Common use of Non-Network Providers Clause in Contracts

Non-Network Providers. Non-Emergency Covered Services from a Non-Network Provider are not covered. It is your responsibility to ensure the Providers you receive services from are in the Health Options Network. In cases where a Network Provider is not available within certain time and distance standards from your residence within the Service Area, Health Options may approve your visit to a Non-Network Provider if you contact us and obtain approval beforehand. In this case, charges for the visit will be applied to your In-Network cost-sharing up to the Maximum Allowable Amount. When you receive services for a Medical Emergency, your Out-of-Pocket Costs (up to the Maximum Allowable Amount determined by Health Options) will be at the Network Provider level whether you see a Network Provider or a Non-Network Provider. Charges from Non-Network Providers above the Maximum Allowable Amount will not apply to your cost-sharing and will be your responsibility, if the Non-Network Provider chooses to bill you (known as balance billing). This means you may have financial responsibility greater than the cost- sharing described on your Schedule of Benefits. When there is an inadequate network, balance billing does not apply. Before you receive a service, you may call Community Health Options® (“Health Options”) toll-free at 1-855-624- 6463 (TTY/TDD: 711) to learn the network status of the provider. If we deny your claim, you have the right to appeal our decision by following the steps in section 8. For Medical Emergency services rendered by a Non- Network Provider, the Plan will provide Benefits at Network Provider Out-of-Pocket Costs based on the Maximum Allowable Amount, as determined by us, for the services received. In the event of a Surprise Bill Health Options will reimburse an Out-of-Network provider at the average network rate under an enrollee’s plan unless the carrier and provider agree otherwise.

Non-Network Providers. Non-Emergency Non‐Emergency Covered Services from a Non-Network Non‐Network Provider are not covered. It is your responsibility to ensure the Providers you receive services from are in the Community Health Options Network. In cases cases, including Second Opinions, where a Network Provider is not available within certain time and distance standards from your residence within the Service Area, Community Health Options may approve your visit to a Non-Network Non‐Network Provider if you contact us and obtain approval beforehand. In this caseIf a Second Opinion is sought from a Non‐Network Provider because a Network Provider is not available, charges for the visit cost‐ sharing will be applied to your In-Network cost-sharing up to as if the Maximum Allowable Amountservice were obtained from an In‐Network Provider. When there is an inadequate network, balance billing does not apply. When you receive services for a Medical Emergency, your Out-of-Pocket Out‐of‐Pocket Costs (up to the Maximum Allowable Amount determined by Community Health Options) will be at the Network Provider level whether you see a Network Provider or a Non-Network Non‐Network Provider. Charges from Non-Network Providers above the Maximum Allowable Amount will not apply to your cost-sharing and will be your responsibilityOut‐of‐pocket costs for emergency services rendered by a non‐network provider only include any applicable Deductible, if the Non-Network Provider chooses to bill you (known as balance billing). This means you may have financial responsibility greater than the cost- sharing described on your Schedule of Benefits. When there is an inadequate networkCoinsurance, balance billing does not applyor Copayment. Before you receive a service, you may call Community Health Options® (“Health Options”) toll-free at 1-855-624- 6463 (TTY/TDD: 711) Options to learn the network status of the provider. If we deny your claim, you have the right to appeal our decision by following the steps in section 8. For Medical Emergency services rendered by a Non- Network Non‐Network Provider, the Plan will provide Benefits at Network Provider Out-of-Pocket Out‐of‐Pocket Costs based on the Maximum Allowable Amount, as determined by us, for the services received. In the event of a Surprise Bill Community Health Options will reimburse an Out-of-Network Out‐of‐Network provider at the average network rate under an enrollee’s plan unless the carrier and provider agree otherwise.

