CareFirst BlueChoice, Inc. 840 First Street, NE Washington, DC

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2 CareFirst BlueChoice, Inc. 840 First Street, NE Washington, DC An independent licensee of the Blue Cross and Blue Shield Association ELECTRONIC CONTRACT ACCURACY DISCLAIMER CareFirst BlueChoice has provided this evidence of coverage, including any amendments or riders applicable thereto, to the Group in electronic format. Any errors, changes and/or alterations to the electronic data, resulting from the data transfer or caused by any person shall not be binding on CareFirst BlueChoice. Such errors, changes and/or alterations do not create any right to additional coverage or benefits under the Group s health benefit plan, in accordance with the health benefit plan provided to the Group in hard copy format. The following policy forms comprise the health benefit plan: MD/CFBC/GC (R. 10/07); MD/CFBC/EOC (R. 7/03); MD/CFBC/DOCS (R. 7/03); MD/BC-OOP/SOB (R. 7/03); MD/CFBC/ELIG (R. 1/08); and any amendments. CareFirst BlueChoice, Inc. Jon Shematek, MD President CFBC E-BK DISCLAIM (1/04) 1 BC & BC -OA

3 CareFirst BlueChoice, Inc. 840 First Street, NE Washington, DC An independent licensee of the Blue Cross and Blue Shield Association Group Number: 0EGQ Group Name: DOCTORS COMMUNITY HOSPITAL Effective Date: January 1, 2008 CFBC/GRP ID (R. 7/06) Group

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5 CareFirst BlueChoice, Inc. 840 First Street, NE Washington, DC An independent licensee of the Blue Cross and Blue Shield Association EVIDENCE OF COVERAGE This Evidence of Coverage, including any Attachments, Amendments and Riders, is a part of the Group Contract issued to the Group through which the Subscriber is enrolled for health benefits. Group Name: DOCTORS COMMUNITY HOSPITAL Group Number: 0EGQ CareFirst BlueChoice, Inc. Jon Shematek, MD President MD/CFBC/EOC (R. 7/03) EOC-1 HMO

6 PART TABLE OF CONTENTS PAGE 1 Definitions EOC-3 2 Eligibility and Enrollment EOC-8 3 Termination of Coverage EOC-14 4 Conversion Privilege EOC-19 5 Multiple Coverage EOC-21 6 General Provisions EOC-28 7 Service Area EOC-34 ATTACHMENTS A Benefit Determinations and Appeals A-1 B Description of Covered Services B-1 C Schedule of Benefits C-1 D Eligibility Schedule D-1 MD/CFBC/EOC (R. 7/03) EOC-2 HMO

7 PART 1 DEFINITIONS The underlined terms when capitalized are defined as follows: Allowed Benefit means: A. For a Contracting Physician or Contracting Provider, the Allowed Benefit for a covered service is the lesser of: 1. The actual charge, which, in some cases, will be a rate set by a regulatory agency; or 2. The benefit amount CareFirst BlueChoice pays for the covered service that applies on the date that the service is rendered. The benefit payment is made directly to a Contracting Physician or Contracting Provider and is accepted as payment in full, except any applicable deductible, copayment or coinsurance as set forth in the evidence of coverage. The Member is responsible for any applicable deductible and copayment and the Contracting Physician or Contracting Provider may bill the Member directly for such amounts. B. For a non-contracting Hospital in the State of MD, a rate set by the state regulatory agency. C. For a non-contracting Trauma Physician for trauma care rendered to a trauma patient in a trauma center, the greater of: % of the rate paid by the Medicare program, as published by the Centers for Medicare and Medicaid Services, for the same covered service, to a similarly licensed provider; or 2. The rate as of January 1, 2001 that the health maintenance organization paid in the same geographic area, as published by the Centers for Medicare and Medicaid Services, for the same covered service, to a similarly licensed provider; D. For any other non-contracting Physician or non-contracting Provider, the greater of: % of the rate the health maintenance organization pays in the same geographic area, as published by the Centers for Medicare and Medicaid Services, for the same covered service, to a similarly licensed provider under written contract with the health maintenance organization; or, 2. The rate as of January 1, 2000 that the health maintenance organization paid in the same geographic area, as published by the Centers for Medicare and Medicaid Services, for the same covered service, to a similarly licensed provider not under written contract with the health maintenance organization. With respect to services rendered by non-contracting Providers, benefits may be paid to the Subscriber or to the non-contracting Provider at the discretion of CareFirst BlueChoice. The Member is responsible for the non-contracting Physician or non-contracting Provider's total charge and the non-contracting Physician or non-contracting Provider may bill the Member directly. Ancillary Services mean hospital services that may be rendered on an inpatient and/or outpatient basis. These services include but are not limited to: diagnostic services such as laboratory and radiology; operating room services; incremental nursing services; blood administration and handling; pharmaceutical services; durable medical equipment and medical supplies. Ancillary Services do not include room and board services billed by a facility for inpatient care. MD/CFBC/EOC (R. 7/03) EOC-3 HMO

