COVENTRY HEALTH AND LIFE INSURANCE COMPANY AND COVENTRY HEALTH CARE OF GEORGIA, INC. POINT OF SERVICE ( POS ) CERTIFICATE OF COVERAGE

Transcription

1 COVENTRY HEALTH AND LIFE INSURANCE COMPANY AND COVENTRY HEALTH CARE OF GEORGIA, INC. POINT OF SERVICE ( POS ) CERTIFICATE OF COVERAGE Under this POS Health Plan, inpatient, outpatient and other Covered Services are available through both In- Network ( Participating ) Providers and Out-of-Network ( Non-Participating ) Providers. Benefits under this Health Plan are subject to Our Utilization Management Program. Please be aware that Coverage may be denied if the Covered Services You receive are not compliant with the Utilization Management Program. See Section 1.2 for more information on Our Utilization Management Program. Keep in mind that using a Participating Provider (Your In-Network benefits) will usually cost You less than using a Non-Participating Provider (Your Out-of-Network benefits). The reason is that Participating Providers are contracted with Us to provide health care services to Members for a lower fee, whereas Non- Participating Providers are not contracted with Us. Please see Section one (1) for more information on how Your In-Network and Out-of-Network benefits work. Informacion en Espanol esta disponible a su pedido. Llame nuestro Servicio al Cliente linea de traduccion al Information in Spanish available upon request. Please call our Customer Service translation line at CHCCHL-GA-POS-COC

2 Dear New Member: Welcome to Coventry Health and Life Insurance Company and Coventry Health Care of Georgia, Inc. ( Coventry )! We are extremely pleased that You have enrolled in Our health plan and look forward to serving You. Coventry is a subsidiary of Coventry Health Care, Inc., a Fortune 500 company operating health plans, insurance companies, network rental and workers' compensation services companies in all 50 states and Puerto Rico. We are one of the country s largest managed health care companies providing a full range of risk and fee-based health care products and services. Coventry s benefit plans emphasize wellness and preventive care. You will find that Our strong network of area physicians, hospitals, and other providers offers a broad range of services to meet Your medical needs. As a Coventry Member, it is important that You understand the way Your health plan operates. This Certificate of Coverage is an important legal document, and contains the information You need to know about Your coverage with Us and how to get the care You need. Please keep it in a safe place where You can refer to it as needed. Please take a few minutes to read these materials and to make Your covered family Members aware of the provisions of Your coverage. Our Customer Services Department is available to answer any questions You may have about Your coverage. You can reach them at (800) Monday through Friday, 7:00 a.m. to 6:00 p.m. ET. You may also access your benefit information 24 hours a day, 7 days a week by registering and logging in at We look forward to serving You and Your family. Sincerely, Thomas Davis Vice President Coventry Health and Life Insurance Company Chief Executive Officer Coventry Health Care of Georgia, Inc. CHCCHL-GA-POS-COC

3 Coventry Health and Life Insurance Company Coventry Health Care of Georgia, Inc. Certificate of Coverage The Agreement between Coventry (hereafter called the Health Plan, Coventry, We, Us, or Our ) and You is made up of the following documents: Certificate of Coverage and any amendments; Enrollment Applications/Health Statements; Schedule of Benefits; Applicable Riders; and Group Contract. Coventry will make available to the Group a certificate, which summarizes the essential features of the Coverage and to whom benefits are payable. No person or entity has any authority to waive any Agreement provision or to make any changes or amendments to this Agreement unless approved in writing by an officer of the Health Plan, and the resulting waiver, change, or amendment is attached to the Agreement. This Agreement begins on the Group Effective Date defined in the Group Contract. It continues, until replaced or terminated, while its conditions are met. You are subject to all terms, conditions, limitations, and exclusions in this Agreement and to all the rules and regulations of the Health Plan. By paying premiums or having premiums paid on Your behalf, You accept the provisions of this Agreement. This Agreement gives You access to both In-Network benefits (provided by Participating Providers) and Out-of-Network benefits (provided by Non-Participating Providers). Keep in mind that using Outof-Network Benefits will cost You more than using In-Network benefits. Please read Section one (1) to learn more about how Your In-Network and Out-of-Network benefits work and call our Customer Service Department at if You have any questions. THIS AGREEMENT SHOULD BE READ AND RE-READ IN ITS ENTIRETY. Many of the provisions of this Agreement are interrelated; therefore, reading just one or two provisions may give You a misleading impression. Many words used in this Agreement have special meanings. These words will appear capitalized and are defined for You. By using these definitions, You will have a clearer understanding of Your Coverage. Many of the capitalized words will be defined within the section in which they are used, or within the Definitions section of this document. From time to time, the Agreement may be amended, as required by and in accordance with Georgia state and federal law. When this occurs, We will provide an Amendment or new Certificate of Coverage to You for this Agreement. You should keep this document in a safe place for Your future reference. HEALTH CARE REFORM Coventry is in compliance with the Federal Patient Protection and Affordable Coverage Act of 2010 and the Federal Health Care and Education Reconciliation Act of 2010 (collectively, the Act ). To the extent any provision of the Act conflicts with any of the provisions of this Contract, the Contract will be interpreted to be compliant with the Act. COVENTRY HEALTH AND LIFE INSURANCE COMPANY COVENTRY HEALTH CARE OF GEORGIA, INC CIRCLE 75 PARKWAY SUITE 1400 ATLANTA, GA (800) CHCCHL-GA-POS-COC

