2018 Evidence of Coverage - Arkansas · Anand Shukla SVP, Individual Health. Arkansas Health &...

2018 Evidence of Coverage

62141AR010

Ambetter.ARhealthwellness.com

https://Ambetter.ARhealthwellness.com

AMBETTER FROM ARKANSAS HEALTH AND WELLNESS

HomeOffice:OneAlliedDrive, Suite2520,LittleRock,AR,72202

MajorMedical ExpenseInsurancePolicy

In this policy, the terms "you" or "your" will refer to the covered person named on the Schedule of Benefits and "we," "our" or "us" willrefer to AmbetterfromArkansas Health & Wellness.

AGREEMENT AND CONSIDERATION In consideration of your application and the timely payment of premiums, we will provide benefits to you, the covered person, for covered services as outlined in this policy. Benefits are subject to policy definitions, provisions,limitations and exclusions.

GUARANTEED RENEWABLE Guaranteed renewable means that this policy will renew each year on the anniversary date unless terminated earlier in accordance with policy terms. You may keep this policy in force by timely payment of the required premiums. However, we may decide not to renew the policy as of the renewal date if: (1) we decide not to renew all policies issued on this form, with the same type and level of benefits, to residents of the state where you then live;or (2)there is fraud or an intentional material misrepresentation made by orwiththe knowledge of a covered person infilinga claimfor policy benefits.

Annually, we may change the rate table used for this policy form. Each premium will be based on the rate table in effect on that premium's due date. The policy plan, and age of covered persons, type and level of benefits, and place of residence on the premium due date are some of the factors used in determining your premium rates. We have the right to change premiums.

At least thirty‐one (31) days' notice of any plantotakean actionormakeachangepermitted bythis clause will be delivered to you at your last address as shown in our records. We will make no change in your premiumsolely because of claims made under this policy or a change in a covered person's health. While this policy is inforce, we will not restrict coverage already in force. Changes to this policy will be approved by the Arkansas InsuranceDepartment.

This policy contains prior authorization requirements. Benefits may be reduced or not covered if the requirements are not met. Please refer to the Schedule of Benefits and the Prior Authorization Section.

You arerequiredtoenrolleachyear in order to receive any subsidies forwhich you may beeligible.

CelticInsuranceCompany,

Anand ShuklaSVP,Indiv idualHealth

ArkansasHealth&Wellness,

John

Ryan CEOand Plan President

62141AR010 Member Services Department: 1‐877‐617‐0390

TDD/TTY1‐877‐617‐0392 Log on to: Ambetter.ARHealthWellness.com

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TABLE OF CONTENTS

PolicyFacePage................................................................................................................................................................................... 1Introduction.................................................. ........................................................................................................................................ 3MemberRightsandResponsibilities............................ .............................................................................................................. 4

Definitions..............................................................................................................................................................................................8 DependentMemberCoverage..................................... ................................................................................................................25

OngoingEligibility........................................... .................................................................................................................................27

Premiums...................................................... .......................................................................................................................................29

CostSharingFeatures......................................... ............................................................................................................................ 31

AccesstoCare..................................................................................................................................................................................... 32

MajorMedicalExpenseBenefits.................................................................................................................................................33

PriorAuthorization..........................................................................................................................................................................55

GeneralLimitations andExclusions..........................................................................................................................................57Termination.........................................................................................................................................................................................60

SubrogationandRightofReimbursement............................................................................................................................. 62

CoordinationofBenefits...................................... ..........................................................................................................................64

Claims.....................................................................................................................................................................................................67

InternalClaimsandAppealsProceduresandExternalReview.... ................................................................................70GeneralProvisions............................................................................................................................................................................77


TDD/TTY1‐877‐617‐0392 Log on to: Ambetter.ARHealthWellness.com

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Member Services Department: 1‐877‐617‐0390 TDD/TTY1‐877‐617‐0392

Log on to: Ambetter.ARHealthWellness.com

INTRODUCTIONWelcometoAmbetterfromArkansasHealth&Wellness!This policyhas beenprepar edby us to helpexplain your coverage.Please referto thispolicy whenever you requiremedicalservices.Itdescribes:

Howtoaccess medical care. Whathealth servicesare covered byus . Whatportion ofthe healthcarecosts you willberequiredtopay.

This policy, the Schedule of Benefits,theapplicationassubmittedtotheexchangeandanyamendmentsorridersattachedshallconstitutethe entirecontract underwhich covered services andsuppliesareprovided orpaidforby us.

This policy shouldbereadinitsentirety. Sincemanyoftheprovisionsareinterrelated,you shouldreadthe entire policy to get a full understanding of yourcoverage.Manywordsusedinthe policy have specialmeanings:thesewordsare italicized andaredefinedfor you intheDefinitionssection.This policy alsocontainsexclusions,soplease be sure toread this policy carefully.

How to Contact UsArkansasHealth&WellnessAmbetterfromArkansasHealth&WellnessOneAlliedDrive,Suite 2520Little Rock,AR 72202

NormalBusinessHoursofOperation8:00a.m.to5:00p.m.CST, MondaythroughFridayMember Services 1‐877‐617‐0390TDD/TTYline 1‐877‐617‐0392Fax1‐877‐617‐0393Emergency 91124/7 Nurse AdviceLine 1‐877‐617‐0390

Interpreter ServicesAmbetterfromArkansasHealth&Wellnesshasafreeserviceto help our members who speaklanguages otherthanEnglish.Thisserviceallows you andyour provider totalk about your medical orbehavioral healthconcernsinaway you bothcanunderstand. Our interpreterservicesare provided atno costto you.Wehave representatives thatspeakSpanish andalsohave medicalinterpreterstoassistwithotherlanguages. Members who areblind or visuallyimpairedandneedhelpwith interpretationcancallMember Servicesforanoralinterpretation.

Toarrangeforinterpretationservices,callMemberServicesat 1‐877‐617‐0390(TDD/TTY 1‐877‐617‐0392).

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MEMBER RIGHTS AND RESPONSIBILITIESWearecommittedto:1. Recognizingandrespecting you as a member.2. Encouragingopen discussionsbetween you, your physician and medical practitioners.3. Providinginformationtohelp you become an informed healthcare consumer. 4. Providingaccessto covered services and our network providers.5. Sharing our expectations of you as a member.6. Providingcoverageregardlessof age,ethnicity orrace,religion,gender,sexualorientation,national origin,physicalormental disability,or expectedhealthorgeneticstatus.

You have the right to:1. Participatewith your physician and medical practitioners inmaking decisionsabout your healthcare. Thisincludesworkingon any treatmentplans and making care decisions. You shouldknowanypossiblerisks,problemsrelatedto recovery, andthe likelihoodofsuccess. You shallnothaveanytreatment withoutconsent freely given by you or yourlegally authorized surrogatedecision‐maker. You willbe informedof your careoptions.

2. Knowwho is approvingandwhois performing the proceduresor treatment.Alllikelytreatmentandthenatureoftheproblem shouldbeexplained clearly.

3. Receive thebenefitsforwhich you havecoverage.4. Betreatedwithrespect anddignity.5. Privacyof your personalhealthinformation,consistentwithstateandfederal laws,and our policies.6. Receiveinformationor makerecommendations,includingchanges, about our organizationandservices, our network of physicians and medical practitioners,and your rightsandresponsibilities.

7. Candidlydiscusswith your physician and medical practitioners appropriate and medically necessary carefor your condition,includingnew usesof technology,regardlessofcostor benefit coverage. Thisincludesinformationfromyour primary care provider aboutwhat mightbe wrong (tothe levelknown),treatment andanyknownlikelyresults.Your primary care provider cantellyouabouttreatmentsthat may or may not becovered by the plan,regardlessofthe cost. You have arightto knowaboutanycosts you willneed topay.Thisshouldbe told to you inwords you can understand. Whenit isnotappropriateto give you informationfor medicalreasons,theinformationcan be givento a legally authorized person. Your provider willaskfor your approvalfor treatmentunless thereis an emergency and yourlife andhealth areinserious danger.

8. Make recommendationsregarding member’s rights,responsibilitiesandpolicies.9. Voice complaints or grievances about: our organization,any benefitorcoveragedecisions we (or ourdesignatedadministrators)make, your coverage,orcareprovided.

10. Refuse treatment for anycondition, illness ordiseasewithout jeopardizingfuturetreatment,andbe informedby your provider(s) ofthemedicalconsequences.

11. See your medical records.12. Bekept informedof covered andnon‐covered services,programchanges,how toaccessservices,

primary care provider assignment, providers,advancedirectiveinformation,referralsand authorizations,benefitdenials, member rightsand responsibilities,and our otherrules andguidelines.

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Member Services Department: 1‐877‐617‐0390TDD/TTY1‐877‐617‐0392


13. Acurrentlistof network providers.14. Selectahealthplanorswitchhealth plans,withinthe guidelines,withoutany threatsor harassment.

15. Adequate accesstoqualified medical practitioners andtreatmentorservices regardlessof age,race,creed,sex,sexual preference, national origin orreligion.

16. Access medically necessary urgent and emergency services 24 hoursaday and seven days aweek. 17. Receiveinformationin a differentformat in compliance with theAmericans withDisabilitiesAct,if

you have adisability.18. Refuse treatment tothe extentthe law allows. You are responsiblefor your actionsiftreatment is refusedorifthe primary care provider’sinstructionsarenot followed. You shoulddiscussall concernsabouttreatmentwithyour primary care provider. Your primary care provider candiscussdifferenttreatmentplans with you,if thereis more than one planthat may help you. You willmakethefinaldecision.

19. Select your primary care provider withinthe network. You alsohavetherighttochangeyour primary care provider orrequestinformationon network providers closetoyourhomeorwork.

20. Knowthe name andjobtitleofpeople giving youcare. You also have the righttoknowwhich physician is your primary care provider.

21. Aninterpreterwhen you donotspeak orunderstandthelanguageof the area. 22. Asecondopinionbya network provider,ornon‐ network provider,inwhich you willberesponsible for the out‐of‐network cost share, if you believe your network provider isnotauthorizing therequestedcare,orif you wantmoreinformation about your treatment.

23. Make advance directives forhealthcare decisions. Thisincludes planning treatment before you need it.

24. Advancedirectivesareforms you cancompletetoprotect your rightsfor medical care.Itcanhelp your primary care provider andother providers understand your wishesaboutyourhealth.Advance directiveswillnottakeaway your rightto make your owndecisionsandwillworkonly when youareunabletospeak foryourself.Examplesofadvancedirectivesinclude:a. LivingWill;b. HealthCare PowerofAttorney; and c. “DoNotResuscitate”Orders. Members alsohave the right torefuseto make advance directives. You shouldnotbe discriminated againstfor not having an advance directive.

You havethe responsibilityto:1. Readthis policy inits entirety. 2. Treatall healthcare professionals andstaffwithcourtesyandrespect. 3. Giveaccurate andcompleteinformationabout presentconditions,past illnesses,hospitalizations,medications,andothermattersabout your health. You shouldmake it known whether you clearlyunderstand your care andwhatis expectedof you. You needtoask questionsofyour provider until you understandthecare you are receiving.

4. Reviewandunderstandtheinformation you receive about us. You needto knowthe properuse of covered services.

5. Show your I.D.cardand keepscheduled appointmentswith your provider,andcallthe provider’s office during officehourswheneverpossibleif you haveadelayorcancellation.

6. Knowthenameof your assigned primary care provider. You shouldestablish arelationshipwith



your physician. You may change your primary care provider verballyor inwritingbycontacting ourMemberServices Department.

7. Readandunderstandtothebestof your abilityallmaterialsconcerning your health benefitsor ask forhelpif you needit.

8. Understand your healthproblemsandparticipate,alongwith your healthcare professionals and physicians in developing mutuallyagreedupontreatment goalstothe degreepossible.

9. Supply,totheextentpossible,informationthat we or your healthcare professionals and physiciansneedin ordertoprovide care.

10. Followthetreatment plansand instructionsforcarethat you have agreed on with your healthcare professionals and physician.

11. Tell your healthcare professional and physician if you donot understand your treatment plan or whatis expectedof you. You shouldworkwithyour primary care provider todeveloptreatment goals.If you donotfollowthetreatmentplan, you have the rightto be advisedofthelikelyresultsof your decision.

12. Followallhealthbenefitplanguidelines,provisions,policies andprocedures.13. Useanyemergencyroom onlywhen you thinkyou haveamedical emergency.Forallothercare, youshouldcall your primary care provider.

14. When you enrollinthiscoverage,giveallinformationabout anyother medicalcoverage you have. If,at anytime, you get othermedical coverage besidesthiscoverage, you musttell us.

15. Pay your monthlypremium ontime and pay all deductible amounts, copayment amounts,or cost‐sharing percentages atthetime ofservice.

16. Informtheentityinwhich you enrolledforthis policy if you haveanychangesto your name, address,orfamily members covered underthis policy within 60days fromthedate ofthe event.

Your Provider DirectoryAlistingof network providers isavailableonline at Ambetter.ARHealthWellness.com. We have plan physicians, hospitals,andother medical practitioners whohave agreedtoprovide you healthcareservices. Youcan findanyofour network providers byvisiting ourwebsite andselectingthe “Find a Provider” function.There you will have the abilityto narrow your searchby provider specialty,zipcode,gender, whetherornottheyarecurrently acceptingnew patients,andlanguagesspoken. Your searchwillproduce alistof providers basedon your searchcriteriaandwillgive you other information such asaddress,phone number,officehours,andqualifications.

Atany time, youcanrequestaprinted copy ofthe provider directoryat no charge by calling Member Servicesat 1‐877‐617‐0390.Inordertoobtain benefits, you mustdesignate a network primary care provider foreach member. We canalsohelp you picka primary care provider (PCP).Wecanmakeyour choiceof primary care provider effectiveonthenextbusinessday.

Callthe primary care provider’s office ifyouwantto make an appointment.If you needhelp,callMember Services at 1‐ 877‐617‐0390. We willhelp you maketheappointment.

Your Member ID CardWhen you enroll, we will mailyoua member ID card after our receiptof your completed enrollmentmaterials,whichincludesreceiptofyourinitial premiumpayment.Thiscardisproofthat you areenrolledinan Ambetterplan andis validonce yourbinder payment has beenpaidandenrollmentprocessing is

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complete. You needtokeepthiscardwith you atalltimes.Pleaseshowthiscardevery time you goforany serviceunderthe policy.

TheIDcardwillshow your name, member ID# and copayment amounts requiredatthetime ofservice.If you donot getyourIDcardwithina fewweeksafter you enroll,pleasecallMember Servicesat 1‐ 877‐617‐0390. We willsend you anothercard.

Our Website Our websitehelps you get the answers to many of your frequentlyaskedquestionsandhasresourcesand featuresthat makeit easy to get qualitycare. Our websitecanbeaccessedat Ambetter.ARHealthWellness.com.Italsogives you information on your benefitsand servicessuchas: 1. Findinga network provider.2. Ourprograms andservices,includingprogramstohelp you get and stay healthy. 3. Asecureportalfor you to checkthestatusof your claims,make paymentsandobtain acopyof your

member IDcard.4. MemberRightsandResponsibilities.5. NoticeofPrivacy.6. Currenteventsandnews.7. Our formularyorpreferreddruglist. 8. Deductible and Copayment Accumulators.9. Selectinga primary care provider.

If you have materialmodifications(examplesincludea change inlife event suchas marriage,death orother changein familystatus),orquestions relatedto your healthinsurancecoverage,contact theHealth Insurance Marketplace (Exchange) at www.healthcare.gov or 1‐800‐318‐2596.

Quality Improvement We are committedto providingqualityhealthcare for you and your family. Our primary goal istoimprove your health andhelp you with any illness ordisability. Our programisconsistentwith NationalCommitteeonQualityAssurance(NCQA)standardsandInstituteofMedicine (IOM)priorities.To helppromote safe, reliable,andqualityhealthcare, our programsinclude:1. Conductingathoroughcheckon providers whenthey becomepartofthe provider network.2. Monitoring member accesstoalltypesofhealthcareservices.3. Providingprogramsandeducational items aboutgeneral healthcareandspecificdiseases. 4. Sendingremindersto members to get annualtestssuchas a physicalexam,cervicalcancer screening, breastcancerscreening,and immunizations.

5. Monitoring thequality of careanddevelopingaction planstoimprovethe healthcare you are receiving.

6. AQuality Improvement Committee whichincludes network providers tohelpusdevelopand monitor ourprogramactivities.

7. Investigatingany member concernsregardingcarereceived.

Forexample, if you have a concern aboutthe care you receivedfromyour network provider orserviceprovidedby us,pleasecontactthe MemberServicesDepartment.

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http://www.healthcare.gov




We believethatgetting member inputcan help make the content and qualityof our programsbetter. Weconducta member surveyeachyear that asksquestionsabout your experiencewiththe healthcare and services you arereceiving.

DEFINITIONS

Inthis policy,italicizedwordsaredefined. Wordsnotitalicizedwillbegiventheirordinarymeaning.

Whereverusedinthis policy:

Abortion meansthe useorprescriptionof anyinstrument, medicine,drug,oranyothersubstance ordeviceintentionallytoterminatethe pregnancy of a member knownto bepregnantwithanintentionotherthanto increase theprobabilityofalivebirth,to preserve the life orhealthofthe childafterlivebirth,ortoremove a deadunborn childwhodiedastheresultofnaturalcauses, accidentaltrauma,or acriminal assaultonthepregnant member orthe member’s unbornchild.

Acute rehabilitation meanstwo or moredifferent types of therapyprovided byone ormore rehabilitation licensedpractitionersandperformedforthreeormorehoursperday,five(5)toseven (7)days per week, whilethe covered person isconfinedas an inpatient in a hospital, rehabilitation facility,or skilled nursing facility.

Ambulatory review means utilization review ofhealthcareservicesperformedorprovidedinanoutpatient setting.

Advanced premium tax credit meansthetaxcreditprovidedby theAffordableCareActtohelpyouaffordhealthcoveragepurchasedthrough theExchange.Advance paymentsof the tax creditcan be usedright away toloweryourmonthlypremium costs.If you qualify, youmaychoosehow muchadvance creditpaymentstoapplytoyour premiums eachmonth,up toa maximum amount. If the amount of advance creditpaymentsyou get forthe yearis lessthan the tax credityou'redue,you'llgetthedifferenceasa refundablecreditwhen youfileyour federalincometaxreturn. If youradvance payments for the year are morethan theamountof yourcredit,youmustrepaytheexcess advancepaymentswithyour taxreturn.

Adverse benefit determination meansadetermination by us that an admission,availabilityofcare,continuedstayorotherhealthcareservicethat is acoveredbenefit has been reviewed and,baseduponthe information provided,doesnot meet ourrequirements for medical necessity,appropriateness,healthcare setting,level ofcare, effectiveness,and therequested serviceor payment for theservice is therefore denied,reducedorterminated.

Referto the Internal Grievance, InternalAppeals andExternal AppealsProceduresectionofthis contract forinformationon your rightto appeal an adverse benefit determination.

Allogeneic bone marrow transplant or BMT meansaprocedureinwhich bone marrow from arelated ornon‐relateddonorisinfusedintothe transplantrecipientand includesperipheralbloodstemcell transplants.

Applicable non‐English language, withrespectto an addressinanyUnitedStatescountytowhich anoticeissent,anon‐Englishlanguageisan applicable non‐English language iftenpercentormoreofthe

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population residingin the countyisliterate only in the same non‐Englishlanguage,asdeterminedin guidance publishedbytheSecretary.

Applied Behavioral Analysis means thedesign,implementation, andevaluation of environmental modificationsby a board‐certifiedbehavior analyst usingbehavioralstimuliandconsequencestoproducesociallysignificantimprovement inhumanbehavior,includingtheuse ofdirectobservation,measurement, andfunctionalanalysisof therelationshipbetween environment andbehavior.

Authorization (also“PriorAuthorization”or“Approval”) meansadecisiontoapprovespecialty orothermedically necessary care for a member bythe member’s PCPor provider group.

Authorized representative means an individualwho represents you in an internalappealor external reviewprocessofan adverse benefit determination whois any of the following:1. Aperson towhomacoveredindividualhasgivenexpress,writtenconsent to representthat individualin an internal appealsprocessorexternalreviewprocessofan adverse benefit determination;

2. Aperson authorized bylawtoprovide substituted consentforacoveredindividual;3. Afamily member but onlywhen you areunable to provideconsent.

Autism spectrum disorder means anyof the pervasivedevelopmentaldisordersasdefinedbythemostrecenteditionoftheDiagnostic andStatisticalManualof Mental Disordersandthe mostcurrentversionoftheInternationalStatisticalClassificationofDiseasesandRelatedHealthProblems,including:autisticdisorder;Asperger’sdisorder;andpervasivedevelopmentaldisordernot otherwisespecified.

Autologous bone marrow transplant or ABMT means aprocedureinwhich the bone marrowinfusedis derivedfrom thesamepersonwho isthetransplantrecipientandincludesperipheralbloodstemcelltransplants.

Balance billing means a non‐network provider billing you forthedifference between the provider’s chargeforaserviceandthe eligible expense. Network providers may notbalance bill you for covered expenses.

Bereavement counseling meanscounselingof members ofa deceasedperson's immediate family thatis designedto aidthem in adjustingtotheperson's death.

Calendar Year is theperiodbeginningontheinitial effective date ofthis policy andendingDecember31ofthatyear.ForeachfollowingyearitistheperiodfromJanuary 1 through December31.

Case Management is a program in whicharegisterednurse,knownasacasemanager,assistsa memberthroughacollaborativeprocessthatassesses,plans,implements,coordinates,monitorsandevaluatesoptionsandhealthcarebenefitsavailableto a member. Case management isinstitutedatthesole optionof us when mutually agreed toby the member andthe member’s physician. Communicationsmadeby a physician responsibleforthedirectcareofa member in case management withinvolved healthcare providers are covered.