8 Benefit Period means the period of time during which Covered Services are eligible for payment. The Benefit Period for this evidence of coverage is on a calendar year basis. Certificate or evidence of coverage, means this Evidence of Coverage. The evidence of coverage includes Attachment A, Benefit Determination and Appeals, Attachment B, Description of Covered Services, Attachment C, Schedule of Benefits, and Attachment D, Eligibility Schedule. In addition, the evidence of coverage may include one or more additional riders or amendments. Contract Renewal Date means the date specified in the Eligibility Schedule (Attachment D), on which this evidence of coverage renews and each annual anniversary of such date. Contracting Physician means a licensed doctor who has entered into a contract with CareFirst BlueChoice to provide services to Members and who has been designated by CareFirst BlueChoice as a Contracting Physician. Contracting Provider means any physician, health care professional or health care facility that has entered into a contract with CareFirst BlueChoice and has been designated by CareFirst BlueChoice to provide services to Members. Conversion Contract means a non-group health benefits contract issued in accordance with state law to individuals whose coverage through the Group has terminated. Cosmetic means a service or supply which is provided with the primary intent of improving appearance, not restoring bodily function or correcting deformity resulting from disease, trauma, or previous therapeutic intervention, as determined by CareFirst BlueChoice. Covered Service means a health care service included in the evidence of coverage and rendered to a CareFirst BlueChoice Member by: A. a provider under contract with CareFirst BlueChoice, when the service is obtained in accordance with the terms of the evidence of coverage; or B. A non-contracting Provider, when the service is 1. obtained in accordance with the terms of the evidence of coverage; or 2. obtained pursuant to a verbal or written referral, or preauthorized or otherwise approved either verbally or in writing by: a. CareFirst BlueChoice; or b. a provider under written contract with CareFirst BlueChoice. C. A health care provider or representative of a health care provider may collect or attempt to collect from the Member: 1. any deductible, copayment or coinsurance owed by the Member; or 2. any payment or charges for services that are not Covered Services. D. For Trauma Care rendered to a Trauma Patient in a Trauma Center by a Trauma Physician, CareFirst BlueChoice will not require a referral or preauthorization for a service to be covered. Dependent means a Member who is covered under this evidence of coverage as the eligible spouse or eligible child. Effective Date means the date on which the Member's coverage becomes effective. Services rendered on or after the Member's Effective Date are eligible for coverage. MD/CFBC/EOC (R. 7/03) EOC-4 HMO

9 Experimental Or Investigational means a service or supply that is in the developmental stage or in the process of human or animal testing. Services or supplies that do not meet all 5 of the criteria listed below are deemed to be Experimental or Investigational: A. The technology* must have final approval from the appropriate government regulatory bodies; B. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes; C. The technology must improve the net health outcome; D. The technology must be as beneficial as any established alternatives; and, E. The improvement must be attainable outside the investigational settings. * "Technology" includes drugs, devices, processes, systems, or techniques. FDA means the Federal Food and Drug Administration. Group means the Subscriber's employer or other organization to which CareFirst BlueChoice has issued the Group Contract and Evidence of Coverage. Group Contract means the agreement issued by CareFirst BlueChoice to the Group through which the benefits described in this evidence of coverage are made available to the Subscriber and his/her Dependents. In addition to the evidence of coverage, the Group Contract includes the Group Contract Application, and any riders, amendments or endorsements to the Group Contract or evidence of coverage signed by an officer of CareFirst BlueChoice. Hospital means any facility in which the primary function is the provision of diagnosis, treatment, and medical and nursing services, surgical or non-surgical and that is: A. Licensed by the appropriate State authorities; or B. Accredited by the Joint Commission on Accreditation of Healthcare Organizations; or, C. Approved by Medicare. The facility cannot be, other than incidentally, a convalescent home, convalescent rest or nursing facilities, facilities primarily affording custodial, educational or rehabilitative care, or facilities for the aged, drug addicts or alcoholics. Institute means the Maryland Institute for Emergency Medical Services Systems. Limiting Age means the age a Subscriber may cover his or her unmarried covered child as stated in the Eligibility Schedule (Attachment D). Medical Child Support Order means an "order" issued in the format prescribed by federal law; and issued by an appropriate child support enforcement agency to enforce the health insurance coverage provisions of a child support order. An "order" means a judgment, decree or a ruling (including approval of a settlement agreement) that: A. is issued by a court or administrative child support enforcement agency of any state or the District of Columbia; and, MD/CFBC/EOC (R. 7/03) EOC-5 HMO

10 B. creates or recognizes the right of a child to receive benefits under a parent's health insurance coverage; or establishes a parent's obligation to pay child support and provide health insurance coverage for a child. Medical Director is a board-certified physician who is appointed by CareFirst BlueChoice. The duties of the Medical Directors may be delegated to qualified persons. Medical Emergency means the sudden unexpected onset of a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine to result in: (1) placing the patient's health in serious jeopardy; (2) serious impairment to bodily functions; (3) serious dysfunction of any bodily organ or part; or, (4) jeopardy to the health of a fetus. Medically Necessary Or Medical Necessity means the use of a service or supply that is: A. Commonly and customarily recognized as appropriate in the diagnosis and treatment of a Member's illness or injury; B. Appropriate with regard to standards of good medical practice; C. Not solely for the convenience of the Member, his or her physician, hospital, or other health care provider; and, D. The most appropriate supply or level of service that can be safely provided to the Member. The term "not Medically Necessary" means the use of a service or supply which does not meet the above criteria for determining Medical Necessity. The decision as to whether a service or supply is Medically Necessary for purposes of payment by CareFirst BlueChoice rests with the Medical Director or his/her designee; however, such a decision shall in no way affect the provider's/practitioner's determination of whether medical treatment is appropriate as a matter of clinical judgment. Member means an individual who meets all applicable eligibility requirements and is enrolled either as a Subscriber or Dependent, and for whom the premiums have been received by CareFirst BlueChoice. Open Enrollment means a single period of time in each benefit year during which the Group gives employees the opportunity to change coverage or enroll in coverage. Primary Care Provider ("PCP") means a Contracting Physician or Contracting Provider selected by a Member to provide and manage the Member's health care. Qualified Medical Support Order ("QMSO") means a Medical Child Support Order issued under State law, or the laws of the District of Columbia, and when issued to an employer sponsored health plan that complies with Section 609(A) of the Employee Retirement Income Security Act of 1974, as amended. Service Area means the geographic area within which CareFirst BlueChoice's services are available. CareFirst BlueChoice may amend the defined Service Area at any time by notifying the Group in writing. Specialist is a licensed health care provider to whom a Member can be referred by a PCP. Subscriber means a Member who is covered under this evidence of coverage as an eligible employee, retiree, or other eligible participant of the Group rather than as a Dependent. Trauma Center means a primary adult resource center Level I Trauma Center, Level II Trauma Center, Level III Trauma Center, or pediatric Trauma Center that has been designated by the Institute to provide care to Trauma Patients. Trauma Center includes an out-of-state pediatric facility that has entered into an agreement with the Institute to provide care to Trauma Patients. MD/CFBC/EOC (R. 7/03) EOC-6 HMO

11 Trauma Patient means a Member that is evaluated or treated in a Trauma Center and is entered into the State trauma registry as a Trauma Patient. Trauma Physician means a licensed physician who has been credentialed or designated by a Trauma Center to provide care to a Trauma Patient at a Trauma Center. Types of Coverage means either Self-Only Coverage, which covers the Subscriber only, or Family or Subscriber and Children Coverage, under which a Subscriber may also enroll his or her Dependents. Some Group Contracts include additional categories of coverage, such as Subscriber and Spouse, or Subscriber and child (Two-Party Coverage). Types of Coverage available under this evidence of coverage are stated in the Group Contract Application and the Eligibility Schedule (Attachment D). MD/CFBC/EOC (R. 7/03) EOC-7 HMO

12 PART 2 ELIGIBILITY AND ENROLLMENT 2.1 Requirements for Coverage. The Group is required to administer all requirements for coverage in strict accordance with the terms that have been agreed to and cannot change the requirements for coverage or make an exception unless CareFirst BlueChoice approves them in advance, in writing. To be covered under the evidence of coverage, all of the following conditions must be met: A. The individual must be eligible for coverage either as a Subscriber or if applicable, as a Dependent pursuant to the terms of the evidence of coverage; B. The individual must elect coverage during certain periods defined in the evidence of coverage; C. The Group must notify CareFirst BlueChoice of the election in accordance with the Group Contract; and, D. Payments must be made by or on behalf of the Member as required by the Group Contract. Note: No individual is eligible as both a Subscriber and Dependent. If both a husband and wife are eligible as Subscribers, they may elect enrollment under two Self-Only coverages, one Two- Party Coverage or one Family Coverage, depending upon which types of coverage the Group has elected to offer. (They may not each have Two-Party or Family Coverage.) 2.2 Subscriber Eligibility. To enroll as a Subscriber, the individual must reside or work in the Service Area. In addition, the individual must meet the eligibility requirements established by the Group. See Attachment D, Eligibility Schedule. 2.3 Eligibility of Subscriber's Spouse. If the Group has elected to include coverage for the Subscriber's spouse under this evidence of coverage then a Subscriber may enroll his or her legal spouse as a Dependent. See Attachment D, Eligibility Schedule. A Subscriber cannot cover a former spouse once divorced or if the marriage had been annulled. 2.4 Eligibility of Children. If the Group has elected to include coverage for the Subscriber's children under this evidence of coverage then a Subscriber may enroll a child as a Dependent as limited below. See Attachment D, Eligibility Schedule. To be eligible, the child must: A. Not have reached the Limiting Age for eligible children as stated in Attachment D, Eligibility Schedule; B. Be unmarried; and C. Be related to the Subscriber, in one of the following ways: 1. A natural child; 2. A legally adopted child or grandchild; 3. A child (including a grandchild) for whom the Subscriber or covered spouse is the legally recognized proposed adoptive parent and who is dependent upon and living with the Subscriber or covered spouse during the waiting period before the adoption becomes final; 4. A stepchild who permanently resides in the Subscriber or covered spouse's household and who is dependent upon the Subscriber or covered spouse for more MD/CFBC/EOC (R. 7/03) EOC-8 HMO

13 than half of his or her support; 5. A grandchild who is in the court ordered custody of and is dependent upon and residing with the Subscriber or covered spouse; 6. A minor child, that resides with, is dependent on, and is in the custody of the Subscriber or covered spouse as a result of guardianship of at least 12 months duration, granted by court or testamentary appointment. 7. A child of the Subscriber or covered spouse who is incapable of self-support due to a mental or physical incapacity. The incapacity must have began before the child reached the Limiting Age. The child must be primarily dependent upon the Subscriber or the covered spouse for support and maintenance. The Subscriber must provide CareFirst BlueChoice with proof of the child's medical or mental incapacity and ongoing support. D. Children whose relationship to the Subscriber is not listed above, including, but not limited to grandchildren (except as provided above), foster children or children whose only relationship is one of legal guardianship are not covered under this Contract, even though the child may live with the Subscriber and be dependent upon him or her for support. E. Upon receipt of a QMSO, when coverage of the Subscriber's family members is available under the evidence of coverage, then CareFirst BlueChoice will accept enrollment submitted by the Subscriber regardless of enrollment period restrictions. If the Subscriber does not attempt to enroll the child then CareFirst BlueChoice will accept enrollment from the non-subscriber custodial parent; or, the appropriate child support enforcement agency of any State or the District of Columbia. If the Subscriber has not completed an applicable waiting periods for coverage the child will not be enrolled until the end of the waiting period. Enrollment for such a child will not be denied because the child: 1. Was born out of wedlock. 2. Is not claimed as a dependent on the Subscriber's federal tax return. 3. Does not reside with the Subscriber. 4. Is covered under any Medical Assistance or Medicaid program. 5. Does not reside in the Service Area. When a child subject to a QMSO does not reside with the Subscriber, CareFirst BlueChoice will: 1. send the non-insuring, custodial parent ID cards, claim forms, the applicable evidence of coverage or Member contract and any information necessary to obtain benefits; 2. allow the non-insuring, custodial parent or a provider of a Covered Service to submit a claim without the prior approval of the subscriber; 3. provide benefits directly to: a. the non-insuring, custodial parent; b. the provider of the Covered Services; or, MD/CFBC/EOC (R. 7/03) EOC-9 HMO

14 2.5 Limiting Age for Covered Children. c. the appropriate child support enforcement agency of any State or the District of Columbia. A. All covered children are eligible for coverage up to the Limiting Age for non-students, as stated in the Eligibility Schedule (Attachment D). B. Covered children may be eligible beyond the Limiting Age if they meet the requirements for Student Dependents, as described below: 1. Student Dependent means a covered child whose enrolled attendance at a public or private high school; college or university; graduate school; or trade school meets the institution's requirements for full-time status. 2. The Member must provide CareFirst BlueChoice with proof of the child's student status, within 31 days after the child's coverage would otherwise terminate or within 31 days after the effective date of the child's coverage under the evidence of coverage, whichever is later. CareFirst BlueChoice has the right to verify eligibility status. Coverage will be provided up to the Limiting Age for Student Dependents as stated in the Eligibility Schedule (Attachment D). C. A covered child will be eligible for coverage past the Limiting Age if at the time coverage would otherwise terminate: 1. The child is incapable of supporting himself or herself because of mental or physical incapacity; 2. The incapacity occurred before the covered child reached the Limiting Age or, if the child was covered beyond the Limiting Age as a non-student or Student Dependent, the incapacity occurred before the covered child reached the Student Dependent Limiting Age; 3. The child is primarily dependent upon the Subscriber or the Subscriber's covered spouse for support and maintenance; and 4. The Subscriber provides CareFirst BlueChoice with proof of the child's medical or mental incapacity within 31 days after the child's coverage would otherwise terminate. CareFirst BlueChoice has the right to verify whether the child is and continues to qualify as an incapacitated child. 2.6 Enrollment Opportunities and Effective Dates. Eligible individuals may elect coverage as Subscribers or Dependents, as applicable, only during the following times and under the following conditions: A. During the Group's Open Enrollment period. Open Enrollment changes will be effective on the open enrollment effective date stated in the Eligibility Schedule (Attachment D). 1. During the Open Enrollment period, the Group will provide an opportunity to all eligible persons to enroll in or transfer coverage between CareFirst BlueChoice and all other alternate health care plans available through the Group without individual underwriting or imposition of waiting periods, exclusions or limitations for pre-existing conditions. MD/CFBC/EOC (R. 7/03) EOC-10 HMO

15 2. In addition, Subscribers already enrolled in CareFirst BlueChoice may change their Type of Coverage (e.g. from Self-Only to Family Coverage) and/or add eligible Dependents not previously enrolled under their coverage. B. Newly Eligible Subscriber. Newly eligible individuals may enroll for themselves and eligible Dependents on the New Subscriber Eligibility Date stated on the Eligibility Schedule, (Attachment D). If such individuals do not enroll within this period and do not qualify for Special Enrollment as described below, they must wait for the Group's next open enrollment period. C. Special Enrollment Periods. 1. CareFirst BlueChoice shall allow an eligible individual or eligible Dependent who did not enroll for coverage during the open enrollment period, a special enrollment period to enroll for coverage if: a. the eligible individual or eligible Dependent was covered under another group health benefit plan or employer-sponsored plan, including COBRA or state continuation coverage, at the time coverage was previously offered under the evidence of coverage; b. the eligible individual stated in writing, at the time coverage was previously offered, that coverage under another group health benefit plan or employer-sponsored plan, including continuation coverage, was the reason for declining coverage under the evidence of coverage, but only if the Group or CareFirst BlueChoice required such statement and provided notification of the requirement to the eligible individual; and c. the coverage was terminated as a result of loss of eligibility for coverage, including loss of eligibility as a result of legal separation, divorce, death, termination of employment, or reduction in the number of hours of employment, or employer contributions towards the coverage were terminated; or in the case of continuation coverage, as a result of exhaustion of continuation coverage. 2. CareFirst BlueChoice shall allow an eligible individual or eligible spouse who is not enrolled under this evidence of coverage and who acquires an eligible Dependent by reason of marriage; birth; adoption; placement for adoption; court or testamentary appointed guardianship; Qualified Medical Support Order; or grandchild by court ordered custody, a special enrollment period to enroll for coverage under the terms of the evidence of coverage. 3. An eligible individual or eligible Dependent can apply for coverage within 31 days of: a. the date of termination of coverage; b. the date continuation coverage was exhausted; c. the date of the event, except if there is a medical child support order, the date CareFirst BlueChoice receives a written copy of the medical child support order by certified mail; or d. wait until the next open enrollment period. 4. If the eligible individual or eligible Dependent applies within this 31-day period, the effective date of coverage will be the date: MD/CFBC/EOC (R. 7/03) EOC-11 HMO

16 a. the prior coverage was terminated or exhausted; or b. the date of the event, except if there is a medical child support order, the date CareFirst BlueChoice receives a written copy of the medical child support order by certified mail. D. Newly eligible children. If the Group has elected to include coverage for the Subscriber's children under this evidence of coverage then a Subscriber may add a child to this evidence of coverage outside the open enrollment period as described below. Other than the categories of children listed below, other eligible children can only be added to this evidence of coverage during the Group's open enrollment period. 1. A newborn child of the Subscriber or covered spouse is automatically covered for the first 31 days from birth. Coverage for congenital defects and birth abnormalities is provided. 2. A grandchild of a Subscriber or covered spouse will be automatically covered for 31 days beginning on the date the grandchild is placed in the court ordered custody of the Subscriber. 3. A legally adopted child or grandchild of a Subscriber or covered spouse is automatically covered for 31 days from the date of adoption. Adoption means the earlier of: a judicial decree of adoption; or, the assumption of custody, pending adoption, of a prospective adoptive child by a prospective adoptive parent. 4. A child covered as a result of guardianship of at least 12 months duration, granted by court or testamentary appointment will be automatically covered for 31 days beginning on the day of the appointment. Coverage beyond 31 days may cost an additional premium. This occurs when the addition of the child changes the Subscriber's Type Of Coverage. When additional premium is due the Subscriber must notify the Group within 31 days of the Effective Date and the additional premium must be paid. Coverage will not be provided beyond the 31 days of automatic coverage when written notification enrolling the eligible child is not received within the 31-day period and/or the additional premium is not paid. Where the addition of a child does not change the Subscriber's Type of Coverage, the Subscriber is requested to provide CareFirst BlueChoice with written notice enrolling the eligible child. 2.7 Eligibility of Individuals Covered Under Prior Continuation Provisions. If at the time the Group Contract is first issued a person is covered under a federal or state required continuation provision of the Group's prior health insurance plan, the person will be considered eligible for coverage under the evidence of coverage. If at the time the Subscriber is first eligible for coverage under this evidence of coverage a person is covered under a federal or state required continuation provision of the Subscriber's prior health insurance plan, the person will be considered eligible for coverage under the evidence of coverage. 2.8 Clerical or Administrative Error. Clerical or administrative errors by the Group or CareFirst BlueChoice in recording or reporting data will not confer eligibility or coverage upon individuals who are otherwise ineligible under this evidence of coverage nor will such an error make an individual ineligible for coverage. 2.9 Cooperation and Submission of Information. CareFirst BlueChoice may require verification from the Group and/or Subscriber pertaining to the eligibility of any individual for whom CareFirst MD/CFBC/EOC (R. 7/03) EOC-12 HMO

17 BlueChoice receives enrollment information. The Group and/or eligible individual agrees to cooperate with and assist CareFirst BlueChoice, including providing CareFirst BlueChoice with reasonable access to Group records upon request. If the written request is sent to the Group and the Group fails to respond within 31 days, CareFirst BlueChoice will then send a copy of that request to the eligible individual and allow the eligible individual an additional 31 days to submit the information or documents required to establish eligibility directly to CareFirst BlueChoice. If such information and/or documents are not submitted by or on behalf of the eligible individual within this 31-day period, CareFirst BlueChoice will not enroll the eligible individual Proof of Eligibility. CareFirst BlueChoice retains the right to require proof of relationships or facts to establish eligibility. CareFirst BlueChoice will pay the reasonable cost of providing such proof. MD/CFBC/EOC (R. 7/03) EOC-13 HMO

18 PART 3 TERMINATION OF COVERAGE 3.1 Disenrollment of Individual Members. Coverage of individual Members will terminate on the date stated in the Eligibility Schedule (Attachment D), for the following reasons. A. CareFirst BlueChoice may terminate a Member's coverage for the following reasons: 1. Nonpayment of charges when due, including premium contributions that may be required by the Group, copayments and applicable deductibles, if any. 2. The Member no longer meets the conditions of eligibility. 3. Violation of reasonable, published policies of CareFirst BlueChoice, or an inability of the medical staff and the Member to establish a reasonable physicianpatient relationship. 4. The Member no longer works or resides in CareFirst BlueChoice's Service Area. 5. Fraudulent use of CareFirst BlueChoice identification card on the part of the Member, the alteration or sale of prescriptions by the Member, or an attempt by the Subscriber to enroll non-eligible persons as Dependents. B. The Group is required to terminate the Subscriber's coverage and the coverage of the Dependents if the Subscriber is no longer employed by the Group; or the Subscriber no longer meets the Group's eligibility requirements for health benefits coverage. C. The Group is required to notify the Subscriber if coverage is canceled. If the Group does not notify the Subscriber, this will not continue coverage beyond the termination date of coverage. The coverage will terminate on the termination date set forth in the Eligibility Schedule (Attachment D). D. The Subscriber and Dependents coverage will terminate if the Subscriber cancels coverage through the Group or changes to another health benefits plan offered by the Group. E. Dependents coverage will terminate if the Subscriber changes the Type Of Coverage to a Self-Only or other non-family contract, or makes a written request to CareFirst BlueChoice to remove an eligible Dependent from coverage. F. Dependent's coverage will automatically terminate if they no longer meet the eligibility requirements of the Group Contract because of a change in their age, status or relationship to the Subscriber. Coverage of an ineligible Dependent will terminate on the termination date set forth in the Eligibility Schedule (Attachment D). G. The Subscriber is responsible for notifying CareFirst BlueChoice (through the Group) of any changes in the status of Dependents that affect their eligibility for coverage under the evidence of coverage. These changes include a divorce, the marriage of a covered child, or termination of a Student Dependent's status as a full-time student. If the Subscriber does not notify CareFirst BlueChoice of these types of changes and it is later determined that a Dependent was not eligible for coverage, CareFirst BlueChoice has the right to recover these amounts from the Subscriber or Dependent, at CareFirst BlueChoice's option. 3.2 Death of a Subscriber. In the event of the Subscriber's death, coverage of any Dependent will end as stated in the Eligibility Schedule (Attachment D) under Termination of Coverage upon death of Subscriber. MD/CFBC/EOC (R. 7/03) EOC-14 HMO

19 3.3 Qualified Medical Support Order. Unless coverage is terminated for non-payment of the premium, a child subject to a Qualified Medical Support Order may not be terminated unless written evidence is provided to CareFirst BlueChoice that: A. The Qualified Medical Support Order is no longer in effect; B. The child has been or will be enrolled under other comparable health insurance coverage that will take effect not later than the effective date of the termination of coverage; C. The Group has eliminated family member's coverage for all Members; or, D. The Group no longer employs the Subscriber, except if the Subscriber elects continuation under applicable State or federal law the child will continue in this post-employment coverage. 3.4 Continuation of Eligibility upon Loss of Group Coverage. A. Federal Continuation of Coverage under COBRA: This provision applies if this group plan is subject to the Consolidated Omnibus Budget Reconciliation Act of 1985 as amended from time to time (COBRA) and a Member's coverage terminates due to a "Qualifying Event" as described under COBRA. If COBRA applies to this group plan, a Member may elect to continue coverage under the Group Contract to the extent and for the time period permitted by COBRA. The sponsor of this group plan is the Plan Administrator as described under the Employee Retirement Income Security Act of 1974 as amended from time to time (ERISA) and the associated regulations issued in connection with ERISA. It is the Plan Administrator's responsibility to notify a Member whether COBRA applies and, if so, the terms, conditions and rights that apply under COBRA. If a Member has any questions regarding rights under COBRA, the Member should contact the Plan Administrator. B. Maryland Continuation. Under Maryland law, applicable changes in status for a Member to qualify for continuation of coverage are: death of the Subscriber; divorce of the Subscriber and spouse; or voluntary or involuntary termination of the Subscriber's employment (other than for cause). 1. State Continuation for Spouse and Children as a Result of the Death of the Subscriber. This provision applies in the event of the death of a Subscriber who is a resident of Maryland and who was covered under the Group Contract or predecessor Group Contract with the same employer for at least three months prior to the death of the Subscriber. This provision also applies to a newborn child of the Subscriber born to the surviving spouse after the date of the Subscriber's death. Continuation of coverage under this provision shall be provided without evidence of insurability or additional waiting periods. Continuation coverage that is elected by or on behalf of a Dependent under the Group Contract shall begin on the date of the death of the Subscriber and end on the earliest of the following: a. 18 months after the date of the death of the Subscriber; b. the date on which the Dependent fails to make timely premium payment; c. the date on which the Dependent becomes eligible for hospital, medical, or surgical benefits under an insured or self-insured group health benefit program or plan, other than the group contract, that is written on an expense-incurred basis or is with a health maintenance organization MD/CFBC/EOC (R. 7/03) EOC-15 HMO

20 d. the date on which the Dependent becomes entitled to benefits under Medicare; e. the date on which the Dependent accepts hospital, medical, or surgical coverage under a non-group contract or policy that is written on an expense-incurred basis or is with a health maintenance organization; f. the date on which the Dependent elects to terminate coverage under the group contract; g. the date on which the employer ceases to provide benefits to its employees under a group contract. h. With regard to the coverage of a covered child, the date on which the Dependent child would no longer have been covered under the Group Contract if the Subscriber had not died. The election period to continue coverage under this provision begins on the date of the death of the Subscriber and expires 45 days after that date. To elect continuation of coverage under this provision, the Dependent or authorized representative must submit a signed election form to the Group within the election period. To continue coverage under this provision, the Dependent shall pay to the Group: the sum of the employer contribution and any contribution that the insured would have been required to pay if the insured had not died; and a reasonable administrative fee, not to exceed 2% of the premium. The payment of the amount specified above may be paid in monthly installments if the Dependent elects to do so. 2. State Continuation for Spouse and Children in the Event of Divorce. This provision applies in the event of the divorce of a Subscriber who is a resident of Maryland and whose coverage included one or more Dependents at the time of divorce. This provision also applies to a newborn child of the Subscriber born to the former spouse after the date of divorce. When this provision applies, Dependents of the Subscriber may continue to be covered under the Group Contract until the earliest of any of the following: a. The date of termination of the Subscriber's coverage under the Group Contract; b. The date on which there is a failure to make timely payment for this continuation coverage; c. The date the Dependent enrolls in other group or non-group coverage; d. The date on which the Subscriber becomes entitled to benefits under Medicare; e. With regard to the coverage of a spouse, the last day of the month in which the spouse remarries; f. With regard to the coverage of a covered child, the date on which the Dependent child would no longer have been covered under the Group MD/CFBC/EOC (R. 7/03) EOC-16 HMO

21 Contract if the Subscriber's divorce had not occurred, for example if the child marries or attains the limiting age; g. The effective date of an election by the Dependent to no longer be covered under the Group Contract; or h. The date on which the Group ceases to provide benefits to its employees under the Group Contract; To receive this continued coverage, the Subscriber or the divorced spouse must notify the Group of the divorce no later than: 60 days following the divorce if, on the date of the divorce, the Subscriber is covered under the Group Contract or another group health plan offered by the Group; or 30 days following the effective date of the Subscriber's coverage under this evidence of coverage if, on the date of the divorce, the Subscriber was covered under a group health plan offered through a different employer. The Subscriber or the former spouse of the Subscriber shall pay to the Group the full cost of the continuation coverage. 3. State Continuation for Subscriber and Dependents in the Event of Voluntary or Involuntary Termination of Employment for Any Reason Other Than Cause. This provision applies in the event of the voluntary and involuntary termination of employment of a Subscriber who is a resident of Maryland, who was terminated from employment for any reason other than cause and who was covered under the Group Contract or predecessor Group Contract with the same employer for at least three months prior to the termination of employment. When this provision applies, the Subscriber and any Dependent who was covered under the Subscriber on the date of termination may elect to remain covered under the Group Contract until the earliest of any of the following: a. 18 months after the date of termination of the Subscriber's employment; b. Failure to make timely payment for this continuation coverage; c. Enrollment in other group or non-group coverage; d. The date on which the Subscriber becomes entitled to benefits under Medicare; e. The effective date of an election by the Subscriber to no longer be covered under the Group Contract; f. the date on which the employer ceases to provide benefits to its employees under a group contract. With regard to the coverage of a covered child, the date on which the covered child would no longer have been covered under the Group Contract if the Subscriber's employment had not terminated, for example if the child marries or attains the limiting age; or the date on which the Group ceases to provide benefits to its employees under the Group Contract. MD/CFBC/EOC (R. 7/03) EOC-17 HMO

22 This continuation coverage must be elected, through submission of a signed election notification form to the Group, within 45 days after termination of the Subscriber's employment. The Subscriber is responsible for payment through the Group of the full cost of this continuation coverage that may include a reasonable administrative fee not to exceed 2% of premium, which is payable to and retained by the Group. No evidence of insurability is required. 3.5 Conversion Privilege. A Member may purchase a Conversion Contract upon expiration of continuation of coverage. 3.6 Extension of Benefits for Totally Disabled Individuals. A. If a Member is Totally Disabled when his/her coverage terminated, CareFirst BlueChoice shall continue to pay covered benefits, in accordance with the evidence of coverage in effect at the time the Member's coverage terminates, for expenses incurred by the Member for the condition causing the disability until the earlier of: 1. The date the Member ceases to be Totally Disabled; months after the date coverage terminates. Totally Disabled means your inability, due to a condition of physical or mental incapacity, to engage in the duties or activities of a person of the same age and sex in reasonably good health. We reserve the right to verify whether you are and continue to be Totally Disabled. CareFirst BlueChoice may at any time require the Member to provided proof of Total Disability. During an extension period required under this section a premium may not be charged. B. This section does not apply if: 1. Coverage is terminated because an individual fails to pay a required premium; 2. Coverage is terminated for fraud or material misrepresentation by the individual; or, 3. Any coverage provided by a succeeding health benefit plan a. is provided at a cost to the individual that is less than or equal to the cost to the individual of the extended benefit required under this section; and b. Does not result in an interruption of benefits. 3.7 Right to Continue Coverage Under Only One Provision. If a Member is eligible to continue coverage under the Group Contract under more than one continuation provision, the Member will receive only one such continuation coverage. The Member may select the continuation coverage of their choice. 3.8 Effect of Termination. No benefits will be provided for any services a Member receives on or after the date on which coverage under this evidence of coverage terminates, including any extension of benefits. This includes services received for an injury or illness that occurred before the effective date of termination. 3.9 Reinstatement. Coverage will not reinstate automatically under any circumstances. MD/CFBC/EOC (R. 7/03) EOC-18 HMO

23 PART 4 CONVERSION PRIVILEGE 4.1 Conversion Privilege. A. Group Conversion. 1. A Member shall be eligible for a conversion contract without evidence of insurability. 2. CareFirst BlueChoice will notify the Member of this conversion right within 31 days of the termination. The Member must apply within 31 days of the termination date, or, 31 days from the date CareFirst BlueChoice notified the Member, whichever is later. If CareFirst BlueChoice does not notify the Member of this conversion right the Member must apply for coverage no later than 90 days after the termination date. 3. Conversion coverage is effective on the Member's termination date under the evidence of coverage. 4. Benefits under the Conversion Contract may vary from the benefits under the evidence of coverage. CareFirst BlueChoice reserves all rights, subject to applicable laws, to determine the form and terms of the Conversion Contracts issued. B. A Member is not eligible for a conversion contract if termination of the Member's contract resulted from: 1. Inability of Contracting Providers and the Member to establish a reasonable physician-patient relationship. 2. Fraudulent use of CareFirst BlueChoice's identification card on the part of the Member, the alteration or sale of a prescription by a Member, or an attempt by the Subscriber to enroll non-eligible persons as Dependents. 3. Failure of the Subscriber to pay any premium charge when due. 4. Failure of a Member to pay any copayment or deductibles, if any, due. 5. The Member moves outside of CareFirst BlueChoice's Service Area. 4.2 Conversion Privilege Triggers. A. Subscriber No Longer Eligible for Group Coverage. If the Subscriber's coverage terminates because the Subscriber is no longer an employee or Member of the Group or no longer meets the Group's eligibility requirements for health benefits coverage, the Subscriber may purchase a conversion contract to cover himself/herself and his/her covered Dependents. B. Upon Subscriber's Death. Following the death of a Subscriber, the enrolled spouse or, if there is no spouse, the covered children of the Subscriber, may purchase a Conversion Contract. C. Upon Termination of Marriage. If a spouse's coverage terminates due to divorce or because the marriage is legally annulled, the spouse is entitled to purchase a Conversion Contract. MD/CFBC/EOC (R. 7/03) EOC-19 HMO

24 D. Upon Termination of Coverage of a Child. If coverage of a child terminates because the child no longer meets the eligibility requirements of this evidence of coverage (e.g., the child marries, attains the limiting age, becomes capable of self-support, etc.) the child is entitled to purchase a Conversion Contract. E. Upon Termination of the Group Contract by the Group. If coverage terminates because of the termination of the Group Contract by the Group, a Member may purchase a Conversion Contract if the Group has not provided for continued coverage through another health plan or other group insurance program offered by or through the Group. F. Upon Expiration of Continued Coverage. A Member may purchase a Conversion Contract upon expiration of continuation of coverage. MD/CFBC/EOC (R. 7/03) EOC-20 HMO

25 5.1 Coordination Of Benefits ("COB") A. Applicability PART 5 MULTIPLE COVERAGE 1. This Coordination of Benefits ("COB") provision applies to this CareFirst BlueChoice plan when a Member has health care coverage under more than one Plan. " Plan " and "this CareFirst BlueChoice plan" are defined below. 2. If this COB provision applies, the Order Of Benefit Determination Rules should be looked at first. Those rules determine whether the benefits of this CareFirst BlueChoice plan are determined before or after those of another Plan. The benefits of this CareFirst BlueChoice plan: a. Shall not be reduced when, under the order of determination rules, this CareFirst BlueChoice plan determines its benefits before another Plan; but b. May be reduced when, under the order of determination rules, another Plan determines its benefits first. The above reduction is described in the "Effect on the Benefits of this CareFirst BlueChoice Plan " section below. B. Terms. For the purpose of this COB section, the following terms are defined. The definitions of other capitalized terms are found in the Definitions section of This Certificate. 1. Plan: any health insurance policy, including those of nonprofit health service Plan's, and those of commercial group, blanket, and individual policies, any subscriber contracts issued by health maintenance organizations, and any other established programs under which the insured may make a claim. The term Plan includes coverage under a governmental Plan, or coverage required or provided by law. This does not include a State Plan under Medicaid (Title XIX, Grants to States for Medical Assistance Programs, of the United States Social Security Act, as amended from time to time.) The term Plan does not include: a. an individually underwritten and issued, guaranteed renewable, specified disease policy; b. an intensive care policy, which does not provide benefits on an expense incurred basis; c. coverage regulated by a motor vehicle reparation law; d. the first $100 per day of a Hospital indemnity contract; or, e. an elementary and or secondary school insurance program sponsored by a school or school system. An "intensive care policy" means a health insurance policy that provides benefits only when treatment is received in that specifically designated health care facility MD/CFBC/EOC (R. 7/03) EOC-21 HMO