4 TABLE OF CONTENTS SECTION 1 USING YOUR BENEFITS. 5 SECTION 2 ENROLLMENT, ELIGIBILITY AND EFFECTIVE DATES.. 12 SECTION 3 TERMINATION OF COVERAGE SECTION 4 CONTINUATION OF COVERAGE. 19 SECTION 5 COVERED SERVICES.. 21 SECTION 6 EXCLUSIONS AND LIMITATIONS SECTION 7 COORDINATION WITH OTHER COVERAGE. 37 Coordination With Other Coverage Definitions.. 37 SECTION 8 COMPLAINTS AND APPEALS.. 42 Complaints and Appeals Definitions. 42 SECTION 9 ACCESS TO RECORDS & CONFIDENTIALITY OF INFORMATION. 47 SECTION 10 GENERAL PROVISIONS SECTION11 DEFINITIONS 50 SECTION 12 SERVICE AREA DESCRIPTION CHCCHL-GA-POS-COC

5 SECTION 1 USING YOUR BENEFITS Under this POS Health Plan, We offer In-Network health care services to You and Your enrolled family members through a network of Participating Providers. Participating Providers have signed a contract with Us in which they agree to provide health care services to Members for a lower fee. Our Participating Provider network may change from time to time. Please visit our website at or call Our Customer Service Department at , to find out if a Provider is a Participating Provider. If a Provider does not have a contractual agreement with Us, the Provider is considered to be a Non- Participating Provider. Keep in mind that using a Participating Provider (Your In-Network benefits) will cost You less than using a Non-Participating Provider (Your Out-of-Network benefits). If services are provided to You by a Non- Participating Provider, those services will be paid at the Out-of-Network level using the Out-of-Network Rate ( ONR ). Please see Section 1.7 for more information on Out-of-Network Providers and the ONR. If You receive Covered Services at an In-Network hospital or outpatient facility, You might inadvertently receive some services from Non-Participating Providers. In this instance, We will pay the In-Network level for Covered Services provided by a Non-Participating Pathologist, Anesthesiologist, Radiologist, or Emergency Room Physician 1.1 Membership Identification (ID) Card. Every Health Plan Member receives a membership ID card. Please carry Your Member ID card with You at all times, and present it before health care services are rendered. If Your Member ID card is missing, lost, or stolen, contact Our Customer Service Department at (800) or visit Our website at to order a replacement. 1.2 Your Primary Care Physician (PCP). If your benefit plan documents indicate a PCP is required, you must choose a PCP for yourself and each member of your family. You have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members. If applicable to your plan, the name and phone number of the PCP you select will be listed on your member identification (ID) card. Even if your plan does not require the selection of a PCP under Your Plan, We encourage You to select a PCP from the Directory of Health Care Providers. The role of the PCP is important to the coordination of Your care, and You are encouraged to contact Your PCP when medical care is needed. This may include preventive health services, consultation with Specialists and other Providers, Emergency Services, and Urgent Care. You can select a PCP from one of the following specialties: Family Practice, Internal Medicine, General Practice, or Pediatrics. You may choose one PCP for the entire family, or each Dependent may select a different PCP. To locate the most current Directory of Health Care Providers, please visit Our website at Our online Provider directory is updated at least monthly. If a PCP is required per you benefit plan documents and You wish to change Your PCP, You must contact Our Customer Service Department at (800) You may also visit Our website at to make this change. Female Members age thirteen (13) and older may select a Participating OB-GYN Physician and seek primary care services directly from their OB-GYN Physician if they wish (no PCP selection or referral is needed). Please visit Our website at to find the most current list of Participating Providers. CHCCHL-GA-POS-COC

6 1.3 Prior Authorization and Utilization Management. When You receive care from an In-Network or Out-of-Network Provider, You must comply with all of the Utilization Management Program policies and procedures noted in this Section 1.3. Our Utilization Management Program is designed to help You receive Medically Necessary health care in a timely manner, and at the most reasonable cost. It is an effective measure in helping to monitor the quality and cost-effectiveness of Your health care. Our utilization management nurses review requests for non-emergency and non-maternity Hospital admissions, outpatient surgeries and other outpatient procedures. Our nurses also monitor the care You receive during a Hospital stay and at home after discharge. General Policies. The following policies apply to both In-Network and Out-of-Network services: Except for emergencies and maternity admissions, all hospitalizations and most outpatient procedures require Prior Authorization. You must ask Your Provider to contact Us at least ten (10) days prior to a scheduled Hospital admission, outpatient surgery or other outpatient procedure (except for emergencies and maternity admissions) to obtain Prior Authorization. If You are admitted to a facility prior to the date Authorized by Us, then You will be responsible for all charges related to the unauthorized days. The only exception to this policy is if You are already admitted to an inpatient facility Your Member Effective Date. Please note that prior authorization is not a guarantee of payment. We will Authorize only Medically Necessary Covered Services. If You obtain services which are not Medically Necessary, and the services are not Authorized by Us, then You will be responsible for all charges for those services. Intentional material misrepresentation: If We Authorize a service that We later determine was based on an intentional material misrepresentation about Your health condition, then payment of the service will be denied. You will be responsible for all charges related to that service. Notification letter: When We approve or deny a Prior Authorization request, We will send a notification letter to You and Your Provider. Right to appeal: You have the right to appeal any Utilization Management Program decision regarding Medical Necessity. Please see the appeal procedures in Section 8. Attending Physician responsibility: Under all circumstances, the attending Physician bears the ultimate responsibility for the medical decisions regarding Your treatment. Prior Authorization requirements are subject to change from time to time. Please ask Your Provider to call Customer Service at to find out if a Covered Service requires Prior Authorization. The Prior Authorization phone number is located on the back of Your Member ID Card. It is Your responsibility to ensure that Your Provider contacts us to obtain Prior Authorization. Please call Our Customer Service Department at to determine if a Covered Service requires Prior Authorization. CHCCHL-GA-POS-COC

