Common use of Keep Your Plan Informed of Address Changes Clause in Contracts

Keep Your Plan Informed of Address Changes. In order to protect your family’s rights, you should keep the Plan Administrator informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. PLAN CONTACT INFORMATION Contact your employer for the name, address and telephone number of the party responsible for administering your COBRA continuation coverage. This group health plan believes this plan is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to your Employer or the Plan Administrator. If your health plan is subject to the Employee Retirement Income Security Act (ERISA),you may also contact the Employee Benefits Security Administration, U.S. Department of Labor at 0-000-000-0000 or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx. This website has a table summarizing which protections do and do not apply to grandfathered health plans. For non- federal governmental plans, inquires may be directed to the U.S. Department of Health and Human Services at xxx.xxxxxxxxxxxx.xxx. ALTHOUGH HEALTH CARE SERVICES MAY BE OR HAVE BEEN PROVIDED TO YOU AT A HEALTH CARE FACILITY THAT IS A MEMBER OF THE PROVIDER NETWORK USED BY YOUR HEALTH BENEFIT PLAN, OTHER PROFESSIONAL SERVICES MAY BE OR HAVE BEEN PROVIDED AT OR THROUGH THE FACILITY BY PHYSICIANS AND OTHER HEALTH CARE PRACTITIONERS WHO ARE NOT MEMBERS OF THAT NETWORK. YOU MAY BE RESPONSIBLE FOR PAYMENT OF ALL OR PART OF THE FEES FOR THOSE PROFESSIONAL SERVICES THAT ARE NOT PAID OR COVERED BY YOUR HEALTH BENEFIT PLAN. This notice is to advise you of certain coverage/benefits provided by your contract with Blue Cross and Blue Shield of Texas (HMO) and is required by legislation to be provided to you. If you have questions regarding this notice, call Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, at 1- 877- 299- 2377 or write us at P.O. Box 660044, Dallas, Texas 75266- 0044.

Keep Your Plan Informed of Address Changes. In order to protect your family’s 's rights, you should keep the Plan Administrator informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. PLAN CONTACT INFORMATION Contact your employer for the name, address and telephone number of the party responsible for administering your COBRA continuation coverage. NOTICE This group health plan believes this plan is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to your Employer or the Plan Administrator. If your health plan is subject to the Employee Retirement Income Security Act (ERISA),you may also contact the Employee Benefits Security Administration, U.S. Department of Labor at 0-000-000-0000 or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx. This website has a table summarizing which protections do and do not apply to grandfathered health plans. For non- non-federal governmental plans, inquires may be directed to the U.S. Department of Health and Human Services at xxx.xxxxxxxxxxxx.xxx. ALTHOUGH HEALTH CARE SERVICES MAY BE OR HAVE BEEN PROVIDED TO YOU AT A HEALTH CARE FACILITY THAT IS A MEMBER OF THE PROVIDER NETWORK USED BY YOUR HEALTH BENEFIT PLAN, OTHER PROFESSIONAL SERVICES MAY BE OR HAVE BEEN PROVIDED AT OR THROUGH THE FACILITY BY PHYSICIANS AND OTHER HEALTH CARE PRACTITIONERS WHO ARE NOT MEMBERS OF THAT NETWORK. YOU MAY BE RESPONSIBLE FOR PAYMENT OF ALL OR PART OF THE FEES FOR THOSE PROFESSIONAL SERVICES THAT ARE NOT PAID OR COVERED BY YOUR HEALTH BENEFIT PLAN. This notice is to advise you of certain coverage/coverage and/or benefits provided by your HMO contract with Blue Cross and Blue Shield of Texas (HMO) and is required by legislation to be provided to you. If you have questions regarding this notice, call Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, at 1- 877- 299- 2377 or write us at P.O. Box 660044, Dallas, Texas 75266- 0044.

