Common use of HOW YOUR PLAN WORKS Clause in Contracts

HOW YOUR PLAN WORKS. A. Care Management and Medical Management (Utilization Review) Community Health Options® (“Health Options”) is committed to ensuring Members receive high-quality, medically appropriate care. An important part of the Plan is our medical management services. Our medical management team performs utilization review of health services to ensure they are Medically Necessary, evidence-based and delivered in the most effective health care setting. If you are hospitalized, have complex or serious health conditions, or are transitioning from one health care facility to another, our team will review your situation and determine whether you may benefit from care management services. These services are provided to you at no additional Out-of-Pocket Cost. When you are hospitalized, our Medical Management team will monitor your care to ensure you receive high-quality services that are most appropriate for your condition. We will also work closely with the Hospital staff to help plan your discharge from the Hospital to help make it a smooth transition and provide you with access to the health care services that are most appropriate for your condition. Our clinical specialists and clinical navigators work closely with your Primary Care Provider and local care management teams to coordinate your care. Our clinical specialists and clinical navigators can coordinate your Specialist appointments and help you obtain prescribed care such as Durable Medical Equipment, medical supplies, or Prescription medications. Health Options applies objective and evidence-based criteria and takes individual circumstances and the local delivery system into account when determining the medical appropriateness of health care services. Under extraordinary circumstances that involve complex care or care management services the Plan may provide Benefits for services that are not listed in the “Covered Services” section 4.B. The Plan may also continue Covered Services beyond the contractual Benefit limit of this Agreement. These decisions are made on an individual basis and a decision to provide alternate services or continue Benefits is not precedent setting, and it does not obligate us to continue to provide those Benefits to you or any other Member in the future. We reserve the right, at any time, to change or stop providing alternate service Benefits or extended Benefits. Should we decide to change or stop your alternate services, we will notify you of that decision in writing. Members, their caregivers, Providers and local care managers can refer Members for care management services by contacting Member Services at 1-855-624-6463 Monday-Friday, 8am-6pm.

HOW YOUR PLAN WORKS. A. Care Management and Medical Management (Utilization Review) Community Health Options® (“Health Options”) is committed to ensuring Members receive high-quality, medically appropriate care. An important part of the Plan is our medical management services. Our medical management team performs utilization review of health services to ensure they are Medically Necessary, evidence-based and delivered in the most effective health care setting. If you are hospitalized, have complex or serious health conditions, or are transitioning from one health care facility to another, our team will review your situation and determine whether you may benefit from care management services. These services are provided to you at no additional Out-of-Pocket Cost. When you are hospitalized, our Medical Management team will monitor your care to ensure you receive high-quality services that are most appropriate for your condition. We will also work closely with the Hospital staff to help plan your discharge from the Hospital to help make it a smooth transition and provide you with access to the health care services that are most appropriate for your condition. Our clinical specialists and clinical navigators work closely with your Primary Care Provider and local care management teams to coordinate your care. Our clinical specialists and clinical navigators can coordinate your Specialist appointments and help you obtain prescribed care such as Durable Medical Equipment, medical supplies, or Prescription medications. Health Options applies objective and evidence-based criteria and takes individual circumstances and the local delivery system into account when determining the medical appropriateness of health care services. Under extraordinary circumstances that involve complex care or care management services the Plan may provide Benefits for services that are not listed in the “Covered Services” section 4.B. The Plan may also continue Covered Services beyond the contractual Benefit limit of this Agreement. These decisions are made on an individual basis and a decision to provide alternate services or continue Benefits is not precedent setting, and it does not obligate us to continue to provide those Benefits to you or any other Member in the future. We reserve the right, at any time, to change or stop providing alternate service Benefits or extended Benefits. Should we decide to change or stop your alternate services, we will notify you of that decision in writing. Members, their caregivers, Providers and local care managers can refer Members for care management services by contacting Member Services at 1-855-624-6463 Monday-Friday, 8am-6pm. The Medical Management team is available to receive after hours communication.

