or visit xxx.xxxxxxxxxxxx.xxx to determine whether a provider is a Participating Provider. For Mental Health Services and Substance Use Disorder Services, Blue Shield has contracted with a Mental Health Service Administrator (MHSA). The MHSA is a specialized health care service plan licensed by the California Department of Managed Health Care, and will underwrite and de- liver Blue Shield’s Mental Health Services and Substance Use Disorder Services through a sepa- rate network of MHSA Participating Providers. MHSA Participating Providers are those providers who participate in the MHSA network and have contracted with the MHSA to provide Mental Health and Substance Use Disorder Services to Blue Shield Members. A Blue Shield Participating Provider may not be an MHSA Participating will not exceed the Copayment or Coinsurance due to an MHSA Participating Provider under similar circumstances. Continuity of care with a Non-Participating Provider is available for the following Members: for Members who are currently seeing a provider who is no longer in the 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 children who are up to 36 months old, or for Members who have received authorization from a now-termi- nated provider for surgery or another procedure as part of a documented course of 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. Provider. It is the Member’s responsibility to en- sure that the provider selected for Mental Health and Substance Use Disorder Services is an MHSA Participating Provider. MHSA Participating Providers are identified in the Blue Shield Behav- ioral Health Provider Directory. Additionally, Members may contact the MHSA directly by call- ing 0-000-000-0000. If a Member receives services at a facility that is an MHSA Participating Provider, MHSA’s pay- ment for Mental Health and Substance Use Disor- der Services provided by a health professional at the MHSA Participating Provider facility will be paid at the MHSA Participating Provider level of Benefits, whether the health professional is an MHSA Participating Provider or MHSA Non-Par- ticipating Provider. The Member’s share of cost 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 second medical opinion. The Member’s at- tending Physician may also offer a referral to an- other Physician for a second opinion. The second opinion visit is subject to the applica- ble Copayment, Coinsurance, Calendar Year De- ductible and all Plan Contract Benefit limitations and exclusions. State law requires that health plans disclose to Members, upon request, the timelines for respond- ing to a request for a second medical opinion. To request a copy of these timelines, you may call the Customer Service Department at the number pro- vided on the back page of this EOC.