7 1.4 Continuity of Care. We make every effort to ensure that Your access to Covered Services is quick and easy and the services are reasonably available. If You wish to see a particular Provider who is not accepting new patients or is no longer participating in Our Provider Network, please call Our Customer Service Department at (800) We can help You find another Participating Provider that meets Your needs. You may also nominate Your Non-Participating Provider to become a Participating Provider with Coventry, or nominate Your Non-Participating Provider under the Consumer Choice Option. If You elect the Consumer Choice Option within the first thirty (30) days of membership, You may nominate Your Non-Participating Provider. Please call Our Customer Service Department for more information. Continuity of care is especially important to Us. If Your Participating Provider unexpectedly stops participating with Us while You are in the middle of treatment, please call Us so We can help You continue treatment with another Participating Provider. In the following situations, We will allow You to continue Your treatment with Your now Non-Participating Provider: a. If You are suffering from terminal or chronic illness or are an inpatient, We will continue to pay for Covered Services You receive from Your Non-Participating Provider for sixty (60) days following the Provider s termination from Our Provider Network; and b. If You are pregnant, and beyond Your first trimester, We will continue to pay for Covered Services rendered by Your now Non-Participating Provider through delivery and including six (6) weeks of post-delivery care. 1.5 Copayments, Coinsurance, Deductibles, and Carryover. Your Copayment, Coinsurance and Deductible amounts are listed in Your Schedule of Benefits. You are responsible for paying Copayments to Your Provider at the time of service. Coinsurance and Deductible amounts, based on the Health Plan s reimbursement to the Provider, may be due to the Provider before or at the time of service. The typical order of payment of these amounts on claims is as follows: Your Copayments are applied first, then Your Deductible and finally Your Coinsurance. However, please be aware that Your specific Plan may have different rules. Please see Your Schedule of Benefits for the specific rules of Your Plan. In-Network: If You receive In-Network Covered Services, You are responsible only for the applicable Copayment, Deductible and/or Coinsurance amounts noted in Your Schedule of Benefits. Out-of-Network: If You receive Out-of-Network Covered Services, You are responsible for the applicable Copayment, Deductible and/or Coinsurance amounts noted in Your Schedule of Benefits, plus any amount in excess of the Out-of-Network Rate (ONR). Please see Section 1.7 for more information on the Out-of Network Rate and Your potential Out-of-Network liability. Please Note: The applicable Copayment, Deductible and/or Coinsurance amounts must be paid for every In-Network and Out-of-Network Physician office visit. Individual Deductible. For services subject to the Deductible, You must satisfy Your individual annual In-Network and Out-of-Network Deductible, as applicable, before the Health Plan will pay for Your Covered Services. You satisfy the annual In-Network and Out-of-Network Deductible by directly paying Your In-Network or Out-of-Network Provider (as applicable) for Covered Services. After the individual annual Deductible is satisfied, the Health Plan will pay for Your Covered Services, minus any applicable Copayments or Coinsurance. Family Deductible. If enrolled as a family each family Member is required to meet all of his/her individual annual Deductible (as noted above) before the Health Plan will pay for Covered Services. In many cases, if there are more than two (2) or three (3) Members in your family, it is possible that not every Member will have to meet their Deductible if the total combined deductible eligible expenses of all the Members meets the total family Deductible. Typically Copayments and Coinsurance are not counted toward the Deductible. Please see your Schedule of Benefits for specific requirements. CHCCHL-GA-POS-COC