Keep Your Plan Informed of Address Changes. In order to protect your family’s rights, you should keep the Plan Administrator informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. PLAN CONTACT INFORMATION Contact your employer for the name, address and telephone number of the party responsible for administering your COBRA continuation coverage. This group health plan believes this plan is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to your Employer or the Plan Administrator. If your health plan is subject to the Employee Retirement Income Security Act (ERISA),you may also contact the Employee Benefits Security Administration, U.S. Department of Labor at 0-000-000-0000 or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx. This website has a table summarizing which protections do and do not apply to grandfathered health plans. For non- federal governmental plans, inquires may be directed to the U.S. Department of Health and Human Services at xxx.xxxxxxxxxxxx.xxx. ALTHOUGH HEALTH CARE SERVICES MAY BE OR HAVE BEEN PROVIDED TO YOU AT A HEALTH CARE FACILITY THAT IS A MEMBER OF THE PROVIDER NETWORK USED BY YOUR HEALTH BENEFIT PLAN, OTHER PROFESSIONAL SERVICES MAY BE OR HAVE BEEN PROVIDED AT OR THROUGH THE FACILITY BY PHYSICIANS AND OTHER HEALTH CARE PRACTITIONERS WHO ARE NOT MEMBERS OF THAT NETWORK. YOU MAY BE RESPONSIBLE FOR PAYMENT OF ALL OR PART OF THE FEES FOR THOSE PROFESSIONAL SERVICES THAT ARE NOT PAID OR COVERED BY YOUR HEALTH BENEFIT PLAN. This notice Notice is to advise You that in addition to the processes outlined in COMPLAINT AND APPEAL PROCEDURES section of the Certificate and in the Plan Description and Member Handbook, you have the right to seek and obtain a full and fair review by HMO of any Adverse Benefit Determinations made by HMO in accordance with the benefits and procedures detailed in Your Certificate. Review of Claim Determinations Claim Determinations. When HMO receives a properly submitted claim, it has authority and discretion under the plan to interpret and determine benefits in accordance with the plan provisions. You have the right to seek and obtain a full and fair review by HMO of any determination of a claim, any determination of a request for preauthorization, or any other determination made by HMO in accordance with the benefits and procedures detailed in Your plan. If a Claim is Denied or Not Paid in Full. If the claim is denied in whole or in part, You will receive a written notice from HMO with the following information, if applicable:  The reasons for the determination;  A reference to the benefit Plan provisions on which the determination is based, or the contractual, administrative or protocol basis for the determination;  A description of additional information which may be necessary to perfect the claim and an explanation of why such material is necessary;  Subject to privacy laws and other restrictions, if any, the identification of the claim, date of service, health care provider, claim amount (if applicable), and a statement describing denial codes with their meanings and the standards used. Upon request, diagnosis/treatment codes with their meanings and the standards used are also available;  An explanation of HMO’s internal review/appeals and external review processes (and how to initiate a review/appeal or external review) and a statement of Your right, if any, to bring a civil action under Section 502(a) of ERISA following a final denial on internal review/appeal;  In certain coverage/benefits situations, a statement in non-English language(s) that written notice of claim denials and certain other benefit information may be available (upon request) in such non-English language(s);  In certain situations, a statement in non- English language(s) that indicates how to access the language services provided by your contract with Blue Cross HMO;  The right to request, free of charge, reasonable access to and Blue Shield copies of Texas (HMO) all documents, records and is required by legislation other information relevant to the claim for benefits;  Any internal rule, guideline, protocol or other similar criterion relied on in the determination, and a statement that a copy of such rule, guideline, protocol or other similar criterion will be provided free of charge on request;  An explanation of the scientific or clinical judgment relied on in the determination as applied to you. If you have questions regarding this noticeclaimant’s medical circumstances, call Blue Cross and Blue Shield if the denial was based on medical necessity, experimental treatment or similar exclusion, or a statement that such explanation will be provided free of Texascharge upon request;  In the case of a denial of an urgent care clinical claim, a Division description of Health the expedited review procedure applicable to such claim. An urgent care clinical claim decision may be provided orally, so long as a written notice is furnished to the claimant within 3 days of oral notification; and  Contact information for applicable office of health insurance consumer assistance or ombudsman. Timing of Required Notices and Extensions. Separate schedules apply to the timing of required notices and extensions, depending on the type of claim. There are three types of claims as defined below.  Urgent Care Clinical Claim is any pre-service claim that requires preauthorization, as described in this Certificate, for benefits for medical care or treatment with respect to which the application of regular time periods for making health claim decisions could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function or, in the opinion of a Physician with knowledge of the claimant’s medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment.  Pre-Service CorporationClaim is any non-urgent request for benefits or a determination with respect to which the terms of the benefit Plan condition receipt of the benefit on approval of the benefit in advance of obtaining medical care.  • Post-Service Claim is notification in a form acceptable to HMO that a service has been rendered or furnished to You. This notification must include full details of the service received, including Your name, age, sex, identification number, the name and address of the Provider, an itemized statement of the service rendered or furnished, the date of service, the diagnosis, the claim charge, and any other information which HMO may request in connection with services rendered to You. Urgent Care Clinical Claims* Type of Notice or Extension Timing If Your claim is incomplete, HMO must notify You within: 24 hours If You are notified that Your claim is incomplete, You must then provide completed claim information to HMO within: 48 hours after receiving notice HMO must notify You of the claim determination (whether adverse or not): if the initial claim is complete as soon as possible (taking into account medical exigencies), but no later than: 72 hours after receiving the completed claim (if the initial claim is incomplete), within: 48 hours * You do not need to submit Urgent Care Clinical Claims in writing. You should call HMO at 1- 877- 299- 2377 the toll- free number listed on the back of Your identification card as soon as possible to submit an Urgent Care Clinical Claim. Pre- Service Claims Type of Notice or write us at P.O. Box 660044Extension Timing If Your claim is filed improperly, DallasHMO must notify You within: 5 days If Your claim is incomplete, Texas 75266- 0044HMO must notify You within: 15 days If You are notified that Your claim is incomplete, You must then provide completed claim information to HMO within: 45 days after receiving notice HMO must notify You of the claim determination (whether adverse or not): if the initial claim is complete, within: 15 days* after receiving the completed claim (if the initial claim is incomplete), within: 30 days If You require post- stabilization care after an Emergency within: the time appropriate to the circumstance not to exceed one hour after the time of request * This period may be extended one time by HMO for up to 15 days, provided that HMO both (1) determines that such an extension is necessary due to matters beyond the control of the Plan and (2) notifies You, prior to the expiration of the initial 15- day period, of the circumstances requiring the extension of time and the date by which HMO expects to render a decision. Post- Service Claims Type of Notice or Extension Timing If Your claim is incomplete, HMO must notify You within: 30 days If You are notified that Your claim is incomplete, You must then provide completed claim information to HMO within: 45 days after receiving notice HMO must notify You of any adverse claim determination: if the initial claim is complete, within: 30 days* after receiving the completed claim (if the initial claim is incomplete), within: 45 days * This period may be extended one time by HMO for up to 15 days, provided that HMO both (1) determines that such an extension is necessary due to matters beyond the control of the Plan and (2) notifies You in writing, prior to the expiration of the initial 30- day period, of the circumstances requiring the extension of time and the date by which HMO expects to render a decision.