Claim involving urgent care means any claimforcare or treatment withrespecttothe applicationof thetimeperiodsformakingnon‐urgent caredeterminations: 1. Couldseriouslyjeopardize the life orhealth oftheclaimantortheabilityofthe claimant to regainmaximum function,or,

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2. Inthe opinion ofa physicianwith knowledge oftheclaimant’s condition,wouldsubjecttheclaimant toseverepain that cannot be adequatelymanaged withoutthe careortreatment isthe subjectoftheclaim.

Thedeterminationwhetheraclaimisa“claim involving urgent care”willbe determinedbythe plan; or,by a physician withknowledgeof the claimant’s medicalcondition.

Coinsurance meansthe percentage of covered expenses that you are required topaywhen you receive a service. Coinsurance amountsare listedinthe Schedule of Benefits.Notall covered services have coinsurance.

Coinsurance percentage means the percentage of covered expenses that arepayable by the member.

Complaint meansanyexpressionof dissatisfactionexpressedtotheinsurerbytheclaimant, oraclaimant’sauthorizedrepresentative,aboutaninsurerorits providers withwhom the insurerhas a directorindirect contract.

Complications of pregnancy means:1. Conditionswhosediagnosesare distinctfrom pregnancy,but are adverselyaffectedby pregnancyorare causedby pregnancy andnot,fromamedicalviewpoint,associatedwithanormal pregnancy.Thisincludes:ectopic pregnancy,spontaneous abortion,eclampsia,missed abortion,andsimilarmedicalandsurgicalconditionsofcomparableseverity; but it doesnotinclude:falselabor, preeclampsia,edema,prolongedlabor, physician prescribedrestduringtheperiodof pregnancy,morningsickness,andconditionsofcomparable severity associatedwithmanagementofadifficult pregnancy,andnotconstitutingamedicallyclassifiabledistinctcomplicationof pregnancy; and

2. An emergency caesareansectionora non‐elective caesarean section.

Continuous loss meansthat covered expenses arecontinuouslyandroutinely beingincurredfortheactive treatment ofan illness or injury.Thefirst covered expense for the illness or injury must havebeen incurred beforeinsuranceofthe covered person ceased underthis policy.Whetherornot covered expenses arebeing incurredfortheactivetreatmentofthecovered illness or injury willbe determined by us basedon generallyacceptedcurrentmedicalpractice.

Copayment, Copay, or Copayment amount meansthespecificdollaramountthat you mustpay when youreceive covered services. Copayment amounts areshownin the Schedule of Benefits.Notall covered services havea copayment amount.

Cosmetic treatment meanstreatments,procedures,orservices thatchange orimproveappearancewithoutsignificantlyimproving physiologicalfunctionandwithoutregardtoanyassertedimprovementtothepsychologicalconsequencesorsociallyavoidantbehaviorresultingfroman injury, illness,orcongenitalanomaly.

Cost sharing meansthe deductible amount, copayment amount and coinsurance that you pay for covered services.The cost sharing amountthat you are requiredtopay foreach type of covered service islistedinthe Schedule of Benefits.

Cost sharing percentage meansthe percentage of covered services that ispayable by us.

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Cost sharing reductions meansreductionsin cost sharing for aneligibleindividual enrolledinasilverlevel planin the Exchange or foran individualwho isanAmerican Indianor AlaskanNativeenrolledin a QHP intheExchange.

Covered expense or Covered service means anexpenseor servicethatis: 1. Incurredwhile your or your dependent's insuranceis inforceunderthis policy;2. Covered byaspecificbenefitprovisionofthis policy; and3. Notexcludedanywhereinthis policy.

Covered person means you, your lawful spouse andeach eligible child:1. Namedin the application; or2. Whom we agreein writing to addas a covered person.

Craniofacial anomaly meansacongenitaloracquired musculoskeletaldisorderthatprimarilyaffectsthe cranial facial tissue.

Craniofacial corrective surgery means the use of surgery toaltertheform andfunctionofthe cranialfacialtissuesdueto a congenitalor acquiredmusculoskeletal disorder.

Custodial care istreatmentdesignedtoassista covered person withactivitiesofdailyliving andwhich canbeprovidedbyalaypersonandnotnecessarilyaimedatcuring orassistinginrecovery from a sicknessor bodily injury.

Custodial care includesbutisnot limitedtothefollowing: 1. Personalcare suchasassistance in walking,getting inandout ofbed,dressing,bathing, feeding and useof toilet;

2. Preparation andadministration ofspecialdiets;3. Supervisionoftheadministrationofmedicationbyacaregiver;4. Supervisionofself‐administrationofmedication;or5. Programsand therapiesinvolving ordescribedas,butnotlimitedto,convalescentcare, restcare,sanatoriacare,educational careorrecreationalcare.

Suchtreatmentiscustodialregardlessofwhoorders,prescribesorprovidesthetreatment.

De minimis meanssomethingnotimportant; somethingsominorthatitcan beignored.

Deductible amount or Deductible meansthe amountthat you mustpay ina calendar year for covered expenses before we willpay benefits. Forfamilycoverage,thereisafamily deductible amount whichistwo timestheindividual deductible amount.Both the individualand the family deductible amounts areshownin the Schedule of Benefits.

If you are a covered member inafamily oftwo ormore members,youwillsatisfy your deductible amount when:1. You satisfy your individual deductible amount;or2. Your familysatisfiesthefamily deductible amount forthe calendar year.

If you satisfy your individual deductible amount,eachoftheother members of yourfamily are still responsibleforthe deductible untilthefamily deductible amount issatisfiedforthe calendar year.

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Dental expenses means surgery orservicesprovidedtodiagnose,prevent,orcorrectanyailmentsor defectsof the teeth andsupportingtissueandanyrelatedsuppliesororal appliances.Expensesforsuch treatment areconsidered dental expenses regardlessofthereasonfortheservices.

Dependent means your lawful spouse oran eligible child.

Durable medical equipment means itemsthat are usedto serve a specific diagnostic ortherapeutic purposeinthetreatmentofan illness or injury,can withstandrepeateduse, aregenerallynotusefultoa personin the absence of illness or injury,andareappropriate forusein the patient'shome.

Effective date means thedate a member becomescoveredunderthis policy for covered services.

Eligible child means thechild of a covered person,ifthatchildis lessthan 26 years of age. As usedinthisdefinition,"child"means:1. Anaturalchild;2. Alegallyadoptedchild;3. Achildplacedwith you foradoption;or4. Achildforwhomlegalguardianshiphasbeen awardedto you or your spouse.

Itis your responsibilitytonotifytheExchange if your childceasestobean eligible child. You mustreimburse us for anybenefitsthat we pay for achild at a timewhenthe child didnotqualify asan eligible child.

Eligible expense means a covered expense asdetermined below. 1. For network providers:When a covered expense isreceived from a network provider,the eligible

expense isthe contracted fee withthat provider.2. For non‐network providers:

a. Whena covered expense (excludingTransplant Benefits)isreceivedfrom a non‐network provider asa resultof an emergency,the eligible expense isthe negotiatedfee,if any,that has beenmutuallyagreeduponby us and the provider (you willnotbebilledforthedifferencebetweenthenegotiatedfeeandthe provider’s charge).However,ifthe provider hasnotagreedto accepta negotiated fee aspayment in full,the eligible expense isthe greatestofthe following:i. theamountthatwouldbe paidunderMedicare, ii. theamountforthe covered service calculatedusingthesame method we generally useto determine paymentsfor out‐of‐network services,or

iii. thecontractedamount paidto network providers forthe covered service.If thereis morethanonecontractedamountwith network providers forthe covered service,theamountisthemedian ofthese amounts.

Youmaybebilledforthedifferencebetweentheamount paidandtheprovider’scharge. b. Whena covered expense (excludingTransplant Benefits)isreceivedfrom a non‐network

provider asapprovedor authorized by usthatis not theresultof an emergency,or because theserviceor supplyisnotofa type providedby any network provider,the eligible expense isthelesser of(1)the negotiatedfee, ifany,thathasbeen mutuallyagreeduponby us and the provider;or(2) the amount acceptedby the provider (nottoexceedthe provider’scharge).

c. Except asprovidedunder (2)(a) and(2)(b)above,whena covered expense (excludingTransplantBenefits)isreceivedfroma non‐network provider,the eligible expense isdetermined basedonthe lowestamount of the following:i. thenegotiatedfee thathasbeen agreedupon by us andthe provider;

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ii. 100%ofthe fee Medicare allowsforthe same orsimilarservicesprovidedinthe samegeographicalarea;

iii. thefee establishedby us bycomparing ratesfrom one ormoreregionalor nationaldatabasesor schedulesfor thesameorsimilarservicesfroma geographicalarea determinedby us;

iv. thefeechargedbythe provider forthe services;or v. afeeschedulethat we develop.

Youmaybebilledforthedifferencebetweentheamount paidandtheprovider’scharge. 3. Transplantbenefitsarecovered as an eligible expense when received by a network provider orby a

non‐network provider,when authorized by us.

Emergency meansamedicalconditionmanifestingitself byacutesymptoms ofsufficientseverityincluding severe pain whichrequiresimmediate (no laterthan 48 hours after onset)medicalor surgicalcare andsuchthat an averagepersonwho possessesanaverageknowledge of health andmedicine,couldreasonably expectthe absenceof immediate medicalattentionto resultin:1. Placingthe health ofthe covered person or,withrespecttoapregnant member,thehealth ofthe

member or the member’s unbornchildinserious jeopardy;2. Seriousimpairmenttobodilyfunctions;or3. Seriousdysfunctionofany bodilyorganorpart.

Emergency services meansthe following:1. Amedicalscreeningexamination, as requiredbyfederallaw,thatiswithin thecapabilityof the emergencydepartment ofa hospital,includingancillaryservices routinelyavailabletothe emergencydepartment,to evaluate an emergency medicalcondition;

2. Suchfurthermedicalexamination andtreatment thatarerequiredby federallawto stabilize an emergency medicalconditionandarewithin the capabilitiesof thestaff and facilitiesavailable at the hospital,includinganytrauma and burn center of the hospital.

Essential health benefits providedwithinthiscertificate are notsubject to lifetimeorannual dollarmaximums.Certain non‐essential health benefits,however,are subjectto eitheralifetimeorannualdollar maximum. Essential health benefits are definedby federal law and refertobenefitsinatleastthefollowing categories:ambulatory patient services, emergency services,hospitalization,maternity andnewborn care,mentalhealthand substance use disorder services,includingbehavioralhealthtreatment, prescription drugs,rehabilitativeand habilitative services anddevices,laboratoryservices, preventiveandwellnessservices,and Chronicdiseasemanagement andpediatricservices,includingoral andvisioncare.

Expedited grievance meansa grievance whereanyofthefollowingapplies:1. Thedurationofthestandardresolutionprocesswillresultin seriousjeopardytothelifeorhealthofthe claimant orthe abilityof the claimant toregainmaximum function;

2. Inthe opinion ofa provider withknowledge ofthe claimant’smedicalcondition,theclaimantis subjectto severepain thatcannot beadequatelymanagedwithoutthecare ortreatmentthat isthe subjectofthe grievance; and

3. A provider withknowledgeoftheclaimant’smedicalconditiondetermines thatthe grievance shallbetreated as an expedited grievance.

Experimental or investigational treatment meansmedical,surgical,diagnostic,orotherhealthcareservices,treatments,procedures,technologies,supplies,devices,drugtherapies,or medicationsthat,afterconsultation withamedicalprofessional, we determinetobe:1. Understudy inan ongoingphase IorIIclinicaltrial assetforth intheUnitedStatesFoodandDrug Administration(FDA)regulation,regardlessofwhetherthe trialissubject to FDA oversight;

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2. An unproven service;3. Subjectto FDA approval, and:

a. Itdoesnothave FDA approval;b. Ithas FDA approvalonlyunderitsTreatment Investigational NewDrugregulationor asimilarregulation;

c. Ithas FDA approval,but isbeing used for an indicationoratadosagethatisnotanaccepted off‐label use.An accepted off‐labeluse ofa FDA‐approveddrugisausethatisdetermined by us tobe:i. Includedinauthoritativecompendia asidentified fromtimeto timebytheSecretary ofHealthandHumanServices;

ii. Safe andeffectiveforthe proposeduse basedonsupportiveclinicalevidence inpeer‐reviewedmedical publications; or

iii. Notan unproven service; ord. Ithas FDA approval,but isbeing used for ause,or totreata condition, that isnotlistedon thePremarketApprovalissuedbythe FDA orhas notbeen determinedthroughpeer reviewed medicalliteraturetotreat the medicalconditionof the covered person.

4. Experimental or investigational accordingtothe provider's researchprotocols.

Items (3)and(4)abovedo not apply tophase III orIV FDA clinicaltrials..Benefitsare available forroutine carecoststhatareincurredin thecourseofaclinicaltrial if the servicesprovidedare otherwise covered services underthis policy.

Final adverse benefit determination meansan adverse benefit determination that isupheldatthe completionofahealthplanissuer'sinternalappealsprocess.

Gastric pacemaker means a medicaldevicethat usesan externalprogrammerand implantedelectrical leadstothe stomach;andtransmitslow‐frequency, high‐energy electricalstimulationtothestomachto entrain and pacethe gastricslowwavestotreat gastroparesis.

Gastroparesis meansa neuromuscular stomach disorderinwhichfood emptiesfrom the stomach more slowlythan normal.

Generally accepted standards of medical practice arestandardsthatare basedoncrediblescientific evidence publishedinpeer‐reviewed medicalliteraturegenerallyrecognizedbythe relevantmedicalcommunity,relyingprimarily oncontrolledclinicaltrials.

Ifnocrediblescientificevidenceisavailable,thenstandards thatarebasedon physician specialtysociety recommendationsorprofessionalstandardsofcaremay be considered. We reservetherighttoconsultmedicalprofessionalsindeterminingwhetherahealthcareservice,supply,ordrugis medically necessary andisa covered expense underthe policy.Thedecisiontoapply physician specialtysociety recommendations,thechoiceofmedicalprofessional,andthedeterminationof whento use any such opinion,willbedeterminedby us.

Grievance means anydissatisfaction withan insureroffering ahealth benefitplanor administrationofahealth benefit plan bythe insurerthat is expressedin writing in any form to theinsurer by,oron behalfof, aclaimantincludingany ofthe following:1. Provisionofservices;2. Determinationto rescinda policy;3. Determinationofadiagnosisor levelofservicerequiredforevidence‐basedtreatment ofautismspectrumdisorders;and

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4. Claimspractices.

Habilitative or Habilitation Services meansservicesprovidedinorder forapersonto attainandmaintainaskillor functionthat was neverlearnedoracquiredandisdue to adisablingcondition. Theseservices mayincludephysical,occupational and speechtherapies,developmentalservicesand durable medical equipment for developmentaldelay,developmentaldisability,developmentalspeechor language disorder, developmentalcoordinationdisorder andmixeddevelopmentaldisorder.

Habilitative Developmental Services meansprovidinginstructionsin the areasof self‐help,socialization,communication,cognition,andsocial/emotional skills.Examplesinclude,butarenot limitedto,toileting, dressing,usingfinemotor skills,crawling,walking,categorization,expressingoneself(making wants andneedsknown),picturerecognition,identifyingletters,numbers,shapes,etc.,appropriateplayskillsandcopingmechanisms.

Healthcare provider or provider meansahealthcareprofessionalorfacility.

Healthcare professional means a physician,psychologist,nursepractitioner,orotherhealthcare practitionerlicensed,accredited, orcertifiedtoperformhealthcareservicesconsistentwithstatelaw.

Home health aide services meansthoseservices providedby a home health aide employedby a home healthcare agency andsupervisedby aregistered nurse,whicharedirectedtoward thepersonalcareofa covered person.

Home healthcare means careortreatment ofan illness or injury at the covered person's homethatis:1. Providedbya home healthcare agency;and2. Prescribedandsupervisedbya physician.

Home healthcare agency meansapublicorprivateagency,oroneofitssubdivisions,that:1. Operatespursuantto law as a home healthcare agency;2. Isregularlyengagedinproviding home healthcare undertheregularsupervisionofaregistered nurse;

3. Maintainsadailymedicalrecordoneachpatient;and4. Provideseachpatientwith aplanned program ofobservation and treatment by a physician, inaccordancewithexisting generally accepted standards of medical practice for the injury or illnessrequiringthe home healthcare.

Hospice meansaninstitutionthat:1. Providesa hospice care program;2. Isseparated from oroperated asa separate unit of a hospital, hospital‐relatedinstitution, home

healthcare agency, mentalhealthfacility, skilled nursing facility, oranyother licensedhealthcareinstitution;

3. Providescareforthe terminally ill; and4. Islicensedby the state in whichitoperates.

Hospice care program meansacoordinated,interdisciplinaryprogramprescribedandsupervisedbya physician to meet the specialphysical,psychological,andsocial needsofa terminally ill covered person andthoseofthe covered person’s immediate family.

Hospital meansaninstitutionthat:1. Operates as a hospital pursuanttolaw;

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2. Operatesprimarily forthe reception,care,andtreatmentofsick or injuredpersons as inpatients;3. Provides24‐hournursing service byregisterednursesondutyorcall; 4. Hasstaffofoneor more physicians availableatalltimes;5. Providesorganizedfacilitiesand equipment for diagnosisandtreatmentofacutemedical,surgical,ormentalconditionseitheron itspremisesorinfacilitiesavailableto it on aprearranged basis; and

6. Isnot primarilyalong‐termcarefacility;a skilled nursing facility,nursing,rest, custodial care,orconvalescent home;ahalfwayhouse,transitional facility,or residential treatment facility; aplace for theaged,drugaddicts,alcoholics,orrunaways;afacilityfor wildernessoroutdoorprograms; or a similarestablishment.

Whileconfinedinaseparateidentifiable hospital unit,section, orwardusedprimarily as anursing,rest, custodial care orconvalescenthome, rehabilitation facility, skilled nursing facility, or residential treatment facility, halfway house, or transitional facility, a covered person willbedeemednot tobeconfinedina hospital forpurposesofthis policy.

Illness meansasickness,disease,ordisorderofa covered person. Illness doesnotinclude learning disabilities,attitudinaldisorders,ordisciplinaryproblems. All illnesses thatexistat thesametimeand thataredue to the same orrelatedcauses aredeemedtobe one illness.Further,ifan illness isdueto causes thatarethesame as,orrelated to,thecausesofaprior illness,the illness willbe deemed acontinuation or recurrenceoftheprior illness andnot aseparate illness.

Immediate family means theparents, spouse,children,orsiblingsofany covered person,orany person residingwitha covered person.

Independent review organization (IRO) means anentitythatisaccreditedbyanationallyrecognizedprivateaccreditingorganization toconductindependentexternalreviewsof adverse benefit determinationsandby the InsuranceCommissionerinaccordancewithArkansaslaw.

Injury meansaccidental bodilydamagesustained by a covered person andinflictedon thebodyby anexternalforce.All injuries dueto the same accident are deemed tobe one injury.

Inpatient meansthatservices,supplies,ortreatment,formedical,behavioralhealth and substance abuse, arereceived by aperson whoisanovernight residentpatient ofa hospital or other facility,usingand being chargedforroomandboard.

Intensive care unit means a unitor area of a hospital that meetstherequiredstandards ofthe Joint Commission.

Intensive day rehabilitation meanstwoormoredifferenttypes oftherapy providedby one or more rehabilitation licensed practitioners andperformedforthree(3)ormorehoursperday,five(5) to seven(7) daysperweek.

Language assistance meanstranslationservicesprovidedifrequested.Contactcustomerservice at1‐877‐617‐0390if oralor writtenservicesare needed. 1. The plan orissuermustprovideorallanguage services(such as atelephone customer assistance hotline)thatincludeansweringquestionsinany applicable non‐English language andproviding assistancewithfilingclaimsandappeals(includingexternalreview) in any applicable non‐English language;

2. The plan orissuermustprovide,upon request,a noticein any applicable non‐English language;and

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3. The plan orissuermustincludeintheEnglishversionsofall notices,astatement prominently displayedinany applicable non‐English language clearlyindicatinghow toaccessthelanguage servicesprovidedby theplanorissuer.

Loss means an event for whichbenefitsarepayableunder this policy.A loss mustoccurwhilethe covered person isinsuredunderthis policy.

Listed transplant means oneofthefollowingproceduresandnoothers:1. Hearttransplants;2. Lung transplants;3. Heart/lungtransplants;4. Kidneytransplants;5. Livertransplants;6. Bonemarrowtransplantsforthefollowingconditions:

a. BMT or ABMT for Non‐Hodgkin'sLymphoma; b. BMT or ABMT for Hodgkin'sLymphoma; c. BMT forSevereAplasticAnemia; d. BMT or ABMT for Acute Lymphocytic and NonlymphocyticLeukemia; e. BMT forChronicMyelogenousLeukemia; f. ABMT for TesticularCancer; g. BMT forSevereCombinedImmunodeficiency; h. BMT or ABMT for Stage IIIor IVNeuroblastoma; i. BMT forMyelodysplasticSyndrome;j. BMT forWiskott‐AldrichSyndrome; k. BMT forThalassemiaMajor; l. BMT or ABMT for Multiple Myeloma;m. ABMT forpediatricEwing'ssarcomaand related primitive neuroectodermaltumors,Wilm'stumor,rhabomyosarcoma,medulloblastoma,astrocytoma and glioma;

n. BMT forFanconi'sanemia; o. BMT formalignanthistiocyticdisorders;and p. BMT forjuvenile.