8 Please be aware that payments You make for non-covered Services will not count toward the satisfaction of Your individual or family annual In-Network or Out-of-Network Deductible, as applicable. Carryover. If You pay any portion of Your annual Deductible (as noted above) during the last three (3) months of the Benefit Year, that paid amount will carryover and be applied toward the satisfaction of Your new annual Deductible in the following Benefit Year. For example: Your Benefit Year begins on October 1 of each year, and Your Deductible is $1,000. During the months of July, August and September of Benefit Year 1, You pay $750 towards Your Deductible. On October 1, the first day of Benefit Year 2, We will carryover and apply the $750 towards Your Deductible for Benefit Year 2, and You will owe only $250 to fully satisfy Your annual Deductible for the remainder of Benefit Year 2. For Members enrolled in a Qualified High Deductible Health Plan with a health savings account (HSA): Please be aware that Deductible carryover may disqualify Your Plan. Under Georgia law (14), amended in 2005, Qualified High Deductible Health Plans purchased in connection with a tax-advantaged program such as an HSA are exempted from the carryover deductible requirement, therefore the example outlined above does not apply to Your Plan. Please visit the Internal Revenue Service website ( or consult with Your financial advisor for more information. 1.6 Out-of-Pocket Maximum ( OOP ). Your In-Network and Out-of-Network OOP amounts are set forth in Your Schedule of Benefits. The individual OOP is the total amount You must pay out of Your pocket annually for In-Network and Out-of-Network Covered Services. The family OOP is the total amount family Members must pay annually for In-Network and Out-of-Network Covered Services. Copayments do not go toward and are not subject to the OOP. Most Coinsurance amounts are applied to the annual OOP. Copayments and Deductible amounts typically are not applied to the annual OOP. Please see Your Schedule of Benefits for the specific rules concerning the amounts that apply to the annual OOP. In-Network: If You satisfy the annual In-Network OOP, then You pay nothing more for In-Network Covered Services for the remainder of the Benefit Year, except for In-Network Copayments. Out-of-Network: If You satisfy the annual Out-of-Network OOP, then You pay nothing more for Outof-Network Covered Services for the remainder of the Benefit Year, except for Out-of-Network Copayments and amounts You pay in excess of the Out-of-Network Rate ( ONR ). Please see Payment to Providers for more information on Out-of-Network benefits and the ONR. Please Remember: When You obtain Out-of-Network services, any amounts You pay in excess of the Out-of-Network Rate (ONR) are not applied to Your Out-of-Network OOP. Even if You have satisfied the Out-of-Network OOP, You must continue to pay amounts in excess of the ONR when You obtain Out-of-Network services. Please see Payment to Providers for more information on Out-of-Network benefits, the ONR and Your potential Out-of Network liability. Please be aware that there may be separate OOP amounts for Covered Services provided under Riders to Your Health Plan. Please refer to the specific Rider for more information 1.7 Payment to Providers In Network Providers (Participating Providers). For In-Network Covered Services, the Participating Provider will bill the Health Plan directly for CHCCHL-GA-POS-COC

9 the services. You do not have to file any claims for these services. CHCCHL-GA-POS-COC

10 You are responsible for payment of: (a) (b) (c) (d) the applicable In-Network Copayment, Deductible and/or Coinsurance amounts; services that require Prior Authorization and which were not Prior Authorized; services that are not Medically Necessary; and services that are not Covered Services Out of Network Providers (Non-Participating Providers). For Out-of-Network Covered Services, the Non-Participating Provider typically expects You to pay for the services. If so, You should submit a claim to Us for reimbursement and We will send the payment directly to You. However, if You assign payment of the services to the Non- Participating Provider, We will send the payment to the Non-Participating Provider. Our payment for Out-of-Network Covered Services is limited to the Out-of-Network Rate, less the applicable Out-of-Network Copayment, Deductible and/or Coinsurance amounts You are required to pay under Your Plan. Out-of-Network Rate ( ONR ): The ONR is the amount We pay for charges billed by Non- Participating Providers. The ONR is based on a percentage of what Medicare would pay the same Provider for the same service. If the amount billed by a Non-Participating Provider is equal to or less than the ONR amount, the charges should be completely covered by Us -- except for any Out-of-Network Copayment, Deductible and/or Coinsurance amounts You are required to pay under Your Plan. However, if the amount billed is greater than the ONR amount, You must also pay the amount in excess of the ONR amount, in addition to Your Copayment, Coinsurance and/or Deductible. This excess amount may be substantial. Please Remember: In addition to the Out-of-Network Copayment, Deductible and/or Coinsurance amounts You are required to pay for Out-of-Network Covered Services, You are also responsible for paying the billed charges that exceed the ONR amount We pay Non- Participating Providers. This excess amount may be substantial. CHCCHL-GA-POS-COC

11 Here is an example of what Your costs could be using an In-Network - Participating Provider under the following scenario: IN-NETWORK RULES IN-NETWORK AMOUNTS (A) Total amount billed by Participating Provider for a $5,000 procedure: (B) Our allowed amount for the procedure, as indicated in the Provider s contract with Us: $4,250 Your In-Network Deductible: $250 (C) We subtract Your Deductible from (B): $4,250 - $250 = $4,000 Your In-Network Coinsurance: 10% (D) We apply Your Coinsurance to (C): 10% of $4,000 = $400 Difference between (A) and (B): PLEASE NOTE: Because We have a contract with the Participating Provider, You are not responsible for paying the difference between the total billed amount and the allowed amount. Total Amount We Pay for Procedure: Total Amount You Pay for Procedure: $5,000 - $4,250 = $750 (You Are Not Required to Pay This Amount) $4,250 (Our Allowed Amount) $250 (Your Deductible) $400 (Your Coinsurance) $3,600 $250 (Your Deductible) + $400 (Your Coinsurance) $650 By contrast, here is an example of what Your costs could be using an Out-of-Network - - Non-Participating - Provider under a similar scenario: OUT-OF-NETWORK - - RULES OUT-OF-NETWORK - - AMOUNTS (A) Total amount billed by Non-Participating Provider for a $5,000 procedure: (B) Our Out-of-Network Rate (ONR) for the procedure. This is the amount We pay all Non-Participating Providers for this procedure: $4,250 Your Out-of-Network Deductible: $500 (C) We subtract Your Deductible from (B): $4,250 - $500 = $3,750 Your Out-of-Network Coinsurance: 30% (D) We apply Your Coinsurance to (C): 30% of $3,750 = $1,125 Difference Between (A) and (B): PLEASE NOTE: Because We do not have a contract with the Non- Participating Provider, You are required to pay the difference between the total billed amount and the ONR. Total Amount We Pay for Procedure: Total Amount You Pay for Procedure: $5,000 - $4,250 = $750 (You Are Required to Pay This Amount in Excess of the ONR) $4,250 (Our Allowed Amount) 500 (Your Deductible) 1,125 (Your Coinsurance) $2,635 $ 500 (Your Deductible) + $1,125 (Your Coinsurance) + $ 750 (Amount in Excess of ONR) $2,375 CHCCHL-GA-POS-COC