Non-Network Providers. Non-Emergency If you receive Covered Services from a Non-Network Provider are not coveredProvider, your cost-sharing will be higher, as described in the Out-of-Network portion of your Schedule of Benefits. It is your responsibility to ensure the Providers you receive services from are in the Health Options Network. In cases where a Network Provider is not available within certain time and distance standards from If the Plan approves your residence within the Service Area, Health Options may approve your visit to claim for payment of services rendered by a Non-Network Provider if you contact us and obtain approval beforehand. In this caseProvider, charges for the visit Plan will be applied to your In-Network cost-sharing pay Benefits up to the Maximum Allowable Amount. When We will pay Benefits directly to you receive services for a Medical Emergency, your Out-of-Pocket Costs (up or to the Maximum Allowable Amount determined by Health Options) will be at the Network Provider level whether you see a Network Provider or a Non-Network Provider. Charges from Non-Network Providers above the Maximum Allowable Amount will not apply to your Out-of-Network cost-sharing and will be your responsibility, if the Non-Network Provider chooses to bill you (known as balance billing)you. This means you may have financial responsibility greater than the cost- cost-sharing described on your Schedule of Benefits. When there This is an inadequate network, balance billing does not applysometimes referred to as Balance Billing. Before you receive a service, you may call Community Health Options® (“Health Options”) toll-free at 1-855-624- 6463 (TTY/TDD: 711) to learn the network status of the provider. If we deny your claim, you have the right to appeal our decision by following the steps in section 8. For Medical Emergency services rendered by a Non- Network Provider, the Plan will provide Benefits at Network Provider Out-of-Pocket Costs based on the Maximum Allowable Amount, as determined by us, for the services received. In the event of a Surprise Bill Health Options will reimburse an Out-of-Network provider at the average network rate under an enrollee’s plan unless the carrier and provider agree otherwise.

Non-Network Providers. Non-Emergency If you receive Covered Services from a Non-Network Provider are not coveredProvider, your cost-sharing will be higher, as described in the Non- Network portion of your Schedule of Benefits. It is your responsibility to ensure the Providers you receive services from are in the Community Health Options Network. If the Plan approves your claim for payment of services rendered by a Non-Network Provider, the Plan will pay Benefits up to the Maximum Allowable Amount. We will pay Benefits directly to you or to the Non- Network Provider. Non-Emergent Charges above the Maximum Allowable Amount will not apply to your Out-of-Network cost-sharing and will be your responsibility if the Non-Network Provider chooses to bill you. This means you may have financial responsibility greater than the cost-sharing described on your Schedule of Benefits. This is sometimes referred to as Balance Billing. In cases cases, including Second Opinions, where a Network Provider is not available within certain time and distance standards from your residence within the Service Area, Community Health Options may approve your visit to a Non-Network Provider if you contact us and obtain approval beforehand. In this caseIf a Second Opinion is sought from a Non-Network Provider because a Network Provider is not available, charges for the visit cost-sharing will be applied to your as if the service were obtained from an In-Network cost-sharing up to the Maximum Allowable AmountProvider. When you receive services for a Medical Emergency, your Out-of-Pocket Costs (up to the Maximum Allowable Amount determined by Community Health Options) will be at the Network Provider level whether you see a Network Provider or a Non-Network Provider. Charges from Out-of-pocket costs for emergency services rendered by a Non-Network Providers above the Maximum Allowable Amount will not apply to your cost-sharing and will be your responsibilityPprovider only include any applicable Deductible, if the Non-Network Provider chooses to bill you (known as balance billing). This means you may have financial responsibility greater than the cost- sharing described on your Schedule of Benefits. When there is an inadequate networkCoinsurance, balance billing does not applyor Copayment. Before you receive a service, you may call Community Health Options® (“Health Options”) toll-free at 1-855-624- 6463 (TTY/TDD: 711) Options to learn the network status of the providerProvider. If we deny your claim, you have the right to appeal our decision by following the steps in section 8. For Medical Emergency services rendered by a Non- Non-Network Provider, the Plan will provide Benefits at Network Provider Out-of-Pocket Costs based on the Maximum Allowable Amount, as determined by us, for the services received. In the event of a Surprise Bill Community Health Options will reimburse an Out-ofNon-Network provider at the average network rate under an enrollee’s plan unless the carrier and provider agree otherwise.