HOW YOUR PLAN WORKS. A. Care Management and Medical Management (Utilization Review) Community Health Options® (“Health Options”) Options is committed to ensuring Members receive high-qualityhigh‐quality, medically appropriate care. An important part of the Plan is our medical management services. Our medical management team performs utilization review of health services to ensure they are Medically Necessary, evidence-based evidence‐based and delivered in the most effective health care setting. If you are hospitalized, have complex or serious health conditions, or are transitioning from one health care facility to another, our team will review your situation and determine whether you may benefit from care management services. These services are provided to you at no additional Out-of-Pocket Out‐of‐Pocket Cost. When you are hospitalized, our Medical Management team will monitor your care to ensure you receive high-quality high‐quality services that are most appropriate for your condition. We will also work closely with the Hospital staff to help plan your discharge from the Hospital Hospital, to help make it a smooth transition and provide you with access to the health care services that are most appropriate for your condition. Our clinical specialists and clinical navigators work closely with your Primary Care Provider and local care management teams to coordinate your care. Our clinical specialists and clinical navigators can coordinate your Specialist appointments and help you obtain prescribed care such as Durable Medical Equipment, medical supplies, or Prescription medications. Community Health Options applies objective and evidence-based evidence‐based criteria and takes individual circumstances and the local delivery system into account when determining the medical appropriateness of health care services. Under extraordinary circumstances that involve complex care or care management services the Plan may provide Benefits for services that are not listed in the “Covered Services” section 4.B. The Plan may also continue Covered Services beyond the contractual Benefit limit of this Agreement. These decisions are made on an individual basis and a decision to provide alternate services or continue Benefits is not precedent setting, and it does not obligate us to continue to provide those Benefits to you or any other Member in the future. We reserve the right, at any time, to change or stop providing alternate service Benefits or extended Benefits. Should we decide to change or stop your alternate services, we will notify you of that decision in writing. Members, their caregivers, Providers Providers, and local care managers can refer Members for care management services by contacting Member Services Services. Chronic Condition Support (Disease Management) As an accredited Health Plan, we work with our Members and Providers to improve the health status of Members with chronic conditions. We believe it is important for you to work directly with your local healthcare Providers, and we are here to provide additional support when needed. The goal of Community Health Options’ Disease Management program is to empower our Members to effectively self‐ manage their chronic conditions. We believe each Member of our CO‐OP contributes to the overall health and wellbeing of our entire community of Members by actively engaging in their own healthcare. When each Member takes responsibility for doing as much as possible to improve his or her health and wellbeing, our entire CO‐OP benefits. We encourage you to engage with your Primary Care Provider, get recommended health screenings, follow evidence‐based, cost‐effective treatment that is prescribed by your Providers. If you have a chronic condition, be sure to see your Primary Care Provider or Specialist at 1-855-624-6463 Monday-Fridayleast once per year. This improves your health and wellbeing and our entire CO‐OP benefits by keeping healthcare costs as low as possible for everyone. Our Medical Management team monitors the health status of all of Members, 8am-6pmand we may contact you by mail, email or phone when we believe you may benefit from additional support. For additional information about Chronic Condition Support (Disease Management) please call Member Services.

HOW YOUR PLAN WORKS. A. Care Management and Medical Management (Utilization Review) Community Health Options® (“Health Options”) Options is committed to ensuring Members receive high-qualityhigh‐quality, medically appropriate care. An important part of the Plan is our medical management services. Our medical management team performs utilization review of health services to ensure they are Medically Necessary, evidence-based evidence‐based and delivered in the most effective health care setting. If you are hospitalized, have complex or serious health conditions, or are transitioning from one health care facility to another, our team will review your situation and determine whether you may benefit from care management services. These services are provided to you at no additional Out-of-Pocket Out‐of‐Pocket Cost. When you are hospitalized, our Medical Management team will monitor your care to ensure you receive high-quality high‐quality services that are most appropriate for your condition. We will also work closely with the Hospital staff to help plan your discharge from the Hospital Hospital, to help make it a smooth transition and provide you with access to the health care services that are most appropriate for your condition. Our clinical specialists and clinical navigators work closely with your Primary Care Provider and local care management teams to coordinate your care. Our clinical specialists and clinical navigators can coordinate your Specialist appointments and help you obtain prescribed care such as Durable Medical Equipment, medical supplies, or Prescription medications. Community Health Options applies objective and evidence-based evidence‐based criteria and takes individual circumstances and the local delivery system into account when determining the medical appropriateness of health care services. Under extraordinary circumstances that involve complex care or care management services the Plan may provide Benefits for services that are not listed in the “Covered Services” section 4.B. The Plan may also continue Covered Services beyond the contractual Benefit limit of this Agreement. These decisions are made on an individual basis and a decision to provide alternate services or continue Benefits is not precedent setting, and it does not obligate us to continue to provide those Benefits to you or any other Member in the future. We reserve the right, at any time, to change or stop providing alternate service Benefits or extended Benefits. Should we decide to change or stop your alternate services, we will notify you of that decision in writing. Members, their caregivers, Providers Providers, and local care managers can refer Members for care management services by contacting Member Services at 1-855-624-6463 Monday-Friday, 8am-6pmServices.

HOW YOUR PLAN WORKS. A. Care Management and Medical Management (Utilization Review) Community Health Options® (“Health Options”) is committed to ensuring Members receive high-quality, medically appropriate care. An important part of the Plan is our medical management services. Our medical management team performs utilization review of health services to ensure they are Medically Necessary, evidence-based and delivered in the most effective health care setting. If you are hospitalized, have complex or serious health conditions, or are transitioning from one health care facility to another, our team will review your situation and determine whether you may benefit from care management services. These services are provided to you at no additional Out-of-Pocket Cost. When you are hospitalized, our Medical Management team will monitor your care to ensure you receive high-high- quality services that are most appropriate for your condition. We will also work closely with the Hospital staff to help plan your discharge from the Hospital to help make it a smooth transition and provide you with access to the health care services that are most appropriate for your condition. Our clinical specialists and clinical navigators work closely with your Primary Care Provider and local care management teams to coordinate your care. Our clinical specialists and clinical navigators can coordinate your Specialist appointments and help you obtain prescribed care such as Durable Medical Equipment, medical supplies, or Prescription medications. Health Options applies objective and evidence-based criteria and takes individual circumstances and the local delivery system into account when determining the medical appropriateness of health care services. Under extraordinary circumstances that involve complex care or care management services the Plan may provide Benefits for services that are not listed in the “Covered Services” section 4.B. The Plan may also continue Covered Services beyond the contractual Benefit limit of this Agreement. These decisions are made on an individual basis and a decision to provide alternate services or continue Benefits is not precedent setting, and it does not obligate us to continue to provide those Benefits to you or any other Member in the future. We reserve the right, at any time, to change or stop providing alternate service Benefits or extended Benefits. Should we decide to change or stop your alternate services, we will notify you of that decision in writing. Members, their caregivers, Providers and local care managers can refer Members for care management services by contacting Member Services at 1-855-624-6463 Monday-Friday, 8am-6pm.

HOW YOUR PLAN WORKS. A. Care Management and Medical Management (Utilization Review) Community Health Options® (“Health Options”) is committed to ensuring Members receive high-quality, medically appropriate care. An important part of the Plan is our medical management services. Our medical management team performs utilization review of health services to ensure they are Medically Necessary, evidence-based and delivered in the most effective health care setting. If you are hospitalized, have complex or serious health conditions, or are transitioning from one health care facility to another, our team will review your situation and determine whether you may benefit from care management services. These services are provided to you at no additional Out-of-Pocket Cost. When you are hospitalized, our Medical Management team will monitor your care to ensure you receive high-high- quality services that are most appropriate for your condition. We will also work closely with the Hospital staff to help plan your discharge from the Hospital to help make it a smooth transition and provide you with access to the health care services that are most appropriate for your condition. Our clinical specialists and clinical navigators work closely with your Primary Care Provider and local care management teams to coordinate your care. Our clinical specialists and clinical navigators can coordinate your Specialist appointments and help you obtain prescribed care such as Durable Medical Equipment, medical supplies, or Prescription medications. SAMPLE Health Options applies objective and evidence-based criteria and takes individual circumstances and the local delivery system into account when determining the medical appropriateness of health care services. Under extraordinary circumstances that involve complex care or care management services the Plan may provide Benefits for services that are not listed in the “Covered Services” section 4.B. The Plan may also continue Covered Services beyond the contractual Benefit limit of this Agreement. These decisions are made on an individual basis and a decision to provide alternate services or continue Benefits is not precedent setting, and it does not obligate us to continue to provide those Benefits to you or any other Member in the future. We reserve the right, at any time, to change or stop providing alternate service Benefits or extended Benefits. Should we decide to change or stop your alternate services, we will notify you of that decision in writing. Members, their caregivers, Providers and local care managers can refer Members for care management services by contacting Member Services at 1-855-624-6463 Monday-Friday, 8am-6pm. The Medical Management team is available to receive after hours communication.