12 1.8 Submission of Bills and Claims. Participating Providers bill the Health Plan directly for all Covered Services. If You receive a bill or claim from a Provider, and have questions, please contact Customer Service. Bills or claims will not be accepted from Members later than one (1) year after the date of service. 1.9 How to Contact the Health Plan. Whenever You have a question or concern, please call Our Customer Service Department at the telephone number on Your Member ID card, or visit Our website at Our contact information is listed below. For Customer Service Department and To Submit Claims Hours Monday-Friday: 7:00 am to 6:00 pm EST Toll Free Telephone Number (800) Address: Coventry Health Care of Georgia, Inc. P.O. Box 7711 London, KY To Request a Review of Denied Claims or to Appeal a Denial of Authorization of Services Hours Monday-Friday: 7:00 am to 6:00 pm EST Toll Free Telephone Number (800) Address: Coventry Health Care of Georgia, Inc Circle 75 Parkway, Suite 1400 Atlanta, GA Attn: Appeals Department To Register a Complaint Hours Monday-Friday: 7:00 am to 6:00 pm EST Toll Free Telephone Number (800) Address: Coventry Health Care of Georgia, Inc Circle 75 Parkway, Suite 1400 Atlanta, GA Attn: Quality Department 1.10 Verification of Benefits. When We provide information about which health care services are covered under Your Plan, that information is referred to as verification of benefits. When You or Your Provider calls Our Customer Service Department at (800) during regular business hours to request verification of benefits, a Health Plan representative will be immediately available to provide assistance. If the health care services are verified as a covered benefit, the Customer Service representative will advise whether Prior Authorization is required. Please be aware that verification of benefits is not a guarantee of payment for services. 2.1 Eligibility. SECTION 2 ENROLLMENT, ELIGIBILITY AND EFFECTIVE DATES Subscriber Eligibility. To be eligible to be enrolled as a Subscriber, You must: a. Live or work in the Service Area; and b. Be an employee of the Group; and d. Meet any eligibility criteria specified by the Group Contract and approved by Coventry; and e. Complete and submit to Coventry such applications or forms that Coventry may CHCCHL-GA-POS-COC

13 reasonably request Dependent Eligibility. To be eligible to be enrolled as a Dependent, an individual must be the lawful spouse of the Subscriber, or be a child of the Subscriber or the Subscriber s spouse including: a. Children under age twenty-six (26) who are either the birth children of the Subscriber or the Subscriber s spouse or legally adopted by or placed for adoption with the Subscriber or Subscriber s spouse; b. Children under age twenty-six (26) for whom the Subscriber or the Subscriber s spouse is required to provide health care coverage pursuant to Qualified Medical Child Support; c. Children under age twenty-six (26) for whom the Subscriber or the Subscriber s spouse is the court-appointed legal guardian; and d. Children twenty-six (26) or older who are either the birth or adopted children of the Subscriber or the Subscriber s spouse, are mentally or physically incapable of earning a living and who are chiefly dependent upon the Subscriber for support and maintenance, provided that: the onset of such incapacity occurred before age twenty-six (26), proof of such incapacity is furnished to Us by the Subscriber upon enrollment of the person as a Dependent child or at the onset of the Dependent child s incapacity prior to age twenty-six (26) and annually thereafter. Notwithstanding the above, a common law spouse qualifies as a spouse under this Agreement only if his/her spousal status is affirmed by a court of competent jurisdiction. 2.2 Change of Group s Eligibility Rules. In order to be eligible for Coverage under this Health Plan, You must also meet specific Group eligibility requirements as defined in the Group Contract. So long as this Agreement is in effect, any change in the Group s eligibility requirements must be approved in advance by Coventry and evidenced in the Group Contract. 2.3 Persons Not Eligible to Enroll. a. A person who fails to meet the eligibility requirements specified in this Agreement shall not be eligible to enroll or continue enrollment with Coventry for Coverage under this Agreement. b. Late enrollees are not eligible to enroll except during the next Group Enrollment Period. A late enrollee is an individual who fails to enroll for Coverage during the required thirty-one (31) day period when they first become eligible for Coverage. c. A child born to or adopted by a Dependent child shall not be eligible to enroll. 2.4 Enrollment and Effective Dates Group Enrollment Period: All eligible employees of a Group and their eligible Dependents may enroll with Coventry for Coverage under this Agreement during the Group Enrollment Period by submitting an Enrollment Application to Coventry. Such employees and Dependents shall be covered under this Agreement as of the Member Effective Date, a date mutually agreed to by Coventry and the Group Newly Hired or Transferred Employees: All newly hired employees or employees transferred into or out of the Service Area and their eligible Dependents may enroll with Coventry for Coverage under this Agreement by submitting an Enrollment Application to Coventry within thirty-one (31) days after becoming eligible. Such employees and Dependents shall be covered under this Agreement as of the Member Effective Date, a date mutually agreed to by Coventry and the Group. If the employee fails to submit the Enrollment Application within thirty-one (31) days after becoming eligible, the employee and Dependents are not eligible to enroll until the next Group Enrollment Period, unless there is a special enrollment qualifying CHCCHL-GA-POS-COC

14 event as described in Section Special Enrollees: Special enrollees and their eligible Dependents may enroll with Coventry for Coverage under this Agreement as described in Section Newborns: A newborn child is automatically covered for the treatment of injury or sickness, including medically diagnosed congenital defects, birth abnormalities, premature birth and routine nursery care, for the first thirty-one (31) days from the date of birth. For Coverage to continue beyond the first thirty-one (31) days, application to add the child as a Dependent must be received within thirty-one (31) days from the date of birth. If no additional premium is required to enroll a Dependent under the family Coverage, then Coverage for the Dependent child is effective from the date of the birth, however, We should be given notice within thirty-one (31) days of the birth to add the Dependent child Adopted Children: An adopted child is automatically covered for the treatment of injury or sickness, including medically diagnosed congenital defects, birth abnormalities, premature birth and routine nursery care, for the first thirty-one (31) days from the date of the placement for adoption or the final decree of adoption, whichever is earlier. For Coverage to continue beyond the first thirty-one (31) days, application to add the child as a Dependent must be received within thirty-one (31) days from the earlier of the date of placement or adoption. If no additional premium is required to enroll a Dependent under the family Coverage, then Coverage for the Dependent child is effective from the date of placement or adoption, however, We should be given notice within thirty-one (31) days of the placement or adoption to add the Dependent child Qualified Medical Child Support Orders: Dependents eligible for Coverage as a result of a Qualified Medical Child Support Order shall be covered as of the date specified in the order. If no date is specified in the order, Coverage shall be effective as of the date the order is issued by the court. 2.5 Special Enrollment and Effective Dates Special Enrollment Qualifying Events. A special enrollment qualifying event is any of the following events: Marriage; Birth of a child; Adoption of a child (including placement for adoption); Involuntary loss of other coverage, including COBRA; and Loss of individual coverage is not a Qualifying Event Special Enrollment Due to Loss of Other Coverage. Subject to the conditions set forth below, an employee and his or her Dependents may enroll in this Health Plan if the employee waived Coverage. This could happen if the employee or Dependent had other coverage at the time the employee was first eligible to enroll and the employee s or Dependent s other Coverage was: a. COBRA continuation Coverage that has since been exhausted; or b. If not COBRA continuation Coverage, such other Coverage terminated due to a loss of eligibility for such coverage or employer contributions toward the other coverage terminated. The term loss of eligibility for such Coverage includes (1) a loss of coverage due to legal separation, divorce, death, termination of employment, or reduction in the number of hours of employment; or (2) in the case of coverage offered through an HMO, loss of coverage because the employee or Dependent no longer lives or works in the HMO s service area. This term does not include loss of coverage due to failure to timely pay required contributions or premiums or loss of coverage for cause (i.e., fraud or intentional misrepresentation); c. Required Length of Special Enrollment: An employee and his or her Dependents CHCCHL-GA-POS-COC

15 must request special enrollment in writing no later than thirty-one (31) days from the date that the other coverage was lost, d. Effective Date of Coverage: If the employee or Dependent enrolls within the thirtyone (31) day period, Coverage under the Health Plan will become effective no later st st than the first (1 ) day of the first (1 ) calendar month after the date the completed request for special enrollment is received. e. Loss of individual coverage is not a Qualifying Event, or considered loss of coverage that would qualify as a Special Enrollment right Special Enrollment Due to New Dependent Eligibility. Subject to the conditions set forth below, an employee and his or her Dependents may enroll in this Health Plan if the employee has acquired a Dependent through marriage, birth, adoption or placement for adoption. a. Non-participating Employee: An employee who is eligible but has not yet enrolled may enroll upon marriage or upon the birth, adoption or placement for adoption of his or her child (even if the child does not enroll). b. Non-participating Spouse: Your spouse may enroll at the time of marriage to You, or upon the birth, adoption or placement for adoption of his or her child (even if the child does not enroll). c. New Dependents of Covered Employee: A child who becomes a Dependent of a covered employee as a result of marriage, birth, adoption or placement for adoption may enroll at that time. d. New Dependents of Non-enrolled Employee: A child who becomes a Dependent of a non-enrolled employee as a result of marriage, birth, adoption or placement for adoption may enroll at that time but only if the non-enrolled employee is eligible for enrollment and enrolls at the same time. e. Required Length of Special Enrollment: An employee and his or her Dependents must request special enrollment in writing no later than thirty-one (31) days from the date of marriage, birth, adoption or placement for adoption. f. Effective Date of Coverage: Coverage shall become effective: (i) (ii) (iii) In the case of marriage, the date of marriage. A completed Enrollment Application must be received by the Health Plan within thirty-one (31) days of the date of marriage. In the case of a Dependent's birth, the date of such birth. In the case of a Dependent's adoption, the earlier of the date of placement for adoption or final decree of adoption. 2.6 Notification of Change in Status. You must notify the Health Plan of any changes in Your status or the status of any Dependent within thirty-one (31) days after the date of the qualifying event. This notification must be submitted on an Enrollment Application to the Health Plan. Events qualifying as a change in status include, but are not limited to, employment, divorce, marriage, dependency status, Medicare eligibility or Coverage by another insurance policy. The Health Plan should be notified within a reasonable time of the death of any Member. You should also notify the Health Plan within thirty-one (31) days of changes of address for You or Your Dependents. Divorce. Upon application made to Us within thirty-one (31) days following the entry of a valid divorce decree or death certificate, and upon payment of the appropriate premium, We will issue You an individual or family policy, providing coverage most nearly to the coverage contained in this policy. 2.7 Inpatient on the Member Effective Date. Regardless of whether a person is confined as an inpatient in any Hospital, Skilled Nursing Facility or Hospice on the date such person is to become a Member, the person shall become a Member on such Member Effective Date. The carrier (or health CHCCHL-GA-POS-COC