Non-Network Providers. SAMPLE Non-Emergency Covered Services from a Non-Network Provider are not covered. It is your responsibility to ensure the Providers you receive services from are in the Health Options Network. In cases where a Network Provider is not available within certain time and distance standards from your residence within the Service Area, Health Options may approve your visit to a Non-Network Provider if you contact us and obtain approval beforehand. In this case, charges for the visit will be applied to your In-Network cost-sharing up to the Maximum Allowable Amount. When you receive services for a Medical Emergency, your Out-of-Pocket Costs (up to the Maximum Allowable Amount determined by Health Options) will be at the Network Provider level whether you see a Network Provider or a Non-Network Provider. Charges from NonOut-Network Providers above the Maximum Allowable Amount will not apply to your costof-sharing and will be your responsibilitypocket costs for emergency services rendered by a non-network provider only include any applicable Deductible, if the Non-Network Provider chooses to bill you (known as balance billing). This means you may have financial responsibility greater than the cost- sharing described on your Schedule of Benefits. When there is an inadequate networkCoinsurance, balance billing does not applyor Copayment. Before you receive a service, you may call Community Health Options® (“Health Options”) toll-free at 1-855-624- 624-6463 (TTY/TDD: 711) to learn the network status of the provider. If we deny your claim, you have the right to appeal our decision by following the steps in section 8. For Medical Emergency services rendered by a Non- Non-Network Provider, the Plan will provide Benefits at Network Provider Out-of-Pocket Costs based on the Maximum Allowable Amount, as determined by us, for the services received. In the event of a Surprise Bill Health Options will reimburse an Out-of-Network provider at the average network rate under an enrollee’s plan unless the carrier and provider agree otherwise.

Non-Network Providers. Non-Emergency If you receive Covered Services from a Non-Network Provider are not coveredProvider, your cost-sharing will be higher, as described in the Out-of-Network portion of your Schedule of Benefits. It is your responsibility to ensure the Providers you receive services from are in the Health Options Network. In cases where a Network Provider is not available within certain time and distance standards from If the Plan approves your residence within the Service Area, Health Options may approve your visit to claim for payment of services rendered by a Non-Network Provider if you contact us and obtain approval beforehand. In this caseProvider, charges for the visit Plan will be applied to your In-Network cost-sharing pay Benefits up to the Maximum Allowable Amount. We will pay Benefits directly to you or to the Non-Network Provider. Charges above the Maximum Allowable Amount will not apply to your Out-of-Network cost-sharing and will be your responsibility, if the Non-Network Provider chooses to bill you. This means you may have financial responsibility greater than the cost-sharing described on your Schedule of Benefits. This is sometimes referred to as Balance Billing. When the Community Health Options network is inadequate, Balance Billing will not apply. Before you receive a service, you may call Community Health Options® (“Health Options”) toll-free at 1- 855-624-6463 (TTY/TDD: 711) to learn the network status of the provider. If we deny your claim, you have the right to appeal our decision by following the steps in section 8. For Medical Emergency services rendered by a Non-Network Provider, the Plan will provide Benefits at Network Provider Out-of-Pocket Costs based on the Maximum Allowable Amount, as determined by us, for the services received. When you receive services for a Medical Emergency, your Out-of-Pocket Costs (up to the Maximum Allowable Amount determined by Health Options) will be at the Network Provider level whether you see a Network Provider or a Non-Network Provider. Charges from NonOut-Network Providers above the Maximum Allowable Amount will not apply to your costof-sharing and will be your responsibility, if the Non-Network Provider chooses to bill you (known as balance billing). This means you may have financial responsibility greater than the cost- sharing described on your Schedule of Benefits. When there is an inadequate network, balance billing does not apply. Before you receive a service, you may call Community Health Options® (“Health Options”) toll-free at 1-855-624- 6463 (TTY/TDD: 711) to learn the network status of the provider. If we deny your claim, you have the right to appeal our decision by following the steps in section 8. For Medical Emergency pocket costs for emergency services rendered by a Non- Network Providernon-network provider only include any applicable Deductible, the Plan will provide Benefits at Network Provider Out-of-Pocket Costs based on the Maximum Allowable AmountCoinsurance, as determined by us, for the services receivedor Copayment. In the event of a Surprise Bill Health Options will reimburse an Out-of-Network provider at the average network rate under an enrollee’s plan unless the carrier and provider agree otherwise.