Keep Your Plan Informed of Address Changes. In order to protect your family’s rights, you should keep the Plan Administrator informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. PLAN CONTACT INFORMATION Contact your employer for the name, address and telephone number of the party responsible for administering your COBRA continuation coverage. Form No. 0009.443 2 Stock No. 0009.443- 0804 This group health plan believes this plan certificate of coverage is only a “grandfathered health plan” under the Patient Protection representative sample and Affordable Care Act (the Affordable Care Act)does not constitute an actual insurance policy or contract. As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to your Employer or the Plan Administrator. If your health plan is subject to the Employee Retirement Income Security Act (ERISA),you may also contact the Employee Benefits Security Administration, U.S. Department of Labor at 0-000-000-0000 or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx. This website has a table summarizing which protections do and do not apply to grandfathered health plans. For non- federal governmental plans, inquires may be directed to the U.S. Department of Health and Human Services at xxx.xxxxxxxxxxxx.xxx. ALTHOUGH HEALTH CARE SERVICES MAY BE OR HAVE BEEN PROVIDED TO YOU AT A HEALTH CARE FACILITY THAT IS A MEMBER HIPAA NOTICE OF THE PROVIDER NETWORK USED BY YOUR HEALTH BENEFIT PLAN, OTHER PROFESSIONAL SERVICES MAY BE OR HAVE BEEN PROVIDED AT OR THROUGH THE FACILITY BY PHYSICIANS AND OTHER HEALTH CARE PRACTITIONERS WHO ARE NOT MEMBERS OF THAT NETWORK. PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE RESPONSIBLE FOR PAYMENT OF ALL OR PART OF THE FEES FOR THOSE PROFESSIONAL SERVICES THAT ARE NOT PAID OR COVERED BY YOUR HEALTH BENEFIT PLANUSED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY. Our Responsibilities Sample We are required by applicable federal and state law to maintain and safeguard the privacy of your Protected Health Information (PHI). PHI is information in any format (electronic, paper, or verbal), about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition or the payment or provision of related health care services. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your PHI. We must follow the privacy practices that are described in this notice while it is in effect. This notice is takes effect September 23, 2013 and will remain in effect until we replace it. We reserve the right to advise change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all PHI that we maintain, including PHI we created or received before we made the changes. Before we make a material change in our privacy practices, we will change this notice and make the new notice available to you as required under the law. For more information about our privacy practices, or for additional copies of certain coverage/benefits provided by this notice, please contact us using the information listed at the end of this notice. Use and Disclosure of Your Protected Health Information We use and disclose PHI about you for treatment, payment, and health care operations. The following are examples of the types of uses and disclosures that we are permitted to make. Treatment: We may use or disclose your contract with Blue Cross and Blue Shield of Texas (HMO) and is required by legislation PHI to be provided a physician or other health care provider providing treatment to you. If you have questions regarding this notice, call Blue Cross and Blue Shield of Texas, We may use or disclose your PHI to a Division of Health Care Service Corporation, at 1- 877- 299- 2377 or write us at P.O. Box 660044, Dallas, Texas 75266- 0044health care provider so that we can make prior authorization decisions under your benefit plan.

Keep Your Plan Informed of Address Changes. In order to protect your family’s rights, you should keep the Plan Administrator informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. PLAN CONTACT INFORMATION Contact your employer for the name, address and telephone number of the party responsible for administering your COBRA continuation coverage. This group health plan believes this plan is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. Sample Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to your Employer or the Plan Administrator. If your health plan is subject to the Employee Retirement Income Security Act (ERISA),you may also contact the Employee Benefits Security Administration, U.S. Department of Labor at 0-000-000-0000 or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx. This website has a table summarizing which protections do and do not apply to grandfathered health plans. For non- federal governmental plans, inquires may be directed to the U.S. Department of Health and Human Services at xxx.xxxxxxxxxxxx.xxx. Sample ALTHOUGH HEALTH CARE SERVICES MAY BE OR HAVE BEEN PROVIDED TO YOU AT A HEALTH CARE FACILITY THAT IS A MEMBER OF THE PROVIDER NETWORK USED BY YOUR HEALTH BENEFIT PLAN, OTHER PROFESSIONAL SERVICES MAY BE OR HAVE BEEN PROVIDED AT OR THROUGH THE FACILITY BY PHYSICIANS AND OTHER HEALTH CARE PRACTITIONERS WHO ARE NOT MEMBERS OF THAT NETWORK. YOU MAY BE RESPONSIBLE FOR PAYMENT OF ALL OR PART OF THE FEES FOR THOSE PROFESSIONAL SERVICES THAT ARE NOT PAID OR COVERED BY YOUR HEALTH BENEFIT PLAN. This notice is to advise you of certain coverage/benefits provided by your contract with Blue Cross and Blue Shield of Texas (HMO) and is required by legislation to be provided to you. If you have questions regarding this notice, call Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, at 1- 877- 299- 2377 or write us at P.O. Box 660044, Dallas, Texas 75266- 0044.