16 plan) on the day of the hospital admission, is responsible for covering the entire inpatient admission and physician charges, until discharge from the hospital. Upon discharge from the hospital, payment of benefits or services rendered after discharge, will be made according to Your new Coventry Health Care of Georgia policy. SECTION 3 TERMINATION OF COVERAGE 3.1 Termination of Member Coverage. Your Coverage shall terminate upon the occurrence of any one of the following events: At least sixty (60) days notice of termination of Your Coverage will be provided in person or by U.S. mail if: a. Your Group policyholder has performed an act or practice that constitutes fraud or intentional misrepresentation of material fact in applying for or procuring coverage under the terms of the Group health insurance policy or contract. b. Your Group policyholder has violated Coventry s minimum employer contribution or Group participation rules. c. You no longer live in the Service Area, unless You agree in writing to return to the Service Area to receive Covered Services (except for Emergency Services). d. You no longer meet the eligibility requirements set forth in this Agreement Due to the nonpayment of premiums Upon the termination or non-renewal of the Group Contract by the Group Upon termination, cancellation or non-renewal by Us of all Coverage under a particular policy form which affects You, provided that: a. Coventry provides at least ninety (90) days notice prior to the termination of the policy form to all policyholders and certificate holders; b. For a policy form used by small employers, We offer to such small employer policyholders the option to purchase all other group policies from Us currently being offered to or renewed by small employers in this State for which the small employer policyholders would otherwise be eligible; c. For a policy form used by large employers, We offer to such large employer policyholders the option to purchase any other group policy from Us currently being offered to or renewed by a large employer in Georgia; and d. We act uniformly without regard to the claims experience of any or all policyholders, covered employers, or any health status related factor relating to any enrollees or other eligibles covered by or eligible for Coverage under the policy If Coventry discontinues offering and terminates, cancels, or does not renew all Coverage in either the small employer market or the large employer market, or both, provided that: a. We provide at least one hundred eighty (180) days notice prior to the discontinuance or non-renewal of a policy or contract to all policyholders and certificate holders; b. We provide at least one hundred eighty (180) days notice to the Commissioner prior to the earliest date of termination or non-renewal related to the discontinuation in the market and indicates in such notice the date described in subparagraph (c) below; and CHCCHL-GA-POS-COC

17 c. We do not issue Coverage in such market for five (5) years beginning with the date of the last health insurance policy or contract in that market not renewed. CHCCHL-GA-POS-COC

18 If Your employer ceases membership in an association through which health insurance coverage is issued, provided that We were still issuing Coverage through that association, or the association was still making such Coverage available, and the coverage cancellation or non-renewal is uniform without regard to any health status related factor relating to any insured. If the association ceases to make coverage available under any health insurance policy or contract, or ceases to exist, employers covered under such association policies shall be considered policyholders and shall be guaranteed renewability by Us Immediate termination of Your Coverage will occur if You participate in fraudulent acts, including but not limited to: a. Performing an act or practice that constitutes fraud or intentionally misrepresenting material facts, including using Your identification card to obtain goods or services which are not prescribed or ordered for You or to which You are otherwise not legally entitled. In this instance, Coverage for the Subscriber and all of Subscriber s Dependents will be terminated. b. Allowing any other person to use Your identification card to obtain services. If a Dependent allows any other person to use his/her identification card to obtain services, the Coverage of the Dependent who allowed the misuse of the card will be terminated. If the Subscriber allows any other person to use his/her identification card to obtain services, the Coverage of the Subscriber and all of Subscriber s Dependents will be terminated.c. Knowingly misrepresenting or giving false information on any Enrollment Application form which is material to Coventry s acceptance of such application. d. You threaten or engage in violent acts against Us, a Provider, or an employee of Us or a Provider Once You have been accepted for Coverage, Your Coverage cannot be terminated by Us due solely to Your individual claims experience. 3.2 Effect of Termination If Your Coverage under this Agreement is terminated under Section 3.1, all rights to receive Covered Services shall cease as of the date of termination, except that if You are an inpatient in a Hospital, Skilled Nursing Facility or Hospice facility on the date of termination You shall continue to be covered under this Agreement until the date of discharge Identification cards are the property of Coventry and, upon request, shall be returned to Us within thirty-one (31) days of the termination of Your Coverage. Identification cards are for purposes of identification only and do not guarantee eligibility to receive Covered Services Your Coverage cannot be terminated on the basis of the status of Your health or the exercise of Your rights under Coventry s appeal and complaint procedures. Coventry may not terminate an Agreement solely for the purpose of effecting the disenrollment of an individual Member for either of these reasons. 3.3 Certificates of Creditable Coverage. At the time Coverage terminates You are entitled to receive a certificate of creditable coverage verifying the type of Coverage, the date of any waiting periods, and the date any creditable coverage began and ended. Certificates of creditable coverage shall be sent: a. Automatically upon a loss of Coverage for any reason under a plan, including due to a COBRA qualifying event (as described in Section 4); b. Automatically upon loss of COBRA Coverage; or c. At any time upon an individual s request within twenty-four (24) months after plan Coverage ends. CHCCHL-GA-POS-COC

19 SECTION 4 CONTINUATION OF COVERAGE 4.1 Continuing Group Coverage Under Federal Law Under federal law, an employer who has twenty (20) or more employees is subject to the Consolidated Omnibus Budget Reconciliation Act (COBRA). COBRA requires an employer to offer to Subscribers and Dependents the option to continue the Group Coverage for up to eighteen (18) months for one of the following qualifying events: a. the Subscriber s employment is terminated for any reason other than gross misconduct; b. reduction in the Subscriber s scheduled work hours (e.g., change from full-time to part-time, lay off, leave of absence, etc.); or c. the Subscriber s notification to the employer of the intent not to return to work, either during or after a Family Medical Leave Act approved leave If the Social Security Administration determines that the Subscriber was disabled during the first sixty (60) days of COBRA Coverage, Coverage for the Subscriber and Dependents may be continued for up to twenty-nine (29) months Coverage for Dependents may be continued for up to thirty-six (36) months for the following qualifying events: a. divorce; b. legal separation; c. attainment of the limiting age; d. the Subscriber s death; or e. the Subscriber becomes eligible for Medicare. There are additional COBRA provisions that address the issue of Group bankruptcy. If a surviving or divorced spouse is sixty (60) years of age or older, coverage may be continued until the surviving or divorced spouse becomes eligible for Medicare You must notify the Group s designated plan administrator within sixty (60) days of Your divorce, legal separation or loss of eligibility as a Dependent. Continuation must be elected by the later of sixty (60) days after the occurrence of Your qualifying event or sixty (60) days after the date You receive notification from the Group s designated administrator. The Group may require You to pay the full cost of the COBRA Coverage. The premium may not exceed 102% of the premium for similarly covered employees. A Member whose Coverage was terminated due to a qualifying event must pay the initial premium due to the Group s designated plan administrator on, or no later than, the forty-fifth (45 th ) day after electing COBRA continuation COBRA Coverage ends when: a. the maximum continuation period ends; b. the Group ceases to provide any group health plan for any employee; CHCCHL-GA-POS-COC

20 c. the required premium is not paid when due; d. coverage begins under another group health plan that does not include a preexisting condition clause; or e. the Member is eligible for coverage under Medicare This explanation is not a legal opinion. It is provided to You as a courtesy, and is merely a general summary of Your continuation of Coverage rights under COBRA. It is important to note that the Internal Revenue Service may change or amend COBRA from time-to-time. Please be aware that Your Group is responsible for complying with and administering COBRA Coverage. When You are hired, Your Group is responsible for informing You of the availability of COBRA Coverage. If Your Coverage under this Plan is terminated, Your Group is responsible for notifying You of Your eligibility for COBRA Coverage. Your Group is also responsible for notifying You if You are no longer eligible for COBRA Coverage. You should direct any questions about COBRA to Your Group. 4.2 Continuing Group Coverage Under Georgia Law (State Continuation Coverage) Under Georgia law, You and/or Your Dependents are entitled to state continuation Coverage if: a. Your employer averaged nineteen (19) or fewer employees for the prior calendar year; b. Your employment with the Group is terminated for any reason other than for cause; c. You have been continuously covered under this Health Plan or any preceding health plan for at least six (6) months immediately prior to termination; d. You are not enrolled in another group plan or Medicare; and e. You pay all required premiums, which is the same premium rate charged for similarly covered Subscribers State continuation Coverage begins on the day after Your termination date, and continues through the rest of the month plus three (3) additional months. At the end of the state continuation Coverage period, You have the right to elect conversion Coverage as described in Section To elect state continuation Coverage, You must notify the Group of Your election within thirty (30) days following Your termination date You are not entitled to state continuation Coverage if: a. termination of Coverage occurred because Your employment was terminated for cause; b. termination of Coverage occurred because You failed to pay any required premium contribution; c. Your discontinued Coverage is immediately replaced by similar group coverage (unless You were declined coverage under the replacement group coverage); d. Coverage was terminated for the entire class of employees to which You belong; CHCCHL-GA-POS-COC