Non-Network Providers. Non-Emergency If you receive Covered Services from a Non-Network Provider are not coveredProvider, your cost-sharing will be higher, as described in the Out-of- Network portion of your Schedule of Benefits. It is your responsibility to ensure the Providers you receive services from are in the Health Options Network. In cases where a Network Provider is not available within certain time and distance standards from If the Plan approves your residence within the Service Area, Health Options may approve your visit to claim for payment of services rendered by a Non-Network Provider if you contact us and obtain approval beforehand. In this caseProvider, charges for the visit Plan will be applied to your In-Network cost-sharing pay Benefits up to the Maximum Allowable Amount. We will pay Benefits directly to you or to the Non- Network Provider. SAMPLE Charges above the Maximum Allowable Amount will not apply to your Out-of-Network cost-sharing and will be your responsibility, if the Non-Network Provider chooses to bill you. This means you may have financial responsibility greater than the cost-sharing described on your Schedule of Benefits. This is sometimes referred to as Balance Billing. When the Community Health Options network is inadequate, Balance Billing will not apply. Before you receive a service, you may call Community Health Options® (“Health Options”) toll-free at 1-855-624-6463 (TTY/TDD: 711) to learn the network status of the provider. If we deny your claim, you have the right to appeal our decision by following the steps in section 8. For Medical Emergency services rendered by a Non-Network Provider, the Plan will provide Benefits at Network Provider Out-of-Pocket Costs based on the Maximum Allowable Amount, as determined by us, for the services received. When you receive services for a Medical Emergency, your Out-of-Pocket Costs (up to the Maximum Allowable Amount determined by Health Options) will be at the Network Provider level whether you see a Network Provider or a Non-Network Provider. Charges from NonOut-Network Providers above the Maximum Allowable Amount will not apply to your costof-sharing and will be your responsibility, if the Non-Network Provider chooses to bill you (known as balance billing). This means you may have financial responsibility greater than the cost- sharing described on your Schedule of Benefits. When there is an inadequate network, balance billing does not apply. Before you receive a service, you may call Community Health Options® (“Health Options”) toll-free at 1-855-624- 6463 (TTY/TDD: 711) to learn the network status of the provider. If we deny your claim, you have the right to appeal our decision by following the steps in section 8. For Medical Emergency pocket costs for emergency services rendered by a Non- Network Providernon-network provider only include any applicable Deductible, the Plan will provide Benefits at Network Provider Out-of-Pocket Costs based on the Maximum Allowable AmountCoinsurance, as determined by us, for the services receivedor Copayment. In the event of a Surprise Bill Health Options will reimburse an Out-of-Network provider at the average network rate under an enrollee’s plan unless the carrier and provider agree otherwise.

Non-Network Providers. Non-Emergency If you receive Covered Services from a Non-Network Provider are not coveredProvider, your cost-sharing will be higher, as described in the Out-of-Network portion of your Schedule of Benefits. It is your responsibility to ensure the Providers you receive services from are in the Health Options Network. In cases where a Network Provider is not available within certain time and distance standards from If the Plan approves your residence within the Service Area, Health Options may approve your visit to claim for payment of services rendered by a Non-Network Provider if you contact us and obtain approval beforehand. In this caseProvider, charges for the visit Plan will be applied to your In-Network cost-sharing pay Benefits up to the Maximum Allowable Amount. We will pay Benefits directly to you or to the Non-Network Provider. Charges above the Maximum Allowable Amount will not apply to your Out-of-Network cost-sharing and will be your responsibility, if the Non-Network Provider chooses to bill you. This means you may have financial responsibility greater than the cost-sharing described on your Schedule of Benefits. This is sometimes referred to as Balance Billing. When you receive services for a Medical Emergency, your Out-of-Pocket Costs (up to the Maximum Allowable Amount determined by Health Options) will be at the Network Provider level whether you see a Network Provider or a Non-Network Provider. Charges from NonOut-Network Providers above the Maximum Allowable Amount will not apply to your costof-sharing and will be your responsibilitypocket costs for emergency services rendered by a non-network provider only include any applicable Deductible, if the Non-Network Provider chooses to bill you (known as balance billing). This means you may have financial responsibility greater than the cost- sharing described on your Schedule of Benefits. When there is an inadequate networkCoinsurance, balance billing does not applyor Copayment. Before you receive a service, you may call Community Health Options® (“Health Options”) toll-free at 1-1- 855-624- 624-6463 (TTY/TDD: 711) to learn the network status of the provider. If we deny your claim, you have the right to appeal our decision by following the steps in section 8. For Medical Emergency services rendered by a Non- Non-Network Provider, the Plan will provide Benefits at Network Provider Out-of-Pocket Costs based on the Maximum Allowable Amount, as determined by us, for the services received. In the event of a Surprise Bill Health Options will reimburse an Out-of-Network provider at the average network rate under an enrollee’s plan unless the carrier and provider agree otherwise.

Non-Network Providers. Non-Emergency Non‐Emergency Covered Services from a Non-Network Non‐Network Provider are not covered. It is your responsibility to ensure the Providers you receive services from are in the Community Health Options Network. In cases cases, including second opinions, where a Network Provider is not available within certain time and distance standards from your residence within the Service Area, Community Health Options may approve your visit to a Non-Network Non‐Network Provider if you contact us and obtain approval beforehand. In this case, charges for the visit will be applied to your In-Network cost-sharing In‐Network cost‐sharing up to the Maximum Allowable Amount. When there is an inadequate network, balance billing does not apply. In cases, including Second Opinions, where a Network Provider is not available within certain time and distance standards from your residence within the Service Area, Community Health Options may approve your visit to a Non‐Network Provider if you contact us and obtain approval beforehand. If a Second Opinion is sought from a Non‐Network Provider because a Network Provider is not available, cost‐sharing will be applied as if the service were obtained from an In‐Network Provider. When you receive services for a Medical Emergency, your Out-of-Pocket Out‐of‐Pocket Costs (up to the Maximum Allowable Amount determined by Community Health Options) will be at the Network Provider level whether you see a Network Provider or a Non-Network Non‐Network Provider. Charges from Non-Network Providers above the Maximum Allowable Amount will not apply to your cost-sharing and will be your responsibilityOut‐of‐pocket costs for emergency services rendered by a non‐network provider only include any applicable Deductible, if the Non-Network Provider chooses to bill you (known as balance billing). This means you may have financial responsibility greater than the cost- sharing described on your Schedule of Benefits. When there is an inadequate networkCoinsurance, balance billing does not applyor Copayment. Before you receive a service, you may call Community Health Options® (“Health Options”) toll-free at 1-855-624- 6463 (TTY/TDD: 711) Options to learn the network status of the provider. If we deny your claim, you have the right to appeal our decision by following the steps in section 8. For Medical Emergency services rendered by a Non- Network Non‐Network Provider, the Plan will provide Benefits at Network Provider Out-of-Pocket Out‐of‐Pocket Costs based on the Maximum Allowable Amount, as determined by us, for the services received. In the event of a Surprise Bill Community Health Options will reimburse an Out-of-Network Out‐of‐Network provider at the average network rate under an enrollee’s plan unless the carrier and provider agree otherwise.

Non-Network Providers. Non-Emergency Covered Services received from a Nonnon-Network Provider network provider are not covered. It is NOT COVERED except in the following limited circumstances: • Emergency care (Emergency Room Services and Ambulance Services); • We specifically approve the use of a non-network provider for covered health care services; • Covered health care services are rendered by a non-network provider at a network facility outside of your responsibility to ensure the Providers control as described in Section 4.1; • Hearing aids, in accordance with Rhode Island General Law § 27-20-46; • Hair prosthetics (wigs), in accordance with Rhode Island General Law §27-20-53; or • Enteral formula or food taken orally, in accordance with Rhode Island General Law §27-20-56 If you receive care from a non-network provider, you are responsible for paying all charges from the non-network provider. If the services from are in the Health Options Network. In cases where a Network Provider is not available within certain time covered health care services and distance standards from your residence are rendered within the Service Arealimited circumstances described above, Health Options may approve your visit to a Non-Network Provider if you contact us and obtain approval beforehand. In this case, charges for the visit will be applied to your In-Network cost-sharing reimbursed up to the provider’s charge or the maximum benefit, less any copayments and deductibles which may apply to the covered health care service. The deductible and maximum out-of-pocket expense are calculated based on our allowance and not on the provider’s charge, unless otherwise specifically stated in this agreement. Benefits may not be assigned, unless the Rhode Island General Laws § 27-19-54 (Dental Insurance assignment of benefits) applies. Deductible/Maximum Allowable Amountout-of-pocket expense Benefit Description Description Benefit Limit/Notes Network Provider Non- Network Provider Deductible The deductible applies to all services (including prescription drugs), except for designated preventive care services. When you receive Services that apply the deductible and services that do NOT apply the deductible are indicated in the Summary of Medical Benefits and the Summary of Pharmacy Benefits. Individual Plan Per benefit year $6,600 Not Covered Family Plan The benefit year family deductible is met by adding the amount of covered health care expenses applied to the deductible for a Medical Emergency, your all family members. $13,200 Not Covered Maximum Out-of-Pocket Costs Expense The deductible and copayments (up including, but not limited to, office visits copayments and prescription drug copayments) apply to the Maximum Allowable Amount determined maximum out-of- pocket expense. Individual Plan Per benefit year $6,600 Not Covered Family Plan The benefit year family maximum out-of-pocket expense is met by adding the amount of covered health care expenses applied to the maximum out- of-pocket expense for all family members. $13,200 Not Covered Medical Benefits Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Ambulance Ground 0% YES The level of coverage is the same as network provider. Air/Water Up to the maximum benefit of $3,000 per occurrence. 0% YES The level of coverage is the same as network provider. Behavioral Health Options) will be - Mental Health Inpatient * Unlimited days at the Network Provider level whether you see a Network Provider general hospital or a Non-Network Providerspecialty hospital. Charges from Non-Network Providers above 0% YES Not Covered Not Covered Intermediate Care Services* See Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. 0% YES Not Covered Not Covered In the Maximum Allowable Amount will not apply office/in your home rendered by PCP First, second, or third submitted claim for an office visit in a benefit year. Benefit limit applies to your cost-sharing and will be your responsibility, if the Non-Network Provider chooses to bill you (known as balance billing). This means you may have financial responsibility greater than the cost- sharing described on your Schedule of Benefits. When there is an inadequate network, balance billing does not apply. Before you receive a service, you may call Community Health Options® (“Health Options”) toll-free at 1-855-624- 6463 (TTY/TDD: 711) to learn the network status of the provider. If we deny your claim, you have the right to appeal our decision by following the steps in section 8. For Medical Emergency services all office visits rendered by a Non- Network PCP, except the annual preventive care office visits. $25 NO Not Covered Not Covered Subsequent submitted claims for sick office visits in a benefit year. 0% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the Plan will provide Benefits at Network Provider Out-of-Pocket Costs difference between the charge amount and the allowance plus: Behavioral Health - Mental Health In the office/in your home rendered by Specialist Prescription drug coverage benefit level is based on type of service and site of service. See 0% YES Not Covered Not Covered Prescription Drug section for details. Includes individual and group sessions. Behavioral Health – Substance Abuse Treatment Inpatient, Substance Abuse Treatment Facility * Detoxification – unlimited days per benefit year. Residential/ Rehabilitation – unlimited days per benefit year. 0% YES Not Covered Not Covered In a Substance Abuse Treatment facility (outpatient), Intermediate Care Services * Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. See Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the Maximum Allowable Amount, as determined by us, for difference between the services received. charge amount and the allowance plus: Behavioral Health – Substance Abuse Treatment In the event office/in your home rendered by PCP First, second, or third submitted claim for an office visit in a benefit year. Benefit limit applies to all office visits rendered by a PCP, except the annual preventive care office visits. $25 NO Not Covered Not Covered Subsequent submitted claims for office visits in a benefit year. 0% YES Not Covered Not Covered In the office/in your home rendered by Specialist 0% YES Not Covered Not Covered Methadone Maintenance Treatment 0% YES Not Covered Not Covered Cardiac Rehabilitation Outpatient Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 0% YES Not Covered Not Covered Chiropractic Medicine In a Provider’s office 12 visits per benefit year. 0% YES Not Covered Not Covered Dental Care Hospital Emergency Room When services are due to accidental injury to sound natural teeth. 0% YES The level of a Surprise Bill Health Options will reimburse an Out-of-coverage is the same as network provider. Services connected to dental care performed in Outpatient See Section for benefit limitations. 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider at For a covered heath care service you pay: Non-network provider For a covered health care service you pay the average network rate difference between the charge amount and the allowance plus: Dental Care Facility * In an office (doctor or dentist) When services are due to accidental injury to sound natural teeth. 0% YES Not Covered Not Covered Dental Care rendered to enrolled children under an enrollee’s plan unless the carrier age of 19 Oral Evaluations Two examinations per benefit year. Exams include the initial examination or periodic examination or emergency oral evaluation when performed by a general dentist including diagnosis and provider agree otherwise.charting per benefit year. 0% YES Not Covered Not Covered