Loss of minimum essential coverage meansin the case of an employee or dependent whohas coverage thatisnotCOBRAcontinuationcoverage,theconditionsare satisfiedat the timethe coverage isterminated asa resultof loss ofeligibilityregardlessofwhethertheindividualiseligiblefororelectsCOBRA continuation coverage. Loss ofeligibilitydoesnotincludea loss dueto the failureof the employeeor dependent to pay premiumson a timelybasis orterminationof coverage for causesuch as makinga fraudulentclaimoranintentionalmisrepresentationof amaterialfactinconnectionwiththeplan. Loss ofeligibilityfor coverageincludes,butis notlimitedto:1. Loss ofeligibilityforcoverageas aresultoflegalseparation,divorce,cessationof dependent statussuchasattainingthemaximum age tobe eligible as a dependent childundertheplan,death ofan employee,termination of employment,reductionin thenumberof hoursofemployment,andany loss of eligibilityforcoverageafter aperiodthat is measuredby reference to anyof the foregoing;

2. Inthe caseof coverage offered throughan HMO,or other arrangement,intheindividual marketthatdoesnotprovidebenefitstoindividualswhonolonger reside,live,or workin a service area, loss ofcoveragebecause anindividual nolongerresides,lives,or worksin the service area whether ornot withinthechoiceoftheindividual;

3. Inthe caseof coverage offered throughan HMO,or other arrangement,inthegroup marketthat doesnot providebenefits toindividualswhono longer reside, live,orwork ina service area, loss of

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coverage because an individualnolongerresides,lives,orworks in the service area whetheror not withinthe choiceof the individual,and nootherbenefitpackageis availableto theindividual;

4. Asituationin whichaplannolongeroffersanybenefitstotheclassofsimilarlysituatedindividualsasdescribed in§ 54.9802‐1(d) thatincludestheindividual;

5. Inthe caseof anemployee or dependent who hascoveragethatisnotCOBRA continuation coverage,theconditions aresatisfiedatthetimeemployer contributionstowardstheemployee'sor dependent's coverageterminate.Employercontributionsinclude contributionsbyanycurrentor formeremployerthatwascontributing to coverageforthe employee or dependent; and

6. Inthe caseof anemployee or dependent who hascoveragethatisCOBRAcontinuationcoverage,the conditionsaresatisfiedatthe time the COBRAcontinuationcoverageisexhausted.Anindividual whosatisfiestheconditionsfor special enrollment,doesnotenroll,andinsteadelectsand exhausts COBRAcontinuation coveragesatisfiestheconditions.

Managed drug limitations meanslimitsincoveragebasedupontime period,amount or dose ofa drug,or otherspecifiedpredeterminedcriteria.

Maximum out‐of‐pocket amount isthesumof the deductible amount, prescription drug deductible amount (ifapplicable), copayment amount and coinsurance percentage of covered services,asshowninthe Schedule of Benefits. Please note: There are separate maximum out‐of‐pocket amounts forin network benefits versus outof network benefits.

Afterthe maximum out‐of‐pocket amount ismet foranindividual,Ambetter pays 100%of eligible expenses forthatindividual.The family maximum out‐of‐pocket amount is twotimestheindividual maximum out‐of‐pocket amount.Boththeindividualand the family maximum out‐of‐pocket amounts areshownin the Schedule of Benefits (in network andoutof network).

Forfamilycoverage,thefamily maximum out‐of‐pocket amountcan be met with thecombinationofany covered persons’ eligible expenses. A covered person’s maximum out‐of‐pocket willnotexceedtheindividual maximum out‐of‐pocket amount.

If you are a covered member inafamily oftwo ormore members, you willsatisfy your maximum out‐of‐pocket when:1. You satisfy your individual maximum out‐of‐pocket;or2. Your familysatisfiesthe family maximum out‐of‐pocket amount for the calendar year.

If you satisfy your individual maximum out‐of‐pocket, you willnotpayanymore cost sharing forthe remainderofthe calendar year, but any other eligible members in your familymustcontinuetopay cost sharing until the family maximum out‐of‐pocket is met forthe calendar year.

Maximum therapeutic benefit meansthepointin the course oftreatment whereno furtherimprovement ina covered person's medicalconditioncan be expected,eventhough there may befluctuationsin levelsof painandfunction.

Medical care meansthe diagnosis,cure,mitigation,treatment, orpreventionofdiseaseorforthepurpose ofaffectinganystructureorfunctionof thebodyandfortransportationprimarilyfor andessentialtothe provisionof suchcare.

Medical practitioner includes,butis notlimitedto,a physician,nurse anesthetist,physician'sassistant, physicaltherapist,licensed mentalhealthand substance use practitioners,nursepractitioners,audiologists,chiropractors,dentists,pharmacists,nurseanesthetists,optometrists,podiatrists,psychologistsor

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midwife.Thefollowing are examples of providers thatareNOT medical practitioners,bydefinitionofthepolicy: acupuncturist,rolfer,registerednurse,hypnotist,respiratory therapist,X‐raytechnician, emergency medicaltechnician,naturopath, perfusionist,massagetherapist orsociologist. Withregardtomedical servicesprovidedtoa covered person,a medical practitioner mustbelicensedorcertifiedbythe state inwhichcareis renderedandperformingserviceswithinthescope ofthatlicenseorcertification.

Medically necessary or medical necessity meansanymedicalservice,supplyortreatment authorized by a provider to diagnose andtreat a covered person’s illness or injury which:1. Isconsistent withthesymptoms ordiagnosis;2. Isprovidedaccordingto generally accepted standards of medical practice;3. Isnot custodial care;4. Isnot solely fortheconvenienceof the provider or the covered person;5. Isnot experimental or investigational;6. Isprovidedin the mostcosteffectivecarefacilityorsetting;7. Doesnot exceedthe scope,duration,orintensityofthatlevel ofcarethatis neededtoprovidesafe, adequate and appropriatediagnosisortreatment; and

8. Whenspecificallyapplied toa hospital confinement,itmeansthatthe diagnosisandtreatment of your medical symptomsor conditionscannot besafelyprovidedasan outpatient.

Chargesincurredfortreatment not medically necessary are not eligible expenses.

Medically stabilized meansthatthe personisnolonger experiencingfurtherdeteriorationas aresultofaprior injury or illness and there are no acute changesinphysicalfindings,laboratory results,orradiologic resultsthatnecessitateacute medical care.Acute medical care doesnot include acute rehabilitation.

Medicare opt‐out practitioner means a medical practitioner who:1. Hasfiled an affidavitwiththe Department ofHealthandHuman Services statingthat he, she,orit willnotsubmitanyclaimsto Medicareduring a two‐year period;and

2. Hasbeendesignatedby theSecretary ofthat Department as a Medicare opt‐out practitioner.

Medicare participating practitioner means a medical practitioner who iseligible to receive reimbursementfromMedicarefor treatingMedicare‐eligibleindividuals.

Member or Covered Person meansanindividualcoveredby thehealthplanincludinganyenrollee, subscriberor policy holder.

Mental disorder means abehavioral, emotionalor cognitivepatternoffunctioningthat islistedinthemostrecenteditionoftheInternationalStatisticalClassification ofDiseasesandRelated HealthProblemsandthemostcurrent edition ofthe Diagnostic andStatisticalManualofMentalDisorders.

Necessary medical supplies mean medicalsuppliesthat are:1. Necessarytothecare ortreatment of an injury or illness;2. Notreusableor durable medical equipment;and3. Notable to be used by others.

Necessary medical supplies donot includefirst aid supplies,cottonballs,rubbingalcohol,orlikeitems routinelyfoundinthehome.

Network meansa group of medical practitioners and providers whohavecontractsthatincludeanagreed uponpriceforhealthcareexpenses.

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Network eligible expense meansthe eligible expense forservicesorsupplies that are providedby a network provider.Forfacilityservices,thisisthe eligible expense thatis providedat andbilledby a networkfacilityfortheservices ofeithera network or non‐network provider. Network eligible expense includesbenefitsfor emergency healthservices even ifprovidedby a non‐network provider.

Network provider means a medical practitioner or provider whoiscontractedtoprovide covered services. The most currentpublishedlistfor the network can be found at Ambetter.ARHealthWellness.com.

Neurologic Rehabilitation Facility meansaninstitutionlicensedas such bythe appropriatestate agency. Aneurological rehabilitation facilitymust:1. beoperatedpursuanttolaw;2. beaccreditedbytheJointCommissionandtheCommissiononAccreditationofRehabilitation Facilities;

3. beprimarilyengagedinproviding,inadditiontoroomandboardaccommodations, rehabilitation servicesfor severe traumatic brain injury underthe supervision ofa dulylicensed physician; and

4. maintainadailyprogress recordfor eachpatient.

Non‐elective caesarean section means:1. Acaesarean sectionwherevaginaldeliveryisnotamedicallyviableoption;or 2. Arepeatcaesarean section.

Non‐network provider means a medical practitioner whoisnotcontractedwiththeplanasaparticipating provider.Servicesreceivedfrom a non‐network provider arecoveredat a reducedamount fromthose servicesreceivedfrom a network provider.Please referto your Schedule of Benefits.

Other plan means any plan or policy thatprovidesinsurance,reimbursement, or service benefits for hospital,surgical,ormedicalexpenses. Thisincludespaymentundergrouporindividual insurancepolicies,automobileno‐faultormedicalpay,homeowner insurancemedical pay,premises medicalpay, nonprofit healthservice plans,health maintenanceorganizationsubscribercontracts,self‐insuredgroupplans, prepayment plans,andMedicarewhenthe covered person isenrolledinMedicare. Other plan willnotincludeMedicaid.

Outpatient services includefacility,ancillary,facilityuse,andprofessionalchargeswhen given as an outpatientat a hospital, alternativecarefacility,retailhealthclinic,orother provider asdeterminedbythe plan.Thesefacilitiesmayincludeanon‐hospital siteprovidingdiagnosticandtherapyservices, surgery,or rehabilitation,orother provider facility as determinedby us.Professionalchargesonlyincludeservices billedbya physician or otherprofessional.

Outpatient surgical facility means anyfacilitywithamedicalstaffof physicians thatoperatespursuantto lawfor thepurposeofperforming surgical procedures,andthatdoesnotprovideaccommodationsfor patientstostayovernight. This doesnotinclude facilitiessuchas:acute‐careclinics, urgent care centers,ambulatory‐careclinics,free‐standingemergencyfacilities,and physician offices.

Period of extended loss meansaperiodofconsecutivedays: 1. Beginningwiththefirstdayonwhicha covered person isa hospital inpatient; and2. Endingwith the30th consecutiveday forwhich a covered person isnot a hospital inpatient.

Physician means alicensed medical practitioner whoispracticingwithinthescope ofhis orherlicensed authorityintreatingabodily injury orsicknessandisrequired to becoveredbystatelaw.A physician does

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https://Ambetter.ARHealthWellness.com



NOT include someone whoisrelated toa covered person byblood,marriageoradoptionorwhoisnormally a member of the covered person's household.

Policy when italicized, meansthis policy issuedand deliveredto you.Itincludestheattachedpages,the applications,and any amendments.

Post‐service claim means any claim for benefits for medical care or treatment that isnot a pre‐service claim.

Pregnancy meansthephysicalconditionof being pregnant,but doesnotinclude complications of pregnancy.

Prescription drug means anymedicinalsubstance whoselabelisrequiredtobearthelegend"RXonly."

Prescription order meanstherequest for each separate drug ormedication by a physician oreach authorized refillorsuchrequests.

Pre‐service claim means anyclaim for benefits for medical care ortreatmentthat requirestheapprovalof the plan in advance of the claimantobtainingthe medical care.

Primary care provider means a provider whoisafamilypractitioner,generalpractitioner,pediatrician,internist,obstetrician,gynecologist,ornursepractitioner.

Prior authorization meansadecisiontoapprovespecialtyorother medically necessary care for a member bythe member’s PCPor provider grouppriortorenderingservices.

Proof of loss meansinformationrequiredby us to decideif a claimispayableandthe amount thatis payable.It mayinclude,butisnot limitedto,claim forms,medicalbillsorrecords, other plan information, paymentofclaimsand network re‐pricinginformation. Proof of loss mustincludeacopyofallExplanation ofBenefit formsfrom anyothercarrier,includingMedicare.

Provider facility means a hospital, rehabilitation facility,or skilled nursing facility.

Qualified health plan or QHP means ahealthplan that hasineffect a certificationthatit meetsthe standardsdescribedinsubpartC ofpart156 issued orrecognizedbyeachExchangethroughwhichsuchplanisofferedinaccordancewiththeprocessdescribedinsubpartKofpart 155.

Qualified individual means,withrespectto an Exchange,anindividualwho has been determined eligibletoenrollthrough theExchangeina qualified health plan intheindividualmarket.

Reconstructive surgery means surgery performedonanabnormalbodystructurecausedby congenital defects,developmentalabnormalities,trauma,infection,tumors,ordiseaseinorderto improvefunctionor toimprovethepatient's appearance, tothe extent possible.

Rehabilitation means carefor restoration(includingbyeducationortraining) ofone'spriorabilitytofunction at alevelof maximum therapeutic benefit.Thisincludes acute rehabilitation, sub‐acute rehabilitation,or intensive day rehabilitation,anditincludes rehabilitation therapy. An inpatienthospitalizationwill be deemedto be for rehabilitation atthe timethepatienthas been medically stabilized andbegins toreceive rehabilitation therapy.

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Rehabilitation facility means an institution ora separateidentifiable hospital unit,section,orwardthat: 1. Islicensedby the state as a rehabilitation facility; and2. Operatesprimarilytoprovide24‐hour primary care or rehabilitation ofsickorinjuredpersonsas

inpatients.

Rehabilitation facility doesnotincludeafacilityprimarilyforrest,theaged,long term care,assistedliving, custodial care, nursingcare, or for careof the mentallyincompetent.

Rehabilitation licensed practitioner means,but isnotlimited to,a physician,physicaltherapist,speechtherapist,occupationaltherapist,orrespiratorytherapist.A rehabilitation licensed practitioner mustbelicensedorcertifiedbythestate in whichcareisrenderedand performingserviceswithin the scope ofthat licenseorcertification.

Rehabilitation therapy meansphysicaltherapy,occupational therapy,speechtherapy,orrespiratory therapy.

Rescission of a policy meansa determination by an insurerto withdrawthe coverage backtothe initial dateofcoverage.

Residence meansthephysicallocation where you live.If you liveinmorethanonelocation,and you file aUnitedStatesincome tax return,the physicaladdress,nota P.O.Box,shown on your UnitedStates income taxreturnas your residence willbe deemedto be your placeof residence.If you donot filea UnitedStates income tax return,the residence where you spendthe greatestamount of timewillbe deemedto be your placeof residence.

Residential treatment facility meansa facilitythatprovides, withorwithoutchargesleeping accommodations,and:1. Isnot a hospital, skilled nursing facility, or rehabilitation facility; or2. Isa unitwhosebeds are notlicensed at alevel equalto ormoreacutethanskillednursing.

Respite care means home healthcare servicesprovidedtemporarilytoa covered person in orderto provide relieftothe covered person's immediate family orother caregiver.

Schedule of Benefits meansa summaryofthe deductible, copayment, coinsurance, maximum out‐of‐pocketandotherlimitsthatapplywhen you receive covered services and supplies.

Service area meansa geographicalarea, made upof counties,where we have been authorized by the State ofArkansas to sellandmarketour healthplans. This iswhere the majority ofour network providers are locatedwhereyouwillreceiveallofyourhealthcareservices andsupplies.

Severe Traumatic Brain Injury meansasudden trauma causing damage to thebrain as aresult of the headsuddenlyandviolentlyhitting an objector an object piercingtheskullandentering brain tissue with anextendedperiodofunconsciousnessoramnesia after the injury oraGlasgowComaScalebelow9within thefirst48hoursof injury.

Skilled nursing facility meansaninstitution,oradistinctpartofaninstitution,that: 1. Islicensed as a hospital, skilled nursing facility,or rehabilitation facility by thestate in whichit operates;

2. Isregularlyengagedinproviding24‐hourskillednursingcare undertheregular supervisionofaphysician andthedirectsupervision of a registerednurse;

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3. Maintainsadailyrecordoneachpatient;4. Hasaneffective utilization review plan; 5. Provideseachpatientwith aplanned program ofobservationprescribedby a physician; and6. Provideseachpatientwith activetreatment ofan illness or injury,inaccordancewithexisting standardsofmedicalpracticefor that condition.

Skilled nursing facility doesnot includea facilityprimarily forrest,the aged,treatment of substance use, custodial care, nursingcare,orforcareof mental disorders orthementallyincompetent.

Specialist provider means a physician whoisnot a primary care provider.

Spouse means your lawfulwife orhusband.

Stabilize, as usedwhen referring toan emergency,meanstheprovisionof suchmedicaltreatmentas maybenecessary to assure,withinreasonable medical probability, thatnomaterialdeteriorationofan individual’s medicalconditionis likelytoresultfromoroccurduringa transfer,ifthemedicalconditioncouldresultinany ofthefollowing:1. Placingthe health oftheindividualor, withrespect to a pregnant member,thehealthofthe member orthe member’s unborn child,inseriousjeopardy;

2. Seriousimpairmenttobodilyfunctions;3. Seriousdysfunctionofany bodilyorganorpart;

Andinthe caseofa memberhaving contractions, “stabilize”meanssuch medicaltreatment as may be necessarytodeliver,includingtheplacenta.

Sub‐acute rehabilitation means oneormoredifferenttypesoftherapyprovidedbyoneor more rehabilitation licensed practitioners andperformedforone‐half(1/2)hour totwo(2)hoursperday, five (5)toseven(7) daysperweek,whilethe covered person isconfined asan inpatient ina hospital, rehabilitation facility,or skilled nursing facility.

Substance use or substance use disorder meansalcohol,drugorchemical abuse, overuse,ordependency. Covered substance use disorders arethoselistedin the mostrecenteditionof theInternationalStatistical Classification ofDiseases andRelated HealthProblems andthe mostcurrent editionofthe Diagnosticand StatisticalManualofMentalDisorders.

Surgery or surgical procedure means:1. Aninvasive diagnosticprocedure; or2. The treatment of a covered person's illness or injury bymanualorinstrumentaloperations, performedbya provider whilethe covered person is under general or local anesthesia.

Surveillance tests for ovarian cancer means annual screening using:1. CA‐125 serum tumor markertesting; 2. Transvaginal ultrasound;or3. Pelvicexamination.

Telemedicine meanshealthcare servicesdelivered byuseof interactive audio,video,orother electronic media,includingthe following:1. Medicalexamsandconsultations.2. Behavioralhealth,including substance abuse evaluationsandtreatment.

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The term doesnot includethe deliveryof healthcareservices byuse ofthe following:1. Atelephonetransmitter fortranstelephonicmonitoring.2. Atelephoneoranyothermeansof communication for theconsultationfrom one(1) provider toanother provider.

Terminal illness counseling meanscounselingofthe immediate family of a terminally ill personforthepurposeof teachingthe immediate family tocare forand adjusttothe illness andimpendingdeathoftheterminally ill person.

Terminally ill means a physician hasgivenaprognosisthat a covered person hassix(6)monthsorlessto live.

Third party meansapersonorotherentitythat isormay be obligatedorliable to the covered person forpayment ofanyofthe covered person's expenses for illness or injury.Theterm "third party" includes,butisnotlimitedto,anindividualperson; afor‐profit or non‐profitbusinessentityororganization;agovernmentagencyorprogram;andaninsurancecompany.However,theterm "third party" willnotincludeanyinsurancecompanywitha policy under whichthe covered person isentitled to benefitsas a namedinsured personoran insured dependent ofa named insured personexcept inthosejurisdictionswherestatutesor commonlaw doesnotspecificallyprohibit our right torecover fromthesesources.

Tobacco use or use of tobacco means use of tobacco byindividualswhomaylegallyuse tobaccounderfederalandstatelaw on average fouror moretimesperweek andwithin thesixmonthsimmediately precedingthedateapplicationforthis policy wascompleted by the covered person,includingalltobaccoproductsbut excluding religious andceremonialusesoftobacco.

Transfer has thesame meaning asin section1867 ofthe “Social SecurityAct,”49Stat.620(1935), 42 U.S.C.A. 1395dd,asamended.

Unproven service(s) meansservices,includingmedications,thatare determinednot to be effective for treatment of the medical condition,or nottohaveabeneficial effect on healthoutcomes, duetoinsufficient andinadequateclinical evidencefrom well‐conducted randomized controlled trials or well‐conducted cohort studies intheprevailingpublishedpeer‐reviewedmedicalliterature. 1. "Well‐conducted randomized controlled trials" meansthattwo or more treatments are comparedto eachother,andthepatientis not allowedtochoosewhichtreatmentisreceived; and

2. "Well‐conducted cohort studies" means patientswho receive studytreatment are comparedtoa groupofpatientswho receivestandard therapy.Thecomparison groupmustbenearlyidenticalto thestudytreatmentgroup.

Urgent care center meansafacility,notincludinga hospital emergency roomora physician's office, that providestreatmentorservicesthat arerequired:1. Topreventseriousdeterioration ofa covered person's health;and2. Asaresultofan unforeseen illness, injury, or the onsetof acute orseveresymptoms.

Utilization review meansaprocessusedtomonitor the use of, orevaluate theclinicalnecessity,appropriateness,efficacy, orefficiency of,healthcareservices,procedures,orsettings.Areasofreview may include ambulatory review,prospectivereview,secondopinion,certification,concurrent review, case management,dischargeplanning,orretrospective review.

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DEPENDENT MEMBER COVERAGEDependent Eligibility Your dependents becomeeligiblefor insuranceon thelatterof:1. The date you became coveredunder this policy; or2. The date of marriagetoadda spouse; or3. Thedateofanewbornsbirth;or4. The date thatan adopted childisplacedwithyou or your spouse forthe purposesofadoptionor youoryour spouse assumestotal orpartialfinancial supportofthechild.

Effective Date for Initial Dependent MembersThe effective date for your initial dependent members, ifany,isshownonthe Schedule of Benefits.Onlydependents includedintheapplicationfor this policy willbe coveredon your effective date.

Coverage for a Newborn ChildAn eligible child bornto a covered person willbecoveredfromthetimeof birthprovidedthat(1)notice ofthenewborn isgiventous bytheExchangewithinninety(90)daysfrom birth,andpremiumbilledforthis 90‐day period,istimelypaidunderthe termsofthis policy andits grace period aftersuchnotice.Thenewbornchildwillbecoveredfromthetimeofits birthfor loss dueto injury and illness,including loss from complicationsofbirth,premature birth,medically diagnosedcongenital defect(s), or birth abnormalities. Covered expense shallalsoincluderoutinenurserycareandpediatriccharges forawellnewbornchildfor upto five (5) fulldaysin a hospital nurseryoruntilthemother isdischargedfromthe hospital followingthebirthofthechild,whichever isthe lesserperiodoftime.

Ifnoticeisnotprovidedwithin ninety(90)daysafterbirth, or premium forsuchninety (90)dayperiodis nottimelypaidaftersuchnoticeundertheterms ofthis policy andits grace period,coverage forthe newborn will notbeeffectiveandthenewborn cannotbeenrolleduntilthenext open enrollmentperiod.

Coverage for an Adopted ChildAnadoptedchildof a covered person shallbe coveredfromthe dateofthe filingof apetitionfor adoptionif(1)the covered person appliesforcoveragewithinsixty(60)days afterthe filing of thepetitionforadoptionandwheretheissueris notified bytheExchange and(2)premiumbilledfor this60‐dayperiodistimelypaidunderthetermsofthis policy and itsgrace periodaftersuchapplication.However,thecoverageshallbeginfromthemomentofbirthif(1) thepetitionforadoption andapplicationforcoverageisfiledwithinsixty(60)daysafter thebirthofthechild,and(2)premiumbilledforthis60‐dayperiodis timelypaid underthetermsofthis policy andits graceperiod aftersuch application.Thechildwillbecoveredfor lossdueto injury and illness,including medically necessary careandtreatmentofconditions existingpriortothedateof placement.

Unlessan applicationisreceivedwithin60daysofpetition of adoption,and premium is timelypaidforthe first60days underthetermsofthis policy andits grace period,coverage for theadoptedchildwillnot beeffectiveandtheadoptedchildcannotbeenrolleduntilthenextopenenrollmentperiod.Coverage foranadoptedchildshallterminateupon the dismissalor denial of a petitionforadoption.

Asusedinthisprovision, "placement" meanstheearlierof: 1. Thedatethat you or your spouse assumephysical custodyofthe childfor the purpose of adoption; or

2. The date of entry of anordergranting you or your spouse custodyof the childforthepurposeof adoption.



Adding Other Dependent MembersIf you areenrolledinanoff‐exchange policyandapplyinwritingto adda dependent and you paytherequiredpremiums,wewillsendyouwrittenconfirmationofthe added dependent’s effective date ofcoverageandIDcardsfortheadded dependent.

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ONGOING ELIGIBILITYFor All Covered PersonsA covered person's eligibilityforinsuranceunderthis policy willceaseonthe earlierof: 1. Thedatethata covered person hasfailedtopaypremiumsorcontributionsinaccordancewith the termsofthis policy orthe datethat we have notreceivedtimely premium payments inaccordance withthetermsofthis policy;or

2. The date the member has performedanact orpracticethat constitutesfraud ormadean intentional misrepresentation ofamaterial fact (e.g.,the date that a member acceptsanydirectorindirectcontributionsorreimbursement byor onbehalfofanemployer, foranyportionof the premium forcoverageunderthis policy;or

3. The date a member's employer anda member treatthis policy aspartof anemployer‐provided healthplan foranypurpose,including taxpurposes; or

4. The date we receivearequestfrom you toterminate this policy, orany later datestatedin yourrequest,orif you areenrolledthrough an Exchange, thedate oftermination that the Exchange providesusuponyourrequestof cancellationto the Exchange; or

5. The date we declinetorenewthis policy, asstatedintheDiscontinuanceprovision;or 6. The date of a covered person’s death;or7. The date a covered person’s eligibility forinsurance under this policy ceases dueto losing networkaccessasthe resultof a permanent move.

For Dependent MembersA dependent willceasetobea covered person atthe endofthepremium periodinwhichthe covered person ceasestobe your dependent dueto divorceor if a childceases tobe an eligible child.For eligible children,theExchangewillsendaterminationletterwithan effective date thelastdayof the dependent’s 26th birthmonth.

Allenrolled dependent members willcontinue to be covereduntilthe agelimitlistedin the definitionof eligible child.

A covered person willnotceasetobe a dependent eligible child solelybecause ofage ifthe eligible child is:1. Notcapable ofself‐sustainingemployment dueto mentalhandicaporphysicalhandicap thatbeganbeforethe agelimitwasreached; and

2. Mainly dependent on you forsupport.

Open EnrollmentThere willbe anopen enrollmentperiodforcoverageon the Exchange.Theopenenrollmentperiod beginsNovember 1,2017 andextendsthroughDecember 15,2017. Qualified individuals who enrollonor beforeDecember 15,2017 will have an effective date of coverage on January 1,2018.

Special EnrollmentAqualified individual has sixty(60) daystoreport aqualifying eventto the Exchange and couldbe granted a60 day SpecialEnrollmentPeriodas aresultofoneof the following events:

Aqualified individual or dependent loses minimum essential coverage; A qualified individual gains a dependent orbecomes a dependent through marriage,birth,adoption orplacement foradoption; Anindividualwhowas notpreviouslyacitizen,national,orlawfullypresentindividualgainssuchstatus;

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A qualified individual’s enrollmentornon‐enrollmentin a qualified health plan isunintentional,inadvertent,orerroneous andis theresultofthe error,misrepresentation,orinactionofanofficer,employee,or agent ofthe ExchangeorHHS,oritsinstrumentalitiesasevaluatedanddeterminedbytheExchange.Insuchcases,theExchange maytakesuchaction asmaybenecessarytocorrectoreliminatetheeffectsofsucherror,misrepresentation,or agent; Anenrollee adequately demonstrates tothe Exchange that the qualified health plan in whichthe covered person isenrolledsubstantiallyviolated amaterial provision of its contractinrelationto theenrollee; An individual isdeterminednewly eligibleornewlyineligiblefor advance payments of the premium tax credit or hasa change ineligibility for cost‐sharing reductions,regardlessofwhether suchindividualisalreadyenrolledina qualified health plan; A qualified individual orenrolleegainsaccesstonew qualified health plans asaresultofapermanentmove;Qualifyinge ventsasdefinedunder section603oftheEmployee RetirementIncomeSecurityActof1974, asamended;AnIndian,asdefinedbysection 4of the IndianHealthCare Improvement Act,may enroll ina qualified health plan or changefrom one qualified health plan to another onetimeper month;or A qualified individual orenrolleedemonstratesto the Exchange,inaccordancewithguidelinesissuedbyHHS,thattheindividualmeetsotherexceptional circumstancesastheExchangemayprovide.

Inthe caseof marriage,orinthe case where qualified individual loses minimum essential coverage,the effective date isthefirstdayofthefollowingmonth.

The Exchangemay provideacoverage effective date for a qualified individual earlierthanspecified inthe paragraphs above,providedthat either:1. The qualified individual hasnot been determined eligible for advance payments of the premium tax

credit or cost‐sharing reductions; or2. The qualified individual paystheentire premium forthe firstpartialmonth ofcoverageaswellas all

cost sharing,therebywaivingthebenefitof advance payments of the premium tax credit and cost‐sharing reduction paymentsuntilthe firstofthe next month.

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PREMIUMSPremium PaymentEachpremium isto be paidonor beforeitsduedate.Theinitial premium mustbe paidpriortothe coverage effectivedate, although an extension may beprovided duringthe annualopen enrollmentperiod.

Grace PeriodWhena member isreceivingapremiumsubsidy:Premiumpaymentsare duein advance,on acalendarmonthbasis. Monthlypayments aredue beforethe firstdayofeachmonthforcoverageeffective during suchmonth. After the first premiumis paid, a graceperiodof3monthsfromthepremiumduedateis given forthepayment ofpremium. Thisprovision means thatifanyrequiredpremiumis notpaidonorbefore the date it isdue,it maybe paidduringthe grace period.Coveragewillremainin forceduringthegraceperiod. If fullpaymentof premiumis notreceived withinthe graceperiod,coverage will beterminatedasofthe lastdayofthe firstmonthduringthegrace period,if advanced premium tax credits are received.

We willcontinuetopayallappropriateclaims for covered services renderedtothe member duringthefirstmonth of the grace period,andmaypendclaims for covered services renderedtothe member inthesecond andthirdmonthofthegraceperiod. We willnotifyHHSofthenon‐paymentofpremiums,the member,aswellas providers ofthepossibilityof deniedclaimswhenthe member isin thesecond andthirdmonthofthegraceperiod. We willcontinuetocollect advanced premium tax credits on behalf of the member fromtheDepartmentofthe Treasury,andwillreturnthe advanced premium tax creditsonbehalfofthe member forthesecond andthird month of the grace periodifthe member exhausts theirgraceperiodasdescribed above.A member isnoteligibleto re‐enrollonceterminated,unlessa member has a specialenrollmentcircumstance,suchasamarriage orbirthinthefamilyorduringannualopenenrollmentperiods.

Whena member isnotreceiving a premium subsidy:Premiumpaymentsare duein advance,on acalendarmonthbasis. Monthlypayments aredue beforethe firstdayofeachmonthforcoverageeffective during suchmonth. After the first premiumis paid, a one (1)month graceperiodstartingfrom the premium due date isgiven for the payment of premium. This provisionmeansthat ifanyrequiredpremiumisnotpaidonor before the dateit isdue,itmay be paid duringthegraceperiod.Coveragewillremaininforceduringthe graceperiod;however, claimsmay pend for covered services renderedtothe member duringthe grace period. We willnotifyHHS,asnecessary,of thenon‐payment ofpremiums,the member,as wellas providers ofthepossibilityof deniedclaimswhenthe member isin the grace period.

Third Party Payment of PremiumsAmbetterrequireseachpolicyholdertopayhisorherpremiums andthisis communicatedon your monthly billingstatements.Ambetter payment policiesweredevelopedbasedonguidancefromthe CentersforMedicareandMedicaid Services (CMS) recommendationsagainstacceptingthirdpartypremiums.ConsistentwithCMSguidance,thefollowingarethe ONLYacceptablethird partieswho may payAmbetterpremiums onyourbehalf:

1.

RyanWhiteHIV/AIDS Program undertitleXXVIof the PublicHealthServiceAct;2. Indiantribes,tribalorganizationsorurbanIndianorganizations;3. State and FederalGovernmentprograms;or4. Family members.

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Upondiscoverythatpremiumswere paidbyapersonorentityother than thoselisted above,wewill rejectthepayment andinform thememberthatthe paymentwasnot acceptedandthatthesubscriptioncharges remaindue.

Misstatement of AgeIf a covered person's age hasbeen misstated,the premiumsmay be adjusted basedonthe premium that shouldhave been paid,basedon the correctage.

Change or Misstatement of ResidenceIf you change your residence, you must notifytheExchange of your new residence within sixty(60)daysofthechange. Asaresultyourpremium may change and you may be eligiblefora Special EnrollmentPeriod.Seethesectionon SpecialEnrollmentPeriodsformoreinformation.

Misstatement of Tobacco UseThe covered person’s answertothe tobaccoquestionlistedonthe covered person’s applicationforcoverageismaterialto our determinationofpremium.Ifa covered person's use of tobacco has been misstated on the covered person's applicationforcoverageunderthis policy, we havetherighttochargecorrectedpremiumsforthe policy back tothe original effective date.

Billing/Administrative FeesUponpriorwrittennotice, we may imposean administrative fee forcreditcardpayments.This doesnotobligate us toacceptcreditcardpayments. We maychargea $20 fee for any check orautomaticpayment deductionthatisreturnedunpaid.

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COST SHARING FEATURESCost Sharing FeaturesWewillpaybenefitsfor covered services asdescribedinthe Schedule of Benefits andthe covered services sectionsofthis policy.All benefitswe paywillbe subjecttoallconditions,limitations,and cost sharing featuresofthis policy. Cost sharing meansthat youparticipate orshare in thecost of yourhealthcare servicesbypaying deductible amounts, copayments and coinsurance for some covered services.Forexample, youmayneed topaya copayment or coinsurance amount when you visityour physician orare admitted intothe hospital.The copayment or coinsurance requiredforeachtypeof serviceaswellasyour deductible islistedinyour Schedule of Benefits.

Copayments Members may berequired topay copayments at thetime ofservicesasshowninthe Schedule of Benefits.Payment ofa copayment doesnot excludethepossibilityofanadditionalbillingifthe serviceisdetermined tobeanon‐covered service. Copayments donotapplytowardthe deductible amount,butdoapplytoward meetingthe maximum out‐of‐pocket amount.

Coinsurance Percentage Members may berequired topay a coinsurance percentage in excessof any applicable deductible amount(s) for a covered service orsupply. Coinsurance amountsdonot applytowardthe deductible butdoapplytowardmeetingthe maximum out‐of‐pocket amount.Whentheannual out‐of‐pocket maximum hasbeen met,additional covered services willbe100%.

DeductibleThe deductible amount meansthe amount of eligible expenses that mustbe paidby all covered persons before any benefitsarepayable. The deductible amountdoes notincludeany copayment amount or coinsurance amount. Notall eligible expenses are subjectto the deductible amount.Seeyour Schedule of Benefits formoredetails.

Theamountpayablewillbesubjectto:1. Anyspecific benefitlimitsstatedin the policy;2. Adeterminationof eligible expenses; and3. Anyreductionfor expensesincurredata non‐network provider.Please refer tothe informationon the Schedule of Benefits.

Theapplicable deductible amount(s), coinsurance percentage, and copayment amounts areshown on the Schedule of Benefits.

Note: Thebill you receiveforservices orsuppliesfroma non‐network provider maybesignificantlyhigher thanthe eligible expenses forthoseservicesorsupplies.Inadditiontothe deductible amount, copayment amount,and coinsurance percentage, you are responsibleforthedifference betweenthe eligible expense andtheamountthe non‐network provider bills you for theservicesorsupplies.Anyamount you areobligatedtopaytothe non‐network provider inexcessofthe eligible expense willnotapplyto your deductible amount or maximum out‐of‐pocket.

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ACCESS TO CAREPrimary Care Provider You mayselectany network primary care provider whoisacceptingnewpatients. You may obtain a list of network primary care providers at our website or bycontacting ourMemberServices department.

Your network primary care provider willberesponsibleforcoordinatingallcoveredhealthservicesand making referralsforservicesfrom other network providers. You donotneedareferralfrom your network primary care provider forobstetricalorgynecological treatment and may seekcare directlyfroma network obstetricianorgynecologist.

You may change your network primary care provider bysubmittingawrittenrequest,onlineat our website, orbycontacting our officeatthenumbershownon your identificationcard.Thechangeto your network primary care provider ofrecordwillbeeffectivenolaterthan30daysfromthedate we receive yourrequest.

Service AreaArkansasHealth&Wellnessoperatesina service area whichcoverstheentirestate.However,our service area issubjecttochangeuponadvancewritten notice.Ifyoumove fromonecountyto anotherwithinthe service area your premium may change. Please refer to the Premium section for moreinformation.Ifyou move outof Arkansas you are no longereligible forcoverageunderthis policy andmay be eligible for enrollmentintoanother qualified health plan duringaspecialenrollmentperiod.

Coverage Under Other Policy ProvisionsChargesforservicesandsuppliesthatqualifyas covered expenses underonebenefit provisionwillnot qualifyas covered expenses underanyotherbenefitprovisionof this policy.

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MAJOR MEDICAL EXPENSE BENEFITSAmbulance Service Benefits Covered expenses willincludeground,airorwater ambulanceservicesforlocal transportation:1. Tothe nearest hospital thatcan provideservices appropriateto the covered person's illness or

injury,incasesof emergency; or2. Tothenearestneonatalspecialcareunitfor newborninfants fortreatment of illnesses, injuries,congenitalbirthdefects,or complicationsofprematurebirth thatrequirethatlevelofcare;or

3. Transportationbetween hospitals orbetweena hospital and skilled nursing or rehabilitation facility when authorized by Ambetter.

Exclusions: Nobenefits willbepaidfor: 1. Expensesincurredforambulance servicescovered by alocal governmentalormunicipal body,unlessotherwiserequiredbylaw;

2. Non‐emergency airambulance;3. Ambulanceservicesprovidedfora covered person's comfortor convenience;or 4. Non‐emergency transportation excluding ambulances(forexample‐transportvan,taxi).

Chelation Therapy Covered expenses forchelationtherapyforcontrolofventriculararrhythmiasorheartblockassociatedwith digitalistoxicity, emergency treatmentofhypercalcemia,extremeconditionsofmetaltoxicity,includingthalassemiaintermediawithhemosiderosis,Wilson’sdisease(hepatolenticulardegeneration),lead poisoningand hemochromatosisiscovered.

Craniofacial Corrective Surgery and Related Expenses Covered expenses shallinclude craniofacial corrective surgery and related medical care for apersonofany agewhoisdiagnosedas havinga craniofacial anomaly,provided thatthe surgery andtreatment are medically necessary to improveafunctionalimpairment that resultsfromthe craniofacial anomaly as determined bytheAmericanCleftPalate‐CraniofacialAssociationin Chapel Hill,NorthCarolina..

Anationallyaccreditedcleft‐craniofacialteamforcleft‐craniofacialconditionsshall:1. Evaluate a covered persons with craniofacial anomalies;and2. Coordinate a treatment planforeachperson.

Covered expenses may include medically necessary dentalcare,visioncare, andtheuse of atleastone(1)hearing aid,ifrelatedto the craniofacial corrective surgery andincludedinthetreatmentplandescribed above.

Durable Medical Equipment (DME), Devices and SuppliesThefollowingare covered services when medically necessary:

OrthopedicAppliances:Orthopedic appliances,whichareattachedtoanimpairedbodysegmentforthepurposeofprotectingthesegmentorassistinginrestorationor improvementof itsfunction. Excluded:archsupports,includingn on‐customshoemodificationsorinserts andtheirfittingsexcept fortherapeuticshoes,andorthopedicshoesthatarenotattach edtoanappli ance.

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OstomySupplies:Ostomysupplies fortheremovalofbodilysecretionsor wastethroughanartificialopening.QuantitiesthataregreaterthanCMS guidelinesmay require prior authorization by us.

DurableMedicalEquipment: Durable medical equipment isequipmentwhichcanwithstandrepeated use,isprimarily andcustomarilyusedtoserve a medical purpose,isusefulonlyinthepresenceofan illness or injury andusedinthe member’s home. Durable medical equipment includes: standard hospital beds,standardnon‐motorizedwheelchairs,wheelchaircushion,standardwalkers,crutches,canes, glucosemonitors,externalinsulinpumps, oxygen, and oxygenequipment. All durable medical equipment mustreceive prior authorization.Wewilldetermineifequipment ismade available on arental orpurchasebasis. Atour option,we may authorizethepurchaseof the equipment inlieuofitsrentaliftherentalpriceis projected toexceed the equipment purchase price, butonly from a provider we authorize before the purchase.

Prosthetic Devices: Prosthetic devices are items which replace all or part of an external body part, or function thereof. When authorized in advance, repair, adjustment or replacement of appliances and equipmentis covered.

Excluded: take‐homedressingsandsuppliesfollowinghospitalization; any othersupplies,dressings, appliances,devicesorserviceswhicharenot specificallylistedascoveredabove; replacement orrepair ofappliances,devices andsuppliesdueto loss,breakagefrom willfuldamage, neglectorwrongfuluse,or duetopersonalpreference.

DiabeticSupplies:includinginsulinsyringes,lancets,urinetestingreagants,bloodglucosemonitoringreagants and insulin.

Electrotherapy stimulators Covered expenses includeusingTranscutaneousElectricalNerve Stimulator(TENS)to treatchronicpain duetoperipheralnerve injury when thatpainisunresponsive tomedication.Coverageis also providedfor NeuromuscularElectrical Stimulation(NMES)fortreatmentofdisuseatrophywhere nervesupplyto themuscleisintact,includingbutnotlimitedtoatrophysecondarytoprolongedsplintingorcastingoftheaffectedextremity,contracture dueto scarringof softtissue, asinburn lesionsandhipreplacement surgery,untilorthotictrainingbegins.

Enteral Feedings Coverage for enteralfeedingswhensuchhave been approvedand documented by a provider asbeingthe member’s solesource ofnutrition.Enteralfeedings require prior authorization by case management.

ContraceptionAllFDA‐approvedcontraceptionmethods(identifiedon www.fda.gov)areapprovedfor members without cost sharing asrequired underthe Affordable Care Act. Members have access tothe methodsavailable and outlinedonourDrug FormularyorPreferredDrugListwithout costshare.Somecontraceptionmethodsare available through a member’s medicalbenefit,includingthe insertion andremovalof thecontraceptive device at nocost share to the member.Thisbenefit containsbothpharmaceuticalandmedicalmethods, including:

1. Intrauterine devices(IUD),includinginsertionand removal;2. Barriermethodsincluding:male andfemalecondoms(Rxrequired from provider,limitedto30permonth),diaphragmwithspermicide,sponge withspermicide, cervicalcapwithspermicide andspermicidealone;

3. Oralcontraceptivesincludingthe pill(combinedpillandextended/continuoususe),andthemini pill(Progestinonly),patch;

http://www.fda.gov



4. Otherhormonalcontraceptives,includinginsertedandimplanted contraceptivedevices, hormonecontraceptiveinjections and thevaginal contraceptive ring;

5. Emergency contraception (themorning after pill);6. Prescription basedsterilization proceduresforwomen;and7. FDA‐approvedtuballigation.

Diabetes CareFor medically necessary servicesandsuppliesused inthetreatment ofdiabetes. Covered expenses include, butarenotlimitedto,examsincludingpodiatricexams;routine foot care such as trimmingofnailsandcorns;laboratoryandradiologicaldiagnostictesting;self‐management equipment, and suppliessuchas urineor ketonestrips,bloodglucosemonitorsupplies,glucose stripsforthe device,andsyringesorneedles;orthoticsanddiabetic shoes;urinaryprotein/microalbuminandlipidprofiles;educationalhealthandnutritionalcounselingforself‐management,eye examinations,andprescriptionmedication;and oneretinopathy examination screeningperyear.

High Frequency Chest Wall Oscillators Covered expenses for a member withcysticfibrosis,isprovidedforone high frequencychest walloscillatorduringsuch member’s lifetime.

Inotropic Agents for Congestive Heart Failure Covered expenses forinfusionof inotropicagentswherethe member ison a cardiactransplantlistat a hospital wherethere isan ongoing cardiactransplantationprogram.

Mental Health and Substance Use Disorder Benefits Our behavioralhealthand substance usevendoroverseesthe deliveryandoversight of coveredbehavioralhealthand substance use disorder servicesforArkansasHealth& Wellness.Mentalhealthserviceswillbe providedonan inpatient andoutpatientbasis andincludetreatable mental disorders.Thesedisordersaffect the member’s ability tocopewith the requirements ofdailyliving. Ifyou need mental health or substance use disorder treatment,youdonotneedareferralfromyour PCPinordertoinitiatetreatment.Anyservicesbeyondoutpatientdiagnosis,treatment,crisisstabilization,medicationmanagement,psychologicalandneuropsychological testingservicesmay beprovidedby an outpatient hospital orothercoveredfacility.Aneligiblefacilitywill belicensedbyArkansas orthestate inwhichit operates and beaccreditedbytheJointCommission,CARFInternational,orCouncilonAccreditation(COA)forthespecificmentalhealthor substance use treatment modalityitisproviding(forexample,outpatient,intensive outpatient,partialhospitalization, rehabilitation orresidentialtreatment).

Deductible amounts, copayment or coinsurance amounts andtreatment limits forcoveredmentalhealthand substance use disorder benefitswill be appliedin the same manneras physicalhealth servicebenefits.

Covered services andsuppliesfor mentalhealth and substance use disorder areincludedon a non‐discriminatorybasisforall members forthediagnosisandtreatment ofmental,emotional,and substance use disorders,asdefinedinthe mostrecent edition oftheInternationalStatisticalClassificationofDiseasesandRelated HealthProblems and the mostcurrent version ofthe DiagnosticandStatisticalManualof MentalDisorders..Diagnosesknown as“VCodes”are eligible expenses onlywhenbilledassupportingdiagnoses.

When makingcoverage determinations, our behavioralhealth andsubstanceuse vendorutilizes establishedlevel ofcareguidelinesand medical necessity criteriathatare based oncurrentlyacceptedstandardsofpracticeandtakeintoaccountlegalandregulatoryrequirements. Our behavioralhealthandsubstanceusevendorutilizes“Interqual”criteriaformentalhealthdeterminationsand AmericanSocietyof

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AddictionMedicine(ASAM)criteriafor substance use determinations.Servicesshouldalwaysbe provided inthe leastrestrictiveclinicallyappropriatesetting.Any determinationthatrequestedservicesarenot medically necessary will be made by a qualified licensedmentalhealthprofessional.

Covered inpatient andoutpatient mentalhealthor substance use disorder servicesareasfollows:

Inpatient1. Inpatient treatment; 2. Inpatient psychiatrichospitalization;3. Diagnostictesting;4. Inpatient detoxificationtreatment;5. Observation;6. CrisisStabilization;7. ElectroconvulsiveTherapy(ECT);8. Rehabilitation;and9. Residentialtreatment facilityformentalhealthand substance use disorders.

Outpatient1. Traditional outpatient services,includingindividualand grouptherapy services; 2. Outpatient services forthe purpose of monitoring drugtherapy;3. Outpatient detoxificationprograms;4. Diagnostictesting;5. Medication management services;6. Biofeedback;7. Psychologicalandneuropsychological testingandassessment;8. Outpatient rehabilitation treatment;9. Mentalhealthdaytreatment;10. AppliedBehavioral AnalysisandAutismSpectrumdisorders; 11. Telemedicine;12. PartialHospitalizationProgram(PHP);13. IntensiveOutpatient program (IOP); and14. ElectroconvulsiveTherapy(ECT).

Expenses for these servicesare covered,if medically necessary andmay be subjectto prior authorization.Pleaseseethe Schedule of Benefits formoreinformationregardingservicesthatrequire prior authorization andspecific benefit,day or visitlimits,ifany.

Autism Spectrum Disorder BenefitsGenerallyrecognizedservices prescribedinrelationto autism spectrum disorder bya physician orbehavioral healthpractitionerin atreatmentplanrecommended by that physician or behavioralhealth practitioner.

Forpurposes ofthissection,generally recognizedservicesmay includeservicessuchas: evaluationandassessmentservices; appliedbehavioranalysis; behaviortrainingandbehaviormanagement; speechtherapy; occupational therapy;physicaltherapy;or

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Habilitation services,limitedtochildrenages0 to 21with a diagnosisof autism spectrum disorder;or

medicationsornutritionalsupplementsusedtoaddresssymptoms ofau tism spectrum disorder.

Rehabilitation Expense Benefits Covered expenses includeexpensesincurredfor rehabilitation services,subjecttothe followinglimitations: 1. Covered expenses availableto a covered person whileconfinedprimarilytoreceive rehabilitation arelimitedtothosespecifiedinthisprovision;

2. Rehabilitation servicesorconfinementina rehabilitation facility must begin within 14daysof a hospital stay of atleast3 consecutivedays andbe fortreatment of,or rehabilitation relatedto,thesame illness or injury that resultedinthe hospital stay;

3. Covered expenses for provider facility servicesare limitedto charges made bya hospital or rehabilitation facility for: a. Dailyroom andboardand nursingservices; b. Diagnostictesting;andc. Drugsandmedicinesthat areprescribedbya physician,filledbyalicensedpharmacistandapproved by theU.S.Food andDrugAdministration; and

4. Covered expenses fornon‐provider facility servicesarelimitedto chargesincurredforthe professionalservicesof rehabilitation licensed practitioners;

5. Outpatient physicaltherapy,occupationaltherapy,speechtherapyandaural therapy for rehabilitativepurposes;

6. Inpatient physicaltherapy,occupationaltherapy, speechtherapyandaural therapy for rehabilitativepurposes;and

7. Cardiac rehabilitation,limitedto36visitsper member peryear.

Outpatientphysicaltherapy,speechtherapy and occupation therapy arelimitedto 30 days per covered person peryear. Inpatient physicaltherapy,speechtherapyandoccupationtherapyarelimitedto60days per covered person peryear.See the Schedule of Benefits forbenefit levelsor additionallimits.

Careceasestobe rehabilitation upon our determinationofany ofthefollowing:1. The covered person hasreached maximum therapeutic benefit;2. Furthertreatment cannotrestorebodilyfunction beyondthe levelthe covered person alreadypossesses;

3. There isno measurable progress towarddocumentedgoals;and4. Careisprimarily custodial care.

Neurological Rehabilitation Facility Services Covered expenses for neurologic rehabilitation facility servicesarelimitedto:1. The member must be suffering from severe traumatic brain injury;2. The admission mustbe within7 daysofrelease from a hospital;3. Prior authorization mustbegivenwithwrittenapprovaloftheadmission tothe neurologic

rehabilitation facility priortothe member receiving neurologic rehabilitation facility services;and 4. The neurologic rehabilitation facility servicesareof a temporary naturewith apotential toincrease abilitytofunction.

ExclusionsandLimitations: Nobenefits willbepaidunderthisbenefitsubsectionforexpensesincurred: 1. Custodial care isnotcovered;and2. Coverageis providedfor a maximum of 60 daysper member perlifetime.

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Skilled Nursing Facility Expense Benefits Covered expenses includeexpensesincurredforservicesorconfinementina skilled nursing facility,subjecttothe followinglimitations:1. Servicesorconfinementin a skilled nursing facility mustbegin within14 daysofa hospital stay ofat least3consecutivedaysandbefor treatmentof,thesame illness or injury thatresultedin the hospital stay;

2. Covered expenses for provider facility servicesare limitedto charges made bya hospital or skilled nursing facility for: a. Dailyroom andboardand nursingservices; b. Diagnostictesting;andc. Drugsandmedicinesthat areprescribedbya physician,must befilled by a licensedpharmacist, andare approved bythe U.S.Foodand Drug Administration.

SkilledNursingFacilitycharges are limitedto 60 daysper covered person peryear.See the Schedule of Benefits forbenefitlevels oradditional limits.

Habilitation Expense Benefits Covered expenses includeexpensesincurredfor habilitation services,subject tothe followinglimitations: 1. Covered expenses for habilitation services,includingphysical,occupationaland speechtherapies, developmentalservicesand durable medical equipment for developmentaldelay,developmentaldisability,developmentalspeech orlanguagedisorder,developmentalcoordinationdisorderandmixeddevelopmentaldisorder;and

2. The habilitation services mustbereceivedon an outpatient basis.

Outpatientphysicaltherapy,speechtherapy and occupation therapy arelimitedto 30 days per covered person peryear. Inpatient physicaltherapy,speechtherapyandoccupationtherapyarelistedto60 days per covered person peryear.See the Schedule of Benefits forbenefit levelsor additionallimits.Please note there areseparate limits fordevelopmentalservicesprovided aspartofthehabilitationbenefitslisted above.

Habilitative Developmental Services arelimitedto180visitsper member per year.Examplesinclude,butarenotlimitedto,toileting,dressing,usingfinemotorskills,crawling,walking,categorization,expressingoneself (makingwantsand needsknown),picturerecognition,identifyingletters,numbers,shapes,etc.,appropriateplayskillsandcopingmechanisms.

Home Health Care Expense Benefits Covered expenses for home health care are limitedto the followingcharges:1. Home health aide services;2. Professionalfeesofalicensedrespiratory,physical,occupational,orspeech therapistrequiredfor

home healthcare and developmental services associated with developmental delays, developmental speech or language disorder, developmental coordination disorder and mixed developmental disorder;

3. I.V.medication andpain medication(I.V.medicationandpain medicationarecoveredservice expensesto theextenttheywouldhave been coveredservice expensesduringaninpatienthospital stay);

4. Hemodialysis,andfor the processingandadministrationofbloodorbloodcomponents;5. Necessary medical supplies;6. Rentalof medically necessary durable medical equipment;and7. Sleepstudies.

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At our option, we may authorizethepurchaseof the equipment inlieu ofits rentalifthe rentalpriceis projected toexceed the equipment purchase price, butonly from a provider we authorize before thepurchase.

Anagencythatisapprovedtoprovide home healthcare tothose receiving Medicarebenefitswillbe deemed tobea home healthcare agency.

Limitations: Covered expenses forho me health aide services willbelimitedto:

1. Seven visitsperweek;and2. A calendar year maximum of fifty (50) visits.

Eacheight‐hourperiodof home health aide services willbecountedasonevisit.

Exclusion: Nobenefits willbepayableforchargesrelatedto custodial care, oreducationalcare,undertheHomeHealthcare Service ExpenseBenefit.

Hospice Care Expense Benefits Hospice carebenefitsareallowablefora terminally ill covered person receiving medically necessary careundera hospice care program.

The listof covered expenses inthe MedicalandSurgicalExpenseBenefitsprovisionisexpandedtoinclude: 1. Roomandboardina hospice whilethe covered person isan inpatient;2. Occupationaltherapy;3. Speech‐languagetherapy;4. Therentalofmedical equipment whilethe terminally ill covered person isina hospice care program tothe extent that these itemswouldhave been coveredunder the policy if the covered person hadbeen confinedina hospital;

5. Medical,palliative,andsupportivecare,andtheproceduresnecessaryforpaincontrolandacuteandchronicsymptommanagement;

6. Counselingthe covered person regardingthe covered person’s terminal illness; 7. Terminal illness counseling of members ofthe covered person's immediate family; and8. Bereavement counseling.

Benefitsfor hospice inpatient,home or outpatient careare available forone continuousperiodupto one hundredeighty(180) daysin a covered person's lifetime.

ExclusionsandLimitations:Anyexclusionorlimitationcontainedinthe policy regarding:1. An injury or illness arisingoutof,or inthecourse of,employmentforwageorprofit; 2. Medical necessity ofservicesorsupplies,tothe extentsuch servicesorsuppliesareprovidedaspart ofa hospice care program; or

3. Expenses for otherpersons,tothe extentthose expenses aredescribedabove,willnotbeappliedto thisprovision.

Respite Care Expense Benefits Respite care iscoveredonan inpatient,home, oroutpatientbasis toallow temporary relieftofamily members from the duties of caring fora covered person under hospice care.Respitedaysthat are applied

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towardthe deductible are considered benefitsprovided andshallapply againstany maximumbenefit limitfortheseservices.Coverageis limited to14 days peryear.

Hospital Benefits Covered expenses arelimitedtocharges made by a hospital for:

a. Dailyroomandboard.i. Hospital admissionsare subjecttopre‐admissionnotification.Pleasecallthe numberlistedon your identificationcardtonotify us ofthe admission.

ii. Servicesrenderedin a hospital in a countryoutsideof the UnitedStates of America shallnotbepaidexceptat our solediscretion;

iii. Admissionstoalong termacutecare hospital orto a longterm acutecare divisionof a hospital are subject topre‐admissionnotification.

b. Dailyroom andboardand nursingserviceswhile confinedin an intensive care unit. c. Inpatient useofan operating,treatment,orrecoveryroom;d. Outpatient useofan operating,treatment,orrecoveryroom for surgery;e. Servicesandsupplies,including drugs andmedicines,that are routinelyprovidedbythe

hospital to personsforuse onlywhiletheyare inpatients;f. Foraconditionrequiringthat you beisolatedfrom otherpatients, we willpayforanisolationunitequippedandstaffedassuch; and

g. Emergency treatment of an injury or illness,even ifconfinementisnot required.When emergency treatment isneededthe covered person shouldseek careatthe nearest facility. Emergency treatmentreceivedwithin forty‐eight(48) hoursof the emergency issubjecttothedeductible, copayment and coinsurance specified inthe Schedule of Benefits.Ifthe covered person isadmitted asan inpatient tothesame hospital where emergency treatment wasrendered,the emergency treatment copayment iswaived andallservicesare subject tothe inpatient deductible, copayment and coinsurance.

1. After‐Hours Clinic or Urgent Care Center. Servicesprovidedinanafter‐hours urgent care center aresubjecttothe urgent care deductible, copayment and coinsurance foreach visit. 2. Observation Services. Observationservices are coveredwhenordered by a physician.3. Transfer to Network Hospital. Continuing or follow‐uptreatmentfor injury or emergency treatment islimitedto carethatmeetsprimarycoveragecriteriabefore youcanbesafely transferred,withoutmedicallyharmfulorinjuriousconsequences, toa network hospital inthe service area.Servicesaresubjectto allapplicable deductible, copayment and coinsurance.4. Emergency Hospital Admissions. You are responsible fornotifying Arkansas Health&Wellnessofan emergency admissionto a hospital within24 hours orthe next businessday.Failureto notifyArkansasHealth&Wellness may result in the covered person paying a greaterportionofthe medicalbill. 5. Medical Review of Emergency Care. Emergency treatmentissubjectto medical review.If,basedupon thesignsandsymptoms presentedatthe timeoftreatment asdocumentedbyattendinghealthcarepersonnel,ArkansasHealth & Wellnessdeterminesthatavisitto theemergencyroomfailsto meet the definitionof emergency treatment,coverageshallbe deniedand the emergencyroom charges willbecomethe covered person’s responsibility.

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In Vitro FertilizationBenefitsforinvitro fertilization proceduresarecoveredwhen:

a) Thepatientis thepolicyholderorthe spouse ofthepolicyholder and acov ereddependen t underthe policy,andthe covered person’s oocytesare fertilizedwiththesperm of thepatient's spouse,andthepatientandthepatient's spousehav e ahistoryofu nexplainedinfertilityofat least two(2)years'duration;or

b) theinfertilityisassociated withoneor more ofthe followingmedicalconditions: •••

•

Endometriosis;Exposureinuteroto Diethylstilbestrol,commonlyknownas DES; Blockageoforremovalofone orbothfallopiantubes(lateral orbilateral salpingectomy) notaresultofvoluntarysterilization;orAbnormalmalefactorscontributing totheinfertility.

Invitrofertilizationproceduresmustbeperformedatamedicalfacility,licensedorcertifiedbytheArkansas Departmentof Health,which conformto theAmericanCollegeofObstetriciansandGynecologists'guidelinesforinvitrofertilizationclinics,orthoseperformedat afacilitycertifiedbythe Arkansas DepartmentofHealthwhichmeet theAmericanFertilitySociety'sminimalstandards forprogramsofinvitrofertilizationandthepatienthas beenunabletoobtainsuccessful pregnancy throughanylesscostly applicableinfertilitytreatment for whichcoverageis available under the policy.

Benefitsforinvitro fertilization shall bethe same asthe benefitsprovidedundermaternitybenefit provisionsandaresubjecttothesame deductibles,co‐insuranceand out‐of‐pocketlimitationsthatapplytomaternity benefits.Cryopreservation, theprocedurewhereby embryos arefrozenfor lateimplantation, shallbeincludedasaninvitrofertilizationprocedure.

Low Protein Modified Food Products Covered expenses shallinclude medically necessary medicalfoods(foodproductsandformulas)forthetherapeutictreatmentofacoveredpersoninflictedwithaninheritedmetabolicdisorderinvolvingafailuretoproperlymetabolizecertain nutrients.The medicalfoodmustbeprescribedbyalicensedhealthcare provider.

Medical and Surgical Expense BenefitsMedical covered expenses are limited to charges:1. For surgery ina physician's officeoratan outpatient surgical facility, includingservicesand supplies;

2. Madebyanassistantsurgeon, limited to 20percent ofthe eligible expense forthe surgical procedure;

3. Servicesofstandby physicians are only coveredintheevent such physician isrequiredtoassistwithcertainhigh‐riskservicesspecifiedbyArkansasHealth&Wellness,andonly forsuch timeassuch physician isin immediate proximity to thepatient;

4. Fortheprofessionalservicesofa medical practitioner,including surgery;5. Forelectronic consultationsbetweena medical practitioner,withother involved medical

practitioners.Benefitsincludetelephonecallsorotherformsofelectronicconsultationsbetweenamedical practitioner and a covered person,orbetween a medical practitioner and another medical practitioner;

6. Fordressings,crutches,orthopedicsplints,braces,casts,or other necessary medical supplies;7. Fordiagnostictestingusingradiologic,ultrasonographic,orlaboratoryservices.Psychometric,behavioral andeducationaltesting are notincludedThisincludesadvanceddiagnosticimaging suchascomputed tomographyscanning (CT SCAN‖),MagneticResonance Angiography or Imaging

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(MRI/MRA‖),NuclearCardiology and positronemissiontomography scans(PETSCAN‖)referredtoas―advanceddiagnosticimaging.Thiswillrequire prior authorization from us;

8. Forchemotherapyandradiationtherapyortreatmentonan inpatient oroutpatient basis;9. Forhemodialysis,andthechargesbya hospital forprocessingandadministrationofblood orbloodcomponents;

10. Forrenaldialysis;11. Forthecostandadministrationofan anesthetic;12. Foroxygen anditsadministration; 13. For dental expenses whena covered person suffersan injury, afterthe covered person's effective date ofcoverage, thatresultsin: a. Damagetothe member’s natural teeth; and b. Expensesareincurredwithinsix months of the accident oras partof a treatment plan that wasprescribedbya physician andbeganwithin sixmonthsof theaccident. Injury tothenatural teeth willnotincludeany injury asaresultofchewing;

14. Forreconstructivebreast surgery chargesasaresultofapartial ortotalmastectomy.Coverage includes surgery andreconstructionofthe diseasedandnon‐diseasedbreastand prostheticdevicesnecessarytorestoreasymmetricalappearance andtreatment in connectionwithotherphysical complicationsresultingfromthe mastectomyincludinglymphedemas;

15. Testingofnewbornchildren,includingtestingforDown’ssyndrome,hypothyroidism,sickle‐cellanemia,phenylketonuria/galactosemia,PKU andotherdisordersof metabolism;

16. Forthefollowingtypesoftissuetransplants:a. Corneatransplants;b. Arteryor vein grafts; c. Heartvalve grafts;d. Prosthetictissuereplacement,includingjointreplacements;ande. Implantableprostheticlenses,inconnectionwith cataracts;

17. Coveragefor anesthesia and hospital orambulatory surgical facility charges forservices performed inconnection withdental procedures ina hospital orambulatorysurgicalfacility,ifthe providercertifiesthatbecauseofthepatient'sageorconditionorproblem,hospitalization or generalanesthesiais requiredin ordertosafelyand effectivelyperform theprocedures;andthe patient isachildunderseven(7) yearsof agewho isdeterminedby(2) licenseddentiststorequiredental treatment ina hospital orambulatorysurgicalcenterfor asignificantlycomplexdentalcondition;apersonwithadiagnosedseriousmentalorphysicalcondition;orapersonwithasignificantbehavioral problem;

18. Coveragefor gastric pacemakers for covered persons diagnosed with gastroparesis,eligiblechargesandlimits are basedon medical necessity and require prior authorization;

19. Infertilitycounselingandplanning serviceswhen providedby a network provider,andtestingtodiagnoseinfertility;

20. Cochlearimplants;21. HearingAids‐limited to onepairper year;22. Oneauditorybrainstemimplant perlifetimefor anindividual twelve yearsof age and older with a diagnosisofNeurofibromatosisType II (NF2) whohas undergone or isundergoing removalofbilateralacoustictumors;

23. Implantableosseointegratedhearingaidforpatientswithsingle‐sideddeafnessandnormalhearingin the otherear. Coverageis furtherlimitedto members with: a. congenitalorsurgicallyinduced malformations(e.g.atresia) of the external earcanal or middleear;

b. chronicexternalotitisor otitismedia,subjecttoPriorApproval; c. tumorsoftheexternalcanalortympaniccavity; and

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d. sudden,permanent,unilateralhearing loss duetotrauma,idiopathicsuddenhearing loss,orauditorynervetumor;and

24. Testing and evaluation limitedto fifteen(15) hours per member peryear:a. Psychologicaltesting,includingbutnot limitedto, assessment ofpersonality,emotionalityandintellectualabilities;

b. Forchildren underthe ageofsix(6),childhooddevelopmental testing,includingbut not limitedtoassessmentofmotor, language,social,adaptiveorcognitivefunctionbystandardized developmentalinstruments;

c. Neurobehavioralstatus examination,including,but notlimited toassessmentofthinking, reasoning and judgment;

d. Neuropsychologicaltesting,including,butnotlimitedtoHalstead‐Reitan, LuriaandWAIS‐R. 25. Medically necessary services madeby a physician inan urgent care center,includingfacilitycostsandsupplies;

26. Radiology services,includingX‐ray, MRI,CAT scan,PET scan, andultrasoundimaging;27. NewIntervention(onethatisnotcommonlyrecognizedasa generally accepted standard of medical

practice) whenitis shown throughscientific evidencethattheinterventionwillachieveitsintendedpurposeandwillprevent,cure,alleviate orenable diagnosisor detectionofamedicalconditionwithoutexposingthe member torisksthatoutweighthepotential benefits.New interventionsinthe processofphase I,II or III trialsarenotcovered;

28. NutritionalandDietarycounselingservicesfor members inconnection with cleftpalate management andfornutritionalassessmentprogramsprovidedin and by a hospital;

29. Allergytesting;30. For medically necessary geneticbloodtests;31. For medically necessary immunizationstoprevent respiratory syncytialvirus(RSV); 32. Telemedicine.33. Oralsurgery(non‐dentalrelatedonly) iscoveredfor:

a. Tumors/cysts(excisionwhenattachedtothejaws, cheeks,lips, tongue,roof orfloor ofmouth when apathologicalexam isrequired);

b. Exostoses(excisionof jawsandhard palate);c. Celluitis(externalincisionandadrainage);andd. Sinuses,salivaryglandsorducts(incisionofaccessorysinuses,salivary glandsorducts).

Medically Necessary Vision ServicesEyeexams forthetreatmentofmedical conditions of the eye are covered when the service is performed by a participating provider (optometristor ophthalmologist). Covered services andsuppliesinclude office visits, testing, and treatmentof eyeconditions producing symptoms that if left untreated may result in the loss of vision.

Excludedservicesforroutineand non‐routinevisioninclude: Visual Therapyforadults isexcluded. VisionTherapyDevelopment Testingforchildren,exceptwhenpre‐approved. Any visionservices,treatment ormaterialnotspecificallylistedasa covered service. Lowvision servicesandhardwareforadults. Outof network care,only asdefinedwithinthisdocumentand Schedule of Benefits. Readingglassesforchildrenmay be furnishedbasedonthemeritsoftheindividualcase. The doctorshouldindicatewhysuch correctionsarenecessary.All suchrequestswillbereviewedon apriorapprovalbasis.

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Outpatient Medical Supplies Expense Benefits Covered expenses foroutpatientmedicalsuppliesarelimitedtocharges:1. Forartificial eyes andpolishingof such,forlarynx,breast prosthesis,orbasicartificiallimbsbutnotthereplacementthereof, unlessrequiredby aphysicalchange inthe covered person and the item cannot bemodified.Ifmorethan oneprostheticdevicecanmeet a covered person's functional needs,only thecharge for the mostcosteffective prostheticdevicewillbeconsidereda covered expense. Coverageprovidedforeligible chargesshallbe no lessthan eighty (80%) of Medicare allowable as defined bytheCenters forMedicare & MedicaidServices,HealthcareCommon ProcedureCodingSystem;

2. Foronepairoffoot orthoticsperyearper covered person;3. Fortwomastectomybrasperyearifthe covered person hasundergoneacovered mastectomy; 4. Forrentalof medically necessary durable medical equipment;5. FortherentalofoneContinuousPassiveMotion (CPM)machineper covered person following a coveredjoint surgery;

6. Forthecostofonewigper covered person necessitatedby hair loss dueto cancertreatmentsor traumaticburns;

7. Fora procedure,treatment,service,equipmentor supplytocorrectarefractiveerroroftheeye iscoveredintwoinstances:(1)if suchrefractiveerrorresults from traumatic injury orcornealdisease,infectiousornon‐infectious,and(2) For onepairof eyeglassesorcontactlensesper covered person following a coveredcataract surgery.Seethe Schedule of Benefits forbenefitlevelsor additionallimits;and

8. Forthecostofamonofocallens,ifthemultifocallensisimplantedafter a cataract extraction.

Prescription Drug Expense Benefits Covered expenses inthisbenefitsubsectionarelimitedtochargesfromalicensed pharmacy for:1. A prescription drug.2. Prescribed,self‐administeredanticancermedication.3. Contraceptivedevices prescribedbya physician.4. Anydrug that,underthe applicablestatelaw,may bedispensed onlyuponthewrittenprescription ofa physician.

5. Off‐labeldrugsthatare: a. Recognizedfortreatmentofthe indicationinatleastone(1) standard reference

compendium;orb. The drug is recommendedforaparticulartypeofcancerandfoundtobesafeandeffectiveinformalclinicalstudies,theresultsofwhichhave beenpublishedinapeer reviewed professionalmedicaljournalpublishedintheUnitedStates or GreatBritain.

Asusedinthissection, Standard Reference Compendia means(a) The AmericanHospital FormularyService DrugInformation(b)TheAmerican MedicalAssociation DrugEvaluationor(c)TheUnitedStates Pharmacopoeia‐Drug Information.

Covered expenses shallincludecoverageforprescribeddrugsordevicesapproved bythe UnitedStates FoodandDrugAdministration for use asa contraceptive.

Seethe Schedule of Benefits for benefit levels oradditionallimits. The appropriatedrug choicefor a covered person isadeterminationthatisbestmade by the covered person andthe covered person’s physician.

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NoticeandProofofLoss: Inorder to obtain paymentfor covered expenses incurredata pharmacy for prescription orders, anoticeofclaimandpr oof of loss mustbesubmitteddirectlyto us.

ExclusionsandLimitations: Nobenefits willbepaidunderthisbenefitsubsectionforexpensesincurred: 1. For prescription drugs for thetreatmentof erectiledysfunctionorany enhancementof sexual performance,unlesslistedontheFormulary;

2. Forimmunizationagentsotherwise notrequiredundertheAffordable CareAct; 3. Formedicationthatisto betakenby the covered person, inwholeorin part, atthe place whereit isdispensed;

4. Formedicationreceivedwhilethe covered person isapatient at an institution that has a facilityfor dispensingpharmaceuticals;

5. Forarefilldispensedmorethan 12 monthsfrom the date of a physician's order; 6. Dueto a covered person's addictionto,ordependencyon foods,unlesssuchmedicationsarelisted ontheformulary;

7. Formorethanthe predetermined managed drug limitations assignedtocertaindrugs or classificationofdrugs;

8. Fora prescription order thatis availablein over‐the‐counterform,orcomprisedofcomponentsthatare available inover‐the‐counterform,andistherapeutically equivalent,exceptforover‐the‐counterproductsthatarecoveredontheformularyorwhenthe over‐the‐counterdrugisusedforpreventivecare.Thisexclusiondoes notapply toprescribedFDAapprovedcontraceptivemethods;

9. Fordrugslabeled"Caution‐ limited by federal lawto investigational use" orfor investigational or experimental drugs;

10. Formorethana31‐daysupplywhen dispensedin anyoneprescriptionorrefill,orfor maintenancedrugsupto a90‐daysupplywhen dispensedbymailorderorapharmacythatparticipatesinextendeddaysupply network;

11. For prescription drugs for any covered person whoenrollsinMedicarePartDasofthedate ofthe covered person’s enrollmentin MedicarePartD. Prescription drug coverage may not bereinstated atalaterdate;

12. Foranydrug thatwe identify astherapeuticduplication throughtheDrugUtilizationReview program;

13. Drugsor dosageamounts determinedbyAmbettertobeineffective,unprovenorunsafefortheindicationforwhichtheyhavebeen prescribed,regardlessofwhetherthedrugsordosage amounts have been approvedby any governmentalregulatory body forthat use;

14. Foreignprescriptionmedications, exceptthose associatedwith an emergency medicalcondition whileyouaretravelingoutside theUnitedStates,orthoseyou purchasewhileresidingoutsidetheUnitedStates.These exceptions applyonlyto medicationswith an equivalentFDA‐approved prescriptionmedication thatwouldbe coveredunderthissectionifobtainedintheUnited States; and

15. Foranycontrolledsubstancethat exceedsstate established maximummorphineequivalentsina particulartimeperiod,as established bystate laws andregulations.

Prescription Drug Exception ProcessStandardexceptionrequestA member,a member’s designee ora member’s prescribing physician may request astandardreview ofadecisionthat adrugisnot coveredby theplan. The requestcan be made in writingor via telephone. Within72hoursoftherequestbeing received,we willprovide the member,the member’s designee orthe member’s prescribing physician withourcoveragedetermination. Shouldthestandardexception requestbe

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granted,wewillprovidecoverage ofthenon‐formularydrugfor thedurationofthe prescription,including refills.

ExpeditedexceptionrequestA member,a member’s designee ora member’s prescribing physician may request an expeditedreview basedon exigent circumstances. Exigent circumstances existwhena member issuffering from a health conditionthatmay seriouslyjeopardizethe enrollee'slife,health,orabilitytoregain maximum functionorwhen an enrolleeisundergoingacurrentcourseoftreatmentusinganon‐formularydrug.Within 24hoursofthe request being received,wewill providethe member,the member’s designee or the member’s prescribing physician withourcoveragedetermination.Shouldthe expeditedexception request be granted,wewillprovidecoverage ofthenon‐formularydrug forthe durationoftheexigency.

ExternalexceptionrequestreviewIf we deny a request for astandard exceptionor for an expeditedexception,the member,the member’s designeeorthe member’s prescribing physician mayrequestthattheoriginal exception request and subsequent denialof suchrequestbe reviewed by an independent review organization. We willmake our determinationon the externalexceptionrequestandnotifythe member,the member’s designee or the member’s prescribing physician of our coveragedeterminationnolater than 72 hours followingreceipt oftherequest,iftheoriginal requestwas astandardexception, andnolaterthan24 hoursfollowingits receiptof the request,iftheoriginalrequest was an expeditedexception.

If we grantanexternalexceptionreview ofastandardexception request, we willprovidecoverageofthenon‐formularydrugforthedurationofthe prescription.If we grant an externalexception reviewof an expeditedexceptionrequest, we willprovidecoverageofthenon‐formulary drugforthe durationofthe exigency.

Pediatric Vision Expense Benefits Covered expenses inthisbenefitsubsectioninclude thefollowing foran eligible child underthe age of 19whoisa member:1. Routinevisionscreening,includingdilationrefractionevery calendar year;2. Visiontherapydevelopmentaltesting;3. Onepair ofprescriptionlenses(singlevision,lined bifocal, linedtrifocal,orlenticularinplastic)or initialsupplyofstandard contactsevery calendar year,includingstandardpolycarbonatelenses,scratchresistantandanti‐reflectivecoating.Standardprogressivelensesif medicallynecessary;

4. Onepair ofprescriptionframes every calendar year;5. Lowvision opticaldevices includinglowvision services,and anaidallowancewithfollow‐upcare whenpre‐authorized;

6. Ifyouelecttoseea non‐network provider forroutineexamand eyewearservices,seeyour Schedule of Benefits for maximum allowances forthese benefits. Youwillbe financiallyresponsiblefor any differences above the maximum benefit.Outof network benefitscannot beutilizedinconjunction within network benefits;

7. Office‐basedorthopticandpleoptictraininginthetreatment ofconvergenceinsufficiencywithcontinuingmedicaldirectionandevaluation;

8. Eyeglassesforchildrendiagnosed as having the followingdiagnosesmusthave a surgical evaluation in conjunctionwithsupplyingeyeglasses;

9. Ptosis(droopylid);10. Congenitalcataracts;11. Exotropiaorverticaltropia;12. Childrenbetween the agesof12 an 18exhibiting exotropia;

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•

•



13. Sensorimotor examination withmultiplemeasurementsofoculardeviatrion(e.g. restrictiveorpareticmusclewithdiplopiawithinterpretationandreport;and

14. Eyeprosthesisandpolishingservices.

Covered expenses donot include:1. Twopairof glasses asa substituteforbifocals; 2. Replacement oflostor stoleneyewear; or3. Any visionservices,treatment ormaterialnotspecificallylistedasa covered service.

Vision Expense Benefits Routine Vision Adult aged 19 years of age and overRoutine eyeexams, prescriptions eyeglasses, and initial supply of standard contact lensesare coveredand aremanaged through your visionvendor. Forinformation regarding your specific copayments or deductible please refer to your specificplaninformation listed in the Schedule of Benefits.Youmay receive one routine eye exam and eyewear once every calendar year. Eyewearincludes either one pair of eyeglasses or initialsupplyofstandardcontacts.

EyeglassesCoveredl enses include single vision,l inedb ifocal,l ined trifocal, orlenticular, in glass or plastic. Coveredlensadd‐onsincludestandardpolycarbonatelenses,scratchresistantandanti‐reflectivecoating. If you require a more complexp rescriptionlens ,c ontactyourvisionvendorfor prior authorization. Lensoptionssuch asprogressivel enses,high i ndextints andUVcoatinga ren otc overed.For coveredframes,refer to your Schedule of Benefitsforyo urmaximum allowance. Shouldyou exceedthe maximum allowance,youwillbefinanciallyresponsibleforthedifference.

Contact LensesCoverage includes evaluation, fitting, and initial supplyofstandardcontact lenses. Pleaserefertoyourspecificp laninformationlisted i nthe Sc hedule of Benefits foryour maximum allowanceforc ontacts.

Ifyouelecttoseeanon ‐network provider forroutine exam and eyewearservices,see yourSchedule of Benefitsform aximum allowances forthesebenefits.You willbefi nancially responsible foranydiffer ences above the maximumb enefit.Out ofnetwor k benefitscannotbeutilizedinconjunctionwithinnetwork benefits.

Foradditional information about covered vision services, including participating vision providers, callMember Services at 1‐877‐617‐0390.

Dental Benefits – Adults 19 years of age or olderCoverageis providedfor adults,age19andolder, Basic(Class 1) and Comprehensive(Class2)dental servicesfromanin‐network provider.Pleaserefer toyour Schedule of Benefits for a detailedlistof cost sharing,annualmaximum andappropriateservicelimitations.To see whichdental providers arepartofthe network,pleasecall 1‐877‐617‐0390 orvisit Ambetter.ARHealthWellness.com.

1. Basic(Class1)benefitsinclude:a. RoutineOralExams;b. Routine Cleanings;c. Bite‐wingX‐rays;d. Full‐Mouth X‐Rays;

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e. PanoramicFilm; f. Topicalfluorideapplication;andg. Palliative Treatment for Relief of Pain (minorprocedures).

2. Comprehensive(Class2) benefitsinclude:a. BasicServices–includingsilverfilingsandtoothcoloredfilings;b. Endodontics–includingtherapeuticpulpotomy;c. Periodontics–includingscaling,root planning andperiodontal maintenance;d. Oral Surgery –includingsimpleextractions, surgicalextractions,removal of impacted tooth andalveoloplasty;and

e. Prosthodontics–includingrelines,rebase,adjustmentandrepairs.

Services notcovered foradult Basic (Class 1) andComprehensive(Class2) benefitsinclude: 1. Dentalservicesthat are notnecessary orspecifically covered; 2. Hospitalizationorother facilitycharges; 3. Prescription drugs dispensedinadentaloffice;4. Anydentalprocedureperformedsolelyasacosmeticprocedure;5. Chargesfordentalprocedurescompletedpriortothe member’s effective date ofcoverage;6. Anesthesiologistsservices;7. Dentalprocedures,appliances,or restorationsthat arenecessarytoalter,restore,ormaintainocclusion,includingbutnotlimitedto:increasingverticaldimension,replacingor stabilizingtoothstructurelostbyattrition(wear),realignmentofteeth,periodontalsplinting,and gnathologicrecordings;

8. Directdiagnosticsurgicalornon‐surgicaltreatmentprocedures appliedtojawjoints or muscles; 9. Any artificial materialimplantedor grafted intosoft tissue, surgicalremoval ofimplants, and implantprocedures;

10. Surgicalreplacements;11. Sinusaugmentation;12. Surgicalapplianceremoval;13. Intraoralplacementof afixationdevice;14. Oralhygieneinstruction,tobacco counseling,nutritionalcounseling; 15. Servicesforteethretained inrelation toan overdenture.Overdenture appliances arelimitedto an allowanceforastandardfulldenture;

16. Anyoral surgery thatincludessurgicalendodontics(apicoectomy andretrograde filling);17. Rootcanaltherapy;18. Analgesia(nitrousoxide);19. Removableunilateraldentures;20. Temporaryprocedures;21. Splinting;22. TMJ appliances,therapy, filmsand arthorograms; 23. Labtestsincluding,butnotlimitedtoviralculture, salivadiagnostics,cariestesting; 24. Consultationsbythe treating provider and office visits; 25. Initialinstallationofimplants, full orpartialdenturesor fixedbridgeworkto replace a toothor teeth extractedpriortothe member’s effective date;

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26. Occlusalanalysis,occlusalguards(nightguards),andocclusal adjustments(limitedandcomplete);27. Veneers(bonding ofcoveringsto the teeth);28. Orthodontictreatmentprocedures;29. Correctionstocongenitalconditions,otherthanfor congenital missingteeth;30. Athleticmouthguards;31. Retreatment oradditionaltreatmentnecessarytocorrectorrelieve the resultsofprevious treatment;and

32. Spacemaintainersforanyone19 years of age or older.

Preventive Care Expense Benefits Covered expenses are expandedto includethe chargesincurred by a covered person forthefollowingpreventive healthservices ifappropriate forthat covered person inaccordancewiththefollowingrecommendationsandguidelines:1. Evidence baseditems orservicesthat have in effect aratingofAorB inthecurrent recommendations ofthe UnitedStatesPreventive Services Task Force;

2. Immunizationsthat haveineffect arecommendationfromtheAdvisoryCommitteeonImmunizationPracticesoftheCenters forDiseaseControlandPreventionwithrespecttoanindividual;

3. Evidence‐informedpreventivecare andscreenings forinfants,children,andadolescents,inaccordancewithcomprehensiveguidelinessupportedbytheHealthResourcesandServicesAdministration;

4. Additionalpreventive careand screeningsnotincludedin(1)above,in accordancewith comprehensive guidelines supported bytheHealthResources and ServicesAdministrationfor women;

5. Complicationsresultingfromthe smallpoxvaccine;6. BRCAgeneticcancertestingfor womenwith afamilyhistoryof certaincancers;and 7. Coverswithout cost sharing:

a. Screeningfor tobacco use;andb. Forthosewho use tobacco products,atleasttwo(2)cessation attemptsper year.Forthis purpose,coveringacessationattemptincludescoverage for:i. Four(4)tobaccocessation counselingsessionsofat leastten (10)minutes each (includingtelephonecounseling,group counselingandindividualcounseling) without prior authorization;and

ii. AllFoodandDrugAdministration (FDA)approvedtobaccocessationmedications(includingbothprescriptionandover‐the‐countermedications) for a 90‐day treatmentregimenwhenprescribedbya healthcare provider without prior authorization.

Benefitsforpreventivehealthserviceslistedinthisprovision,except under theadministrationofreasonable medical managementtechniquesdiscussedinthe next paragraph,are exemptfrom any deductiblesor coinsurance provisions,and copayment amounts under the policy when theservices are providedbya network provider.

Benefitsfor covered expenses forpreventive care expensebenefitsmayincludethe use ofreasonable medical managementtechniques authorized byfederallaw topromote the useofhighvaluepreventive servicesfrom network providers.Reasonablemedicalmanagement techniques may resultinthe application ofdeductibles or coinsurance provisions,or copayment amounts toservices when a covered person choosesnotto use a high value servicethat is otherwise exempt from deductiblesor coinsurance provisions,and copayment amounts,when receivedfrom a network provider.62141AR010 49



Asnewrecommendations and guidelinesareissued,thoseserviceswillbeconsidered covered expenses whenrequiredby the UnitedStates Secretary ofHealth andHuman Services,butnot earlierthan oneyear after the recommendation or guidelineisissued.

Colorectal Cancer Covered expenses shallincludecolorectalcancer examinationsand laboratorytestsfor covered persons whoare fifty (50) yearsofage orolder; covered persons whoare less than fifty (50)yearsof age and athighriskforcolorectalcanceraccording toAmericanCancerSocietycolorectalcancerscreeningguidelinesastheyexistedonJanuary1,2005;and covered persons experiencingthefollowingsymptomsofcolorectalcancer asdeterminedby a physician licensedundertheArkansasMedicalPracticesAct:Bleedingfrom therectumorbloodinthestool;orachangeinbowelhabits,suchasdiarrhea,constipation,ornarrowingofthestool,thatlastsmorethanfive(5)days.

Colorectalscreeningshallinvolveanexaminationofthe colon, includingthe followingexaminationsor laboratorytests,orboth:(i)An annual fecaloccult bloodtestutilizingthetake‐homemultiplesample method,or anannualfecalimmunochemicaltestinconjunctionwithaflexiblesigmoidoscopyeveryfive(5) years; (ii)A double‐contrastbarium enema everyfive(5)years;or(iii)Acolonoscopyeveryten(10) years;andanyadditionalmedicallyrecognizedscreeningtestsforcolorectalcancerrequired bythe Directorof theDivisionofHealthoftheDepartment of Healthand HumanServices,determined inconsultationwith appropriate healthcare organizations.

A covered person shalldeterminethechoiceofscreeningstrategiesin consultationwith a healthcare provider.Screeningsshallbelimited tothe following guidelines:(1)Iftheinitialcolonoscopyisnormal,follow‐upis recommendedinten(10)years;(2)Forindividuals withone(1)ormore neoplasticpolypsor adenomatouspolyps,assuming thattheinitialcolonoscopywascomplete to the cecum andadequatepreparationandremovalofallvisualizedpolyps,follow‐upis recommended inthree (3) years; ifsingle tubular adenoma of lessthan one centimeter (1cm) isfound,follow‐upisrecommendedinfive(5)years; andforpatientswithlargesessileadenomasgreaterthanthree centimeters(3cm),especiallyifremovedin piecemeal fashion,follow‐upisrecommendedin six (6)months oruntil completepolyp removalis verified bycolonoscopy.

Mammography Screening Covered expenses for a covered person shallbe paid atthe following frequency schedule: Age 35through 39, one baseline mammogram;Age 40 and older,one mammogram every year. Mammograms without regard toage are covered,upon recommendationfrom a physician,whenthereis apriorhistoryofbreastcancer, familyhistory ofbreastcancer,positive genetictestingor otherriskfactors.

Prostate Cancer Screening Covered expenses shallincludecoverageforprostatecancerscreeningsfora covered person 40 years of age orolderinaccordancewiththe National Comprehensive Cancer Networkguidelines.Ifrecommendedbya physician, covered expenses shallincludeaprostatespecificantigen bloodtest.

Maternity CareCoveragefor maternity care: outpatientand inpatient pre‐andpost‐partumcareincluding exams,prenataldiagnosisofgeneticdisorder,laboratoryandradiologydiagnostictesting,healtheducation,nutritionalcounseling,riskassessment, childbirthclasses,and hospital stays fordeliveryor other medically necessary reasonsless any applicable deductible, or coinsurance.An inpatient stayiscoveredforatleastforty‐eight (48) hoursfollowing a vaginal delivery,andforat leastninety‐six(96)hours following a caesarean delivery.Othermaternity benefitsinclude complications of pregnancy, parent education,assistance, and

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trainingin breastor bottlefeeding andtheperformanceof any necessaryandappropriateclinical tests, includingoneobstetricalultrasound.

Newborns’ and Mothers’ Health Protection Act Statement of RightsIfexpensesfor hospital confinementin connection withchildbirthare otherwiseincludedas covered expenses, we willnotlimit the number ofdaysforthese expensestolessthanthat statedinthisprovision.

Underfederallaw,healthinsuranceissuersgenerallymaynot restrictbenefitsotherwiseprovidedforany hospital lengthofstayinconnectionwith childbirthfor themotheror newbornchildtolessthan forty‐eight(48) hoursfollowing a vaginal delivery or less than ninety‐six (96) hoursfollowing a delivery by cesarean section.However, we mayprovidebenefitsfor covered expenses incurredforashorter stayiftheattending provider (e.g., your physician,nursemidwifeorphysicianassistant),afterconsultationwiththemother, dischargesthemother or newbornearlier.

Thelevelofbenefitsandout‐of‐pocketcostsforanylater part of the 48‐hour or96‐hour staywillnot be lessfavorabletothemotherornewbornthan any earlierpart ofthestay. We donot requirethat a physicianorother healthcare provider obtain authorization forprescribing a length of stayof up to 48hoursor 96hours.

Note: Thisprovisiondoesnotamendthe policy torestrictanyterms,limits,orconditionsthatmay otherwiseapplyto covered expenses forchildbirth.

Temporomandibular Joint Disorder and Craniomandibular Disorder Expense Benefits Covered service expenses expandedtoincludethe charges incurredfordiagnosisandtreatment services,bothsurgical andnonsurgicalfortemporomandibularjointdisorder(TMJ)andcraniomandibulardisorder.These expensesshallbe thesame asthat fortreatment to any otherjoint in thebody.Coverageshallapply ifthe treatmentis administeredorprescribedby a physician or dentist.

Transplant Service Expense Benefits Covered expensesfortr ansplantexpenses: If we determinethata covered person isan appropriatecandidate for a listed transplant, MedicalBenefits covered expenses willbeprovidedfor: 1. Pre‐transplantevaluation;2. Pre‐transplantharvesting;3. Pre‐transplantstabilization,meaningan inpatient staytomedically stabilize a covered person toprepareforalatertransplant, whether ornot the transplant occurs;

4. Highdosechemotherapy;5. Peripheralstemcellcollection;6. Post‐transplantfollow‐up;and7. Fordonor testingisthedonorisfoundcompatible.

TransplantDonorExpenses: We willcoverthemedicalexpensesincurredbyalivedonoras if they were medicalexpensesofthe covered person if: 1. They wouldotherwise be considered covered expenses underthe policy;2. The covered person receivedanorgan orbonemarrowofthelivedonor;and3. The transplantwas a listed transplant.

A covered person mayobtainservicesin connection witha listed transplant fromany physician. We willpayamaximum of$10,000perlifetime for the followingservices:

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a. Transportationforthe covered person, anylive donor,andthe immediate family toaccompanythe covered person. Reimbursementformilestraveledwillbe made atthecurrentIRSstandardmileage rate formedical purposes.

b. Lodging for any livedonorandthe immediate family accompanyingthe covered person whilethe covered person isconfined. We will paythecostsdirectlyfortransportationandlodging, however, you must make the arrangements.

Exclusions: Nobenefits willbepaid underthese Transplant Expense Benefitsfor charges: 1. Foraprophylacticbonemarrowharvestorperipheralbloodstem cellcollectionwhenno listed

transplant occurs;2. For animal to human transplants;3. Forartificialormechanicaldevicesdesignedto replacea humanorgan temporarilyorpermanently;4. Forprocurement ortransportationoftheorganortissue,unlessexpresslyprovidedfor inthisprovision;

5. Tokeep a donoralive for thetransplantoperation;6. Foralivedonorwhere the live donorisreceivingatransplanted organtoreplacethedonated organ; and

7. Relatedtotransplantsnotincludedunderthisprovisionasa listed transplant.

LimitationsonTransplantExpensesBenefits: In additionto the exclusionsandlimitationsspecifiedelsewhere inthissection covered expenses for listed transplants willbelimitedtotwotransplantsduringany10‐yearperiodfor each covered person.

Trans‐telephonic Home Spirometry Coverage for eligible service expenses fortrans‐telephonichomeorambulatoryspirometryfor members whohave had alungtransplant.

Clinical Trial CoverageClinicalTrialCoverageincludes routinepatientcarecostsincurredasthe resultofan approvedphaseI,II,IIIorphaseIVclinicaltrialand theclinicaltrialisundertakenforthepurposesofprevention,earlydetection,or treatmentof cancer orotherlife‐threateningdiseaseor condition.Coveragewillincluderoutinepatientcarecostsincurredfor(1)drugsanddevicesthathavebeenapprovedfor salebytheFood andDrug Administration (FDA),regardlessofwhetherapproved bytheFDAforuseintreatingthepatient’s particularcondition,(2)reasonable and medically necessary servicesneededtoadminister thedrugor use thedevice underevaluationin theclinicaltrialand(3)allitems andservicesthat are otherwisegenerally available to a qualified individual that areprovidedintheclinicaltrialexcept:

The investigational item orserviceitself; Items and services provided solely to satisfy data collection and analysis needs and that are notusedinthedirectclinicalmanagemento fthe pa tient; and Items and services customarily provided by the research sponsors free of charge for any enrolleeinthetrial.

Clinicaltrialsmustmeetthefollowingrequirements:Phase I and II of a clinical trial is sanctioned by the National Institutes of Health (NIH) or NationalC ancer Institute (NCI)a ndc onducteda t academico r National Cancer Institute Center; and The insured is enrolled in the clinical trial. This section shall not apply to insureds who are only followingtheprotocolofphaseI orIIofaclinicaltrial,butnotactuallyenrolled.

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“Clinical trial” means a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life‐threatening disease or condition, funded or approvedby:

Oneof the NationalInstitutesofHealth (NIH);TheCentersforDisease ControlandPrevention; TheAgencyforHealthCare ResearchandQuality;TheCentersforMedicare &Medicaid Services; A cooperative group or center of any of the entities listed above or the Department of Defense orthe Department of Veteran Affairs; AnNIHCooperativeGrouporCenter; The FDAin theform ofan investigational new drug application; ThefederalDepartmentsof Veterans’ Affairs,Defense,or Energy; Aninstitutionalreview boardinthisstatethat has an appropriateassurance approved by theDepartmentof Healthand Human Servicesassuringcompliancewith andimplementationofregulationsfortheprotectionof humansubjects; The study or investigation is a drug trial that is exempt from having such an investigational new drug application; or Aqualified non‐governmentalresearchentity that meets the criteriaforNIH Centersupport granteligibility.

Inaclinicaltrial,thetreatingfacilityandpersonnelmusthavetheexpertiseandtrainingtoprovidethetreatment andtreat asufficientvolumeof patients. A qualified individual mustbeeligibletoparticipate intheclinicaltrial,andeither(a)haveareferralfromadoctor statingthattheclinicaltrialwouldbeappropriate basedupontheindividualhavingcanceror alife‐threateningdiseaseorcondition;or(b) theindividualmustprovidemedical andscientificinformationestablishingthattheirparticipationin theclinicaltrialwouldbeappropriatebasedontheindividualhavingcanceroralife‐threateningdiseaseor condition.

Providers participatinginclinicaltrials shallobtain a patient’s informedconsentforparticipationin theclinicaltrialinamannerthatisconsistentwithcurrentlegalandethicalstandards. Suchdocuments shall bemade available to Arkansas Health&Wellnessuponrequest.

Second Medical Opinion Members are entitledto a secondmedical opinion underthe followingconditions:

1.

Wheneveraminor surgical procedure isrecommendedto confirm the needforthe procedure; 2. Wheneveraserious injury or illness exists;or3. Whenever you findthat you are not responding to the current treatment planin a satisfactory manner.

Ifrequested,thesecondopinionconsultationistobeprovided bya provider ofthe member’s choice.The member mayselecta network provider listedintheHealthcareProviderDirectory.Ifa member choosesa network provider,the member willonlybe responsibleforthe applicableco‐paymentfor the consultation.Anylabtestsordiagnosticand therapeuticservicesaresubjecttotheadditionalco‐payment.

Wellness and Other ProgramsBenefitsmay be available from time to timeto members forparticipatingincertainprogramsthat we may makeavailablein connection withthis policy.Suchprograms mayincludewellness programs,diseaseorcase management programs, andotherprograms.The benefits availableto members forparticipatinginsuchprogramsaredescribedonthe Schedule of Benefits.You may

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obtain information regardingthe particularprograms available atany giventimebyvisiting ourwebsiteat Ambetter.ARHealthWellness.com orby contacting MemberServicesbytelephoneat1‐877‐617‐0390. Theprograms and benefitsavailable at any given time aremadepart ofthis policybythisreference and are subjectto change from timeto time by us throughan update toprogram information available on our websiteorbycontacting us.

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PRIOR AUTHORIZATION

Prior Authorization RequiredSome covered expenses require prior authorization.In general, network providers mustobtain authorization from us priortoproviding a service orsupplyto a covered person. However, therearesome network eligible expenses forwhich you must obtain the prior authorization.

Forservices orsuppliesthatrequire prior authorization,asshownon the Schedule of Benefits, you mustobtain authorization from us before you or your dependent member: 1. Receivesaserviceor supply; or2. Areadmittedintoa facility.

Prior Authorization requestsmustbereceivedbyphone/efax/ provider portalasfollows:1. Atleast 5dayspriorto anelective admissionas an inpatient ina hospital, extendedcareor

rehabilitation facility,or hospice facility. 2. Atleast 30dayspriortotheinitialevaluation for organ transplantservices. 3. Atleast 30dayspriortoreceivingclinicaltrialservices.4. Within24hoursofanadmission forinpatientmentalhealthor substanceabusetreatment.5. Atleast 5dayspriortothe start of home healthcare.

After prior authorization hasbeen requestedandallrequiredorapplicabledocumentationhasbeen submitted,wewillnotifyyouand your provideriftherequest hasbeen approvedas follows: 1. Forimmediaterequestsituations,within1 businessday,whenthelack oftreatment may resultin an emergency room visitor emergency admission.

2. Forurgent concurrentreviewwithin 24 hoursof receiptofthe request. 3. Forurgent pre‐service,within1 businessday ofreceiptofall information,butnolater than72 hoursfrom date ofreceipt ofrequest.

4. Fornon‐urgentpre‐servicerequests within2 businessdays of receiptofall information,butno laterthan15daysofreceiptofthe request.

5. Forpost‐servicerequests,within30calendardaysofreceiptoftherequest.

How to Obtain Prior AuthorizationTo obtain prior authorization ortoconfirmthat a network provider hasobtained prior authorization,contact us by telephone at thetelephonenumberlistedon your healthinsuranceidentificationcardbefore theserviceor supplyisprovidedtothe covered person.

Failure to Obtain Prior AuthorizationFailureto complywiththe prior authorization requirements willresultinbenefitsbeingreduced.

Network providers cannotbill you forservicesforwhichtheyfailtoobtain prior authorization as required.

Benefitswillnotbereduced for failure tocomplywith prior authorization requirementsprior to an emergency. However, you mustcontact us assoon asreasonablypossible afterthe emergency occurs.

Prior Authorization Does Not Guarantee Benefits Our authorization doesnotguaranteeeither paymentofbenefitsortheamountof benefits. Eligibility for,andpaymentof,benefitsaresubjecttoalltermsandconditionsofthe policy.

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Requests for Predeterminations You may requestapredetermination of coverage. We willprovideoneifcircumstances allow us to do so. However, we are not requiredtomake apredetermination ofeithercoverage orbenefitsforanyparticular treatment or medical expense.Anypredetermination we may make willbe reviewedafterthemedical expenseisincurredand a claimis filed. Areviewthatshows oneormoreofthefollowingmaycause us toreversethe predetermination:1. The predetermination wasbasedonincompleteor inaccurateinformationinitiallyreceivedby us. 2. Another partyhas alreadypaidorisresponsibleforpaymentof the medicalexpense.

We willmakeallbenefitdeterminationsaftera loss ingoodfaith. All benefit determinationsaresubjectto our receiptofproper proof of loss.

Hospital Based ProvidersWhenreceivingcare at anAmbetter participating hospital itispossiblethat some hospital‐basedproviders(forexample,anesthesiologists, radiologists,pathologists)maynotbeunder contractwithAmbetterasparticipatingproviders.These providersmaybill you for thedifference between Ambetter’s allowed amount and theproviders billedcharge–thisisknown as“balance billing”.We encourage you toinquire about theproviderswhowillbetreatingyou before you begin yourtreatment,soyoucanunderstandtheir participationstatuswithAmbetter.

ALTHOUGH HEALTHCARESERVICESMAYBE ORHAVE BEEN PROVIDED TO YOUATAHEALTHCARE FACILITY THAT ISA MEMBEROF THE PROVIDERNETWORKUSEDBYAMBETTER,OTHERPROFESSIONALSERVICESMAYBE ORHAVE BEEN PROVIDED ATORTHROUGH THE FACILITY BYPHYSICIANSANDOTHERMEDICALPRACTITIONERSWHOARENOTMEMBERS OFTHATNETWORK.YOUMAY BE RESPONSIBLE FORPAYMENT OFALLORPARTOFTHE FEESFORTHOSEPROFESSIONAL SERVICES THATARENOTPAID ORCOVEREDBYAMBETTER.

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GENERAL LIMITATIONS AND EXCLUSIONSNobenefits willbepaidfor:1. Anyserviceorsupplythatwould be providedwithoutcostto you or your covered dependent intheabsenceof insurancecoveringthecharge;

2. Expenses,fees,taxesor surcharges imposedon you or your covered dependent by a provider, includinga hospital,butthatareactuallythe responsibilityofthe provider topay;

3. Anyservices performed fora member bya covered person's immediate family; and4. Anyservices notidentifiedandincludedas covered expenses under the policy. You willbefullyresponsibleforpaymentforany servicesthat are not covered expenses.

Even ifnot specificallyexcludedbythis policy, no benefitwillbe paidfora serviceorsupplyunlessitis: 1. Administeredorordered byaprovider; and2. Medically necessary to the diagnosisortreatment ofan injury or illness, orcoveredunderthe Preventive Care Expense Benefitsprovision.

Covered expenses willnotinclude,andnobenefits willbepaidforanycharges thatareincurred:1. Forservices orsuppliesthat areprovidedpriortothe effective date oraftertheterminationdate ofthis policy,except asexpresslyprovidedforunder theBenefitsAfter CoverageTerminatesclausein this policy's Terminationsection;

2. Foranyportionofthecharges that are inexcess of the eligible expense; 3. Forweightmodification,orfor surgicaltreatment of obesity, includingwiring oftheteethand all formsofintestinalbypass surgery, bariatricsurgeryand weightlossprograms;

4. Forcosmetic breastreductionor augmentation (doesnotinclude reduction mammoplastywhen deemed medically necessary by us);

5. Forthereversalofsterilizationandthereversalof vasectomies;6. Foranelective abortion forany reasonotherthan:

a. Topreventthedeathofthemother uponwhom the abortion isperformed.However,an abortion shall not bedeemed an elective abortion topreventthedeathof the mother based on aclaim or diagnosisthatwithoutthe abortion the motherwill engagein conductthat will resultinthemother’sdeath;or

b. Ina pregnancy resultingfromrapeor incest.7. Fortreatmentofmalocclusions,disordersofthetemporomandibularjoint, orcraniomandibulardisorders,exceptasdescribedin covered expenses oftheMedicalBenefits provision;

8. Forexpensesfortelevision,telephone,orexpensesforotherpersons;9. Fortelephoneconsultationsorforfailureto keepa scheduled appointment; 10. For hospital roomandboardandnursingservicesforthefirstFridayorSaturday of an inpatientstaythatbeginsononeofthosedays,unlessitisan emergency,or medically necessary inpatient surgery isscheduledfortheday after thedateof admission;

11. Forstand‐byavailabilityofa medical practitioner whennotreatmentisrendered; 12. For dental expenses, includingbracesforanymedicalordentalcondition, surgery andtreatmentfororal surgery,except as expresslyprovided forunderMedicalBenefits;

13. For cosmetic treatment,exceptfor reconstructive surgery thatisincidentaltoorfollows surgery or an injury that wascovered underthe policy or isperformedto correctabirthdefectinachildwho hasbeen a covered person from itsbirthuntilthe date surgery is performed;

14. Fordiagnosis ortreatmentofattitudinaldisorders,ordisciplinaryproblems;15. Forchargesrelatedto,orinpreparationfor,tissue ororgan transplants,exceptasexpressly providedfor undertheTransplant ExpenseBenefits;

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16. Forhighdosechemotherapypriorto,inconjunctionwith,orsupportedby ABMT/BMT,exceptas specificallyprovidedunderthe Transplant Expense Benefits;

17. Foreyerefractive surgery, when the primary purposeistocorrectnearsightedness,farsightedness, orastigmatism;

18. Whileconfinedprimarilytoreceive rehabilitation, custodial care, educationalcare,ornursing services,unlessexpresslyprovidedforbythe policy;

19. Forvocationalorrecreationaltherapy,vocational rehabilitation,outpatient speechtherapy,or occupational therapy,exceptas expresslyprovidedforinthis policy;

20. Foralternativeor complementarymedicineusingnon‐orthodox therapeuticpracticesthatdo not followconventional medicine.Theseinclude,but arenot limitedto,wildernesstherapy,outdoortherapy,bootcamp,equinetherapy,andsimilarprograms;

21. Foreyeglasses,contactlenses, eyerefraction,visualtherapy, orforanyexaminationorfitting relatedto thesedevices,except asspecificallyprovidedunder the policy;

22. For experimental or investigational treatment(s) or unproven services. The fact that an experimental or investigational treatment or unproven service istheonly availabletreatmentfora particular conditionwillnotresultin benefitsiftheprocedure isconsideredtobean experimental or investigational treatment or unproven service forthetreatmentofthatparticularcondition;

23. FortreatmentreceivedoutsidetheUnitedStates,except for a medical emergency whiletravelingforup to a maximum of ninety (90)consecutive days.Iftravel extendsbeyondninety(90) consecutivedays,nocoverage isprovidedfor medical emergencies forthe entireperiodoftravel includingthefirstninety(90) days;

24. Asaresultofan injury or illness arisingoutof,orinthecourse of,employmentforwageorprofit,if the covered person isinsured,orisrequiredto be insured, byworkers' compensationinsurance pursuanttoapplicablestate or federallaw.If you enterinto asettlementthatwaivesa covered person's righttorecover future medical benefitsundera workers'compensationlawor insurance plan,thisexclusionwillstillapply.In theeventthat theworkers' compensationinsurancecarrier deniescoveragefora covered person's workers'compensationclaim,thisexclusionwillstillapplyunlessthatdenialisappealedto thepropergovernmental agencyandthedenialisupheldbythatagency;

25. Asaresultof: a. Intentionallyself‐inflicted bodilyharm,unlessthe injury resultsfromanactofdomesticviolenceoramedicalcondition (includingbothphysicalandmentalhealthconditions);

b. An injury or illness causedbyanyactofdeclaredor undeclaredwar;c. The covered person taking part in a riot;or d. The covered person's commissionof afelony,whetherornotcharged;

26. Forany illness or injury incurredasaresultofthe covered person’s useofacontrolledsubstance,unlessadministeredorprescribedbya physician,exceptas expresslyprovidedforundertheMentalHealthandSubstanceUseExpenseBenefits provision;

27. Fororrelated tosurrogate parenting;28. For or related to treatment of hyperhidrosis (excessive sweating); 29. Forfetalreduction surgery;30. Exceptasspecificallyidentifiedasa covered expense underthe policy,expensesfor alternativetreatments,includingacupressure,acupuncture,aromatherapy, hypnotism, massagetherapy, rolfing, andother forms of alternativetreatment asdefinedby the Officeof Alternative Medicine of theNational InstitutesofHealth;

31. Asaresultofany injury sustainedduringorduetoparticipating,instructing,demonstrating,guiding,oraccompanyingothers in anyofthe following: professionalorsemi‐professionalsports;intercollegiatesportsnotincludingintramural sports;racing or speedtesting any motorized vehicleorconveyance,ifthe covered person ispaid toparticipate ortoinstruct;racingorspeedtestinganynon‐motorizedvehicleorconveyance,ifthe covered person ispaidtoparticipateorto

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instruct;rodeosports;horsebackriding,ifthe covered person ispaidtoparticipateor toinstruct; rockormountain climbing,ifthe covered person ispaidtoparticipateor to instruct;or skiing,ifthe covered person ispaidtoparticipateortoinstruct;

32. Asaresultofany injury sustainedwhileoperating,ridingin,ordescendingfromanytypeofaircraft ifthe covered person isapilot,officer,or member ofthecrewofsuchaircraftorisgivingorreceivinganykindoftrainingorinstructionsorotherwisehas any dutiesthatrequirehim or herto beaboardtheaircraft;

33. For prescription drugs for any covered person whoenrollsinMedicarePartDasofthedate ofthe covered person’s enrollmentin MedicarePartD. Prescription drug coveragemaynotbereinstated at alaterdate;

34. Forthefollowingmiscellaneous items:artificial insemination exceptwhererequiredbyfederalor statelaw; careorcomplicationsresultingfromnon‐covered expenses;chelatingagents;domiciliary care;foodand foodsupplements; routinefoot care, footorthotics,correctiveshoes,ororthopedic shoesthat are not attachedtoan appliance; healthclub memberships,unlessotherwisecovered; hometestkits; careorservicesprovidedtoanon‐member biologicalparent; nutritionor dietarysupplements; pre‐marital labwork; processingfees; privatedutynursing; rehabilitation services fortheenhancement ofjob,athleticorrecreationalperformance;routine or elective care outside the service area; sclerotherapyfor varicoseveins; treatment of spiderveins; transportationexpenses; unlessspecificallydescribedinthis policy;

35. Diagnostictesting,laboratoryprocedures,screeningsor examinationsperformed forthe purposeofobtaining,maintainingor monitoringemployment;

36. Take‐homedressingsand supplies following hospitalization; any othersupplies,dressings, appliances,devicesorserviceswhicharenot specificallylistedascoveredabove; replacement or repairofappliances,devicesandsuppliesdueto loss,breakagefrom willful damage,neglector wrongfuluse,ordue topersonalpreference;and

37. Servicesorsupplieseligiblefor paymentundereitherfederal orstateprograms(except Medicaid).Thisexclusionapplieswhetherornot you assert your rightsto obtain thiscoverage orpaymentoftheseservices.

Limitation On Benefits For Services Provided By Medicare Opt‐Out Practitioners Benefitsfor covered expenses incurredbyaMedicare‐eligibleindividualforservicesand suppliesprovided bya Medicare opt‐out practitioner willbe determinedasiftheservicesandsupplieshad been providedby a Medicare participating practitioner.Benefitswillbe determinedas ifMedicarehad,in fact,paid the benefitsitwouldhavepaidifthe servicesand supplieshad beenprovidedby a Medicare participating practitioner.

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TERMINATION Termination of PolicyAllinsurancewillceaseonterminationofthis policy. This policy willterminateontheearliestof: 1. Thedatethata member hasfailedto paypremiumsorcontributionsin accordancewith the terms ofthis policy (including,butnot limitedto,theGracePeriodprovision)or the date that we have notreceivedtimelypremium payments inaccordancewiththetermsofthis policy;

2. The date we receivearequestfrom you toterminate this policy, orany later datestatedin yourrequest,orif you are enrolledthroughan Exchange,the date ofterminationthatthe Exchange providesusuponyourrequestof cancellationto the Exchange;

3. The date we declinetorenewthis policy, asstatedintheDiscontinuanceprovision; 4. The date of your death,ifthis policy isanIndividualPlan;5. The date a covered person’s eligibility forinsurance under this policy ceases dueto losing networkaccessasthe resultof a permanent move;

6. The date the member has performedanact orpracticethat constitutesfraud ormadean intentional misrepresentation ofamaterial fact (e.g.,the date that a member acceptsanydirectorindirectcontributionsorreimbursement byor onbehalfofanemployer, foranyportionof the premium forcoverageunderthis policy;

7. The date a member's employer anda member treatthis policy aspartof anemployer‐provided healthplan foranypurpose,including taxpurposes; or

8. The date a covered person's eligibilityforinsuranceunder this policy ceases dueto any of thereasonsstatedinthe Ongoing Eligibilitysection in this policy.

Refund upon Cancellation We willrefundanypremiumpaidand notearneddueto policy termination. You maycancelthepolicyat anytimebywrittennotice,deliveredormailedtotheExchange,orifan off‐exchange member bywrittennotice,deliveredor mailedto us.Such cancellationshallbecome effectiveuponreceipt, oron suchlater datespecified inthe notice.If you cancel, we shallpromptlyreturnanyunearnedportion ofthepremium paid,butin anyeventshallreturnthe unearnedportionof the premium within30 days.Theearned premium shallbe computedon apro‐ratabasis.Cancellationshallbewithoutprejudicetoanyclaim originatingpriortothe effective date ofthecancellation.

Discontinuance90‐DayNotice:If we discontinueofferinganddecide nottorenew allpoliciesissuedonthis form,withthesame typeand levelofbenefits,forallresidentsofthe state where you reside, we willprovideawrittennoticeto you atleastninety (90)dayspriortothe datethat we discontinuecoverage. You willbeoffered an option topurchaseanyothercoverage intheindividualmarket we offer in your state atthe time of discontinuanceofthis policy.Thisoptionto purchaseother coveragewillbe ona guaranteedissuebasiswithoutregardto healthstatus.

180‐DayNotice:If we discontinueofferingandrefusetorenewallindividualpolicies/certificatesintheindividualmarketinthestatewhere you reside, we willprovideawrittennoticeto you andtheCommissionerofInsuranceatleastonehundredeighty(180) days priortothe datethat we stopofferingandterminateall existing individualpoliciesintheindividual market inthestatewhere you reside.

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Benefits After Coverage TerminatesBenefitsfor covered expenses incurredaftera covered person ceasestobe insuredare providedfor certain illnesses and injuries. However,nobenefitsareprovidedifthis policy isterminatedbecause of: 1. Arequestby you;2. Fraudor an intentionalmaterialmisrepresentation on your part;or3. Your failureto pay premiums.

The illness or injury mustcausea period of extended loss, asdefinedbelow. The period of extended loss mustbeginbeforeinsuranceofthe covered person ceases underthis policy.No benefits areprovidedfor covered expenses incurredafterthe period of extended loss ends.

In additionto the above, ifthis policy is terminated because we refusetorenewallpoliciesissuedonthis form,with the sametype andlevelof benefits,toresidentsof thestate where you live,terminationofthis policy willnotprejudiceaclaimfora continuous loss that beginsbeforeinsurance ofthe covered person ceasesunder this policy. In thisevent,benefitswill be extended forthat illness or injury causingthecontinuous loss, butnotbeyondthe earlierof: 1. The date the continuous loss ends; or 2. Twelve (12) months after thedaterenewalisdeclined.

Continuity of Care We shalldevelopprocedurestoprovidefor thecontinuity ofcare of members.Weshallensurethat:

(1)When a member isenrolled inan Ambetter plan and isbeing treated by a non‐network provider foracurrentepisodeof an acute condition,the member may continue toreceive treatmentas an in‐network benefit from that provider untilthe currentepisode oftreatment endsoruntilthe endofninety(90)days, whicheveroccursfirst;and

(2)When a provider's participationis terminated,theprovider’spatients underthe plan may continuetoreceivecarefromthat provider asan in‐network benefit until a currentepisodeoftreatment for an acute conditioniscompletedoruntiltheendof ninety (90) days,whicheveroccursfirst.

Duringthe periodscoveredby (1) and(2)of this section,the provider shallbedeemed tobe a network provider forpurposesofreimbursement, utilizationmanagement,andqualityofcare.

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SUBROGATION AND RIGHT OF REIMBURSEMENTAsusedherein,theterm “third party” meansany partythatis,or may be,oris claimedto beresponsiblefor illnessorinjuriestoa covered person.Such injuries or illness arereferredtoas“third party injuries”. Third party includesanypartiesactually, possiblyorpotentiallyresponsibleforpayment ofexpensesassociatedwiththecareortreatmentof third party injuries.

If a covered person's illness or injury is causedby the acts oromissionsof a third party, we willnotcovera loss tothe extentthatit ispaidaspart of a settlementorjudgmentbyany third party.

Ifthis plan providesbenefitsunderthiscontracttoa covered person forexpensesincurreddueto third party injuries,thenthe planretainstherighttorepaymentofthefullcost of allbenefits providedby this planonbehalfofthe covered person thatare associatedwith the third party injuries.The plan’s rights ofrecoveryapplytoanyrecoveries madeby oron behalfof the covered person fromanysources,including,butnotlimitedto:

Paymentsmadebya third party or anyinsurancecompanyonbehalf ofthe third party; Anypaymentsorawardsunderanuninsuredorunderinsured motoristcoverage policy; AnyWorkers’Compensationordisabilityaward or settlement; Medicalpaymentscoverageunderanyautomobile policy,premisesorhomeownersmedicalpaymentscoverage orpremises orhomeownersinsurancecoverage; and Anyotherpaymentsfrom asourceintendedto compensate a covered person for third party injuries.

Byacceptingbenefits underthisplan,the covered person specificallyacknowledges Arkansas Health & Wellness’srighttosubrogation. Whenthisplanprovideshealthcarebenefits for expensesincurred dueto third party injuries,ArkansasHealth&Wellness shallbesubrogatedtothe covered person’s rightsof recovery againstany party tothe extentofthefull costof allbenefitsprovidedby thisplan.Arkansas Health& Wellnessmayproceedagainstany party withorwithout the covered person’s consent.

Byacceptingbenefits underthisplan,the covered person alsospecificallyacknowledges ArkansasHealth& Wellness’srightofreimbursement.Thisrightofreimbursement attaches whenthisplanhasprovided healthcare benefitsforexpensesincurreddueto third party injuries andthe covered person orthe covered person’srepresentativehasrecovered anyamountsfrom any source.Byprovidinganybenefitunderthisplan,ArkansasHealth&Wellness isgrantedanassignmentoftheproceedsofanysettlement,judgmentorotherpaymentreceived byyouto the extent ofthe fullcostof allbenefitsprovidedby thisplan.ArkansasHealth&Wellness’srightofreimbursementiscumulativewithandnotexclusiveofArkansasHealth&Wellness’ssubrogationrightand ArkansasHealth&Wellnessmay chooseto exerciseeitherorbothrights ofrecovery.

Asacondition for our payment,the covered person oranyoneactingonthe covered person’s behalf including,butnotlimitedto,theguardian,legalrepresentatives,estate,orheirsagrees:1. Tofullycooperatewith us inordertoobtain informationaboutthe loss anditscause; 2. Toimmediatelyinform us inwriting ofanyclaim madeorlawsuitfiledonbehalf of a covered person inconnection withthe loss;

3. Toincludetheamount of benefitspaid by us on behalfofa covered person in any claim made against any third party;

4. TogiveArkansasHealth&Wellnessafirst‐prioritylienonany recovery,settlementorjudgmentor othersourcesofcompensationwhich may be hadfrom any partytothe extentofthefullcostofall benefitsassociatedwith third party injuries providedby thisPlan(regardlessofwhetherspecificallysetforthin therecovery,settlement,judgmentor compensationagreement);

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5. Topay, asthe firstpriority,fromanyrecovery,settlement,judgment,orothersourceofcompensation,any andallamountsdueArkansasHealth& Wellnessasreimbursementforthefullcostofallbenefitsassociatedwith third party injuries providedbythisPlan(regardless ofwhetherspecificallysetforthin therecovery,settlement,judgment,orcompensation agreement);

6. That we: a. Willhavealienonall moneyreceivedbya covered person inconnectionwiththe loss equal tothe amount we have paid;

b. Maygivenoticeofthat lientoany third party or third party's agentor representative; c. Willhave the right tointervenein any suitor legal actionto protect our rights;d. Aresubrogatedto allofthe rights ofthe covered person against any third party totheextent ofthe benefitspaidon the covered person's behalf;and

e. Mayassertthatsubrogationright independentlyof the covered person;7. Totake no actionthat prejudices our reimbursementandsubrogation rights,including,butnotlimitedto,refrainingfrommaking any settlement orrecovery whichspecificallyattemptstoreduce orexcludethefullcostofall benefits providedbythisplan;

8. Tosign,date, anddeliver to us any documents we request that protect our reimbursementandsubrogationrights;

9. Tonotsettleanyclaim orlawsuitagainsta third party withoutproviding us withwrittennoticeoftheintenttodoso;

10. Toreimburse us fromany moneyreceivedfromany third party,tothe extentof benefits we paidforthe illness or injury,whetherobtainedbysettlement, judgment, orotherwise,andwhetherornot the third party's payment isexpresslydesignatedasapaymentformedicalexpenses; and

11. That we mayreduceotherbenefitsunderthe policy by the amountsa covered person hasagreed to reimburse us.

Ourrightofsubrogationandreimbursement only existsto the extentthe covered person hasbeen madewhole.Any costsassociatedwithsubrogationshallbesharedinthesameproportion as eachparticipantsharedintherecoveryamount.

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COORDINATION OF BENEFITSWe coordinatebenefitswithother payerswhen a member iscoveredby two or more grouphealth benefit plans.Coordination ofBenefits(COB)istheindustrystandard practiceusedtoshare the costof care betweentwo ormorecarrierswhena member iscoveredbymorethanonehealthbenefitplan.

Itisacontractualprovisionof amajorityofhealth benefit contracts. We complywithFederalandstateregulationsforCOBandfollowsCOBguidelinespublishedbyNationalAssociationofInsuranceCommissioners(NAIC).

UnderCOB,thebenefitsof one plan aredetermined tobe primary andare firstappliedto the costof care. Afterconsideringwhathasbeen coveredbytheprimaryplan,thesecondaryplan maycoverthe cost of careup tothe fullyallowedexpenseaccordingtotheplan’spayment guidelines. Our ClaimsCOBand Recovery Unitprocedures aredesignedtoavoidpaymentin excessofallowableexpense whilealso makingsureclaimsareprocessed both accuratelyandtimely.

“Allowable expense”isthenecessary,reasonable,andcustomary item of expense forhealthcare,whentheitemiscoveredatleastin partunderanyoftheplansinvolved, except whereastatuterequiresadifferentdefinition. When aplan providesbenefitsin the formofservices,thereasonablecashvalueof each service willbeconsideredasboth an allowableexpenseanda benefit paid.

Theterm“Plan”includes: 1. Grouphealthinsurance benefits and group blanket or group remittancehealthbenefits

coverage,whetheruninsuredarrangementsofgroupcoverage,insured,self‐insured,or self‐funded.This includesgroupHMO insuranceandotherprepayment,grouppracticeandindividualpracticeplans,andblanket contracts,exceptasexcludedbelow.

2. Planincludesmedicalbenefitscoverage,ingroupandindividualautomobile “no‐fault”and traditionalliability“fault”typecontracts.

3. Planincludes hospital,medical,andsurgicalbenefitscoverageofMedicareoragovernmentalplanoffered,required,orprovidedbylaw,except Medicaid orany other or anyother federalgovernment plan as permittedbylaw.

4. Plandoes notincludeblanketschoolaccidentcoverageor coverage’sissuedtoasubstantiallysimilargroup(e.g.,GirlScouts,BoyScouts)where theschoolor organization paysthe premiums.

5. Plandoes notincludeIndividual orFamily:Insurancecontracts,directpaymentsubscribercontracts,coveragethroughhealth maintenance organizations(HMO’s)orcoverage under otherprepayment,group practice andindividualpracticeplans.

6. Planwhose benefits are bylaw excesstoanyprivate benefits coverage.

“Primaryplan”isonewhosebenefitsmustbe determinedwithout takingtheexistenceofany other plan intoconsideration.A planisprimary ifeither:

1. theplanhasnoorderofbenefitsrules oritsrulesdiffer fromthoserequiredbyregulation;or2. allplanswhichcovertheperson usetheorderofbenefitsrulesrequiredbyregulationandunderthoserulestheplandetermines itsbenefitsfirst.Morethan oneplan may be aprimary plan(forexample,two planswhich have no orderofbenefit determination rules).

“Secondary plan”isone whichis not a primaryplan. If a personiscovered by more thanonesecondary plan,the orderofbenefit determinationrulesdecidetheorder inwhichtheirbenefits are determinedin relationtoeachother.

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Order of Benefit Determination RulesThe firstof theruleslistedbelowin paragraphs 1‐6that applieswilldeterminewhich planwillbeprimary:

1. The Primary planpaysor providesitsbenefitsasiftheSecondaryplanorplansdidnotexist.APlan may considerbenefitspaidorprovidedby anotherPlanin determiningitsbenefits onlywhenit issecondaryto that other plan.

2. Ifthe other plan doesnotcontain acoordination ofbenefitsprovisionthatis consistentwiththis provisionisalwaysprimary. There are two exceptions: a. Coveragethatisobtained byvirtue of membership in a groupthatisdesignedtosupplementapartofa basicpackage of benefits mayprovidethatthe supplementary coverage shallbe excessto any other partsofthe Planprovidedbythecontractholder, and

b. Anynoncontributorygrouporblanketinsurance coveragewhichisinforceonJanuary1,1987which providesexcessmajor medicalbenefitsintendedtosupplementanybasicbenefitsona covered person may continueto be excesstosuch basicbenefits.

Thefirstofthefollowingrules that describeswhichplanpays itsbenefits before anotherplanisthe ruleto use.

3. Ifthe person receiving benefitsisthe member andisonlycoveredas an eligible dependent underthe other plan,this policy willbeprimary.

4. SubjecttoStateStatues:Social Security Actof 1965, as amended makesMedicaresecondaryto theplancoveringthepersonas a dependent ofan activeemployee,the order ofbenefit determinationis: a. Ifachildiscoveredunderthe plansof bothparentsandtheparentsare not separated ordivorced,the plan of theparent whose birthday falls earlierin theyear(excluding year ofbirth)shallbeprimary.

b. Ifboth parentshavethe same birthday,the plan whichcovered theparentlongerwill be primary. To determine whosebirthdayfallsearlier intheyear,onlythemonthanddayare considered. However,if the other plan doesnothavethis birthdayrule, but insteadhasa rulebasedonthe sexof theparent andasa result theplansdonotagreeonwhichis primary,thentheruleinthe other plan willdeterminewhichplanisprimary.

5. If a childiscovered by bothparents’plans,theparentsare separated ordivorced,andthereisnocourtdecreebetweentheparents that establishesfinancial responsibilityfor thechild’s healthcare expenses: a. The plan oftheparentwhohas custodywillbeprimary;b. Ifthe parent withcustody hasremarried,andthechildisalso covered as achildunderthe step‐parent’splan,the plan oftheparentwith custodywillpay first,thestep‐parent'splanwillpaysecond,andthe planoftheparentwithout custodywillpaythird;

c. If a courtdecreebetween theparentssayswhichparentisresponsibleforthechild’shealthcare expenses,thenthat parent’splan willbe primaryif thatplan has actual knowledgeof the decree.

6. Ifthepersonreceivingservices iscoveredunder one plan as an active employeeor member (i.e.,notlaid‐off or retired),or asthe spouse orchildofsuchan active employee,andis alsocoveredunderanotherplanasalaid‐off orretiredemployee orasthe spouse orchildofsuchalaid‐offor retiredemployee,theplanthat coverssuchpersonasanactive employee or spouse orchildofan

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activeemployeewill beprimary.Ifthe other plan doesnot havethisrule, andas aresult theplans donot agree onwhichwill beprimary, thisrulewill be ignored.

7. If noneof the above rules determine whichplanis primary,the plan that coveredtheperson receivingserviceslongerwillbeprimary.

Effects of CoordinationWhenthisplanissecondary,itsbenefitswillbereducedsothat thetotal benefitspaidbythe primaryplanandthisplanduringaclaimdeterminationperiodwillnotexceed our maximum availablebenefitfor each covered service.Also,the amount we paywillnotbe morethan theamount we wouldpay if we were primary. As eachclaim is submitted, we willdetermineourobligationtopayforallowableexpensesbased upon allclaimsthat have beensubmittedupto thatpointin timeduringtheclaimdeterminationperiod.

Right to Receive and Release Needed InformationCertainfactaboutheathcarecoverageandservicesare needed toapplytheseCOBrulesandtodeterