Situation

CHOICE PLUS

NETWORK

CHOICE PLUS

NON-NETWORK

Notification Requirements

The following procedures require that you notify Care Coordination prior to receiving services in order for Care Coordination to determine if they are Covered Health Services:

●  Breast reduction and reconstruction (except for after cancer surgery);

·  Vein stripping, ligation and

sclerotherapy; and

·  Blepharoplasty (surgery to correct aging of the eyelids).

These services will not be covered when considered to be Cosmetic Procedures.

Special Note Regarding Medicare

If you are enrolled in Medicare and Medicare pays benefits before the Plan, you are not required to notify Care Coordination before receiving Covered Health Services.

Prior notification is required before you receive certain Covered Health Services.

You are responsible for notifying Care Coordination before you receive the following Covered Health Services:

·  Dental Services -Accident Only

●   Emergency Health Services if you are admitted to a non-Network Hospital.

·  As soon as the possibility of a transplant arises (and before the time a pre-transplantation evaluation is performed at a transplant center).

·  As soon as Congenital Heart Disease is suspected or diagnosed (in utero detection, at birth, or as determined and before the time an evaluation for CHD is performed).

Please refer to the Mental Health and Substance Abuse section for notification requirements pertaining to Mental Health and Substance Abuse treatment.

**REFER TO SPECIFIC BENEFIT SECTION FOR APPLICABLE PENALTIES FOR NOT CALLING CARE COORDINATION

Prior notification is required before you receive certain Covered Health Services.

You are responsible for notifying Care Coordination before you receive the following Covered Health Services:

·  Dental Services -Accident Only

·  Home Health Care

·  Hospice Care

·  Reconstructive Procedures

·  Elective admissions to a Skilled Nursing Facility/ Inpatient Rehabilitation Facility

·  Hospital-Inpatient Stay

·  For an Inpatient Stay of a mother and/or the newborn that will be more than the time frames described of:

·  48 hours for the mother and newborn child following a normal vaginal delivery.

·  96 hours for the mother and newborn child following a cesarean section delivery.

·  As soon as the possibility of a transplant arises (and before the time a pre-transplantation evaluation is performed at a transplant center).

·  Breast reduction and reconstruction (except after cancer surgery), vein stripping, ligation and sclerotherapy, and upper lid blepharoplasty. These services will not be covered when cosmetic in nature.

·  As soon as Congenital Heart Disease is suspected or diagnosed (in utero detection, at birth, or as determined and before the time an evaluation for CHD is performed).

·  You must notify Care Coordination before obtaining any single item of Durable Medical Equipment that costs more than $1,000 (either purchase price or cumulative rental of a single item.)

If you don't notify Care Coordination, Benefits will be subject to a $300 penalty.

Please refer to the Mental Health and Substance Abuse section for notification requirements pertaining to Mental Health and Substance Abuse treatment.

**REFER TO SPECIFIC BENEFIT SECTION FOR APPLICABLE PENALTIES FOR NOT CALLING CARE COORDINATION

Ambulance Services –Emergency Only

Emergency ambulance transportation by a licensed ambulance service to the nearest Hospital where Emergency Health Services can be performed. Ambulance service by air is covered in an Emergency if ground transportation is impossible or would put life or health in serious jeopardy.

Ground Transportation:

90% of eligible expenses.

Air Transportation:

90% of eligible expenses.

Ground Transportation:

90 of eligible expenses.

Air Transportation:

90% of eligible expenses.

Ambulance Services - Non-Emergency

Transportation by professional ambulance, other than air ambulance, to and from a medical facility.

Transportation by regularly scheduled airline, railroad or air ambulance, to the nearest medical facility qualified to give the required treatment.

Ground Transportation:

90% of eligible expenses.

Air Transportation:

90% of eligible expenses.

Non-Emergency covered only if medically necessary.

Ground Transportation:

90% of eligible expenses.

Air Transportation:

90% of eligible expenses.

Non-Emergency covered only if medically necessary.

Ambulatory Surgical Center

Refer to Outpatient Surgery benefit below for a description of Covered Health Services.

Refer to Outpatient Surgery benefit below for a description of Covered Health Services.

Outpatient Surgery, Diagnostic and Therapeutic Services

Outpatient surgery, diagnostic and therapeutic services received on an outpatient basis at a Hospital or Alternate Facility are paid by the Plan including:

·  Surgery and related services;

·  Lab and radiology/X-ray;

·  Mammography testing, other than as described under Preventive Care;

·  Computerized tomography (CT) scans;

·  Position emission tomography (PET) scans;

·  Magnetic resonance imaging (MRIs);

·  Nuclear medicine; and

·  Other diagnostic tests and therapeutic treatments (including cancer chemotherapy or intravenous infusion therapy).

Benefits include only the facility charge and the charge for required services, supplies and equipment. Benefits for the professional fees, including a surgeon's fee related to outpatient surgery, diagnostic and therapeutic services are described under Professional Fees for Surgical and Medical Services.

When these services are performed in a Physician's office, Benefits are described under Physician's Office Services.

90% of eligible expenses.

80% of eligible expenses after satisfying $300 deductible.

Emergency Health Services

Services that are required to stabilize or initiate treatment in an Emergency. Emergency Health Services must be received on an outpatient basis at a Hospital or Alternate Facility.

True-Emergency:

90% of eligible expenses.

True Emergency Room for bonified emergencies are based on the "prudent layperson rule".

Non-Emergency:

50% of eligible expenses.

Non Emergency coinsurance doesn't apply to Out-of-Pocket limitation.

True-Emergency:

90% of eligible expenses after satisfying $300 deductible.

True Emergency Room for bonified emergencies are based on the "prudent layperson rule".

Non-Emergency:

50% of eligible expenses after satisfying $300 deductible.

Non Emergency coinsurance doesn't apply to Out-of-Pocket limitation.

Notify Care Coordination

To ensure prompt and accurate payment of your claim, notify Care Coordination within two business days or as soon as possible after you receive outpatient Emergency Health Services at a non-Network Hospital or Alternate Facility.

Please remember that if you are admitted to a Hospital as a result of an Emergency, you must notify Care Coordination within two business days or the same day of admission, or as soon as reasonably possible.

If you don't notify Care Coordination, Benefits for the Hospital Inpatient Stay will be subject to a $300 penalty. Benefits will not be reduced for the outpatient Emergency Health Services.

Hospital Inpatient Stay

If a Covered Person is confined in a private Hospital room, the difference between the cost of a Semi-private Room in the Hospital and the private room is not an allowable expense (unless the patient's stay in a private Hospital room is necessary in terms of generally accepted medical practice.)

Benefits for an Inpatient Stay in a Hospital are available only when the Inpatient Stay is necessary to prevent, diagnose or treat a Sickness or Injury.

Inpatient Stay in a Hospital. Benefits are available for:

●  Services and supplies received during the Inpatient Stay.

●  Room and board in a Semi-private Room (a room with two or more beds).

Benefits for an Inpatient Stay in a Hospital are available only when the Inpatient Stay is necessary to prevent, diagnose or treat a Sickness or Injury. Benefits fro non-Hospital-based Physician services are described un Professional Fess for Surgical and Medical Services.

Benefits for Emergency admissions and admissions of less than 24 hours are described under Emergency Health Services and Outpatient Surgery, Diagnostic and Therapeutic Services, respectively.

90% of eligible expenses.

80% of eligible expenses after satisfying $300 deductible.

Notify Care Coordination

Please remember that for Benefits you must notify Care Coordination as follows:

●  For elective admissions: 5 business days before admission.

●  For Emergency admissions (also termed non-elective admissions): within 2 business days, or as soon as is reasonably possible.

If you don't notify Care Coordination, Benefits will be subject to a $300 penalty.

Urgent Care Center Services

Covered Health Services received at an Urgent Care Center. When services to treat urgent health care needs are provided in a Physician's office, Benefits are available as described under Physician's Office Services.

90% of eligible expenses.

80% of eligible expenses after satisfying $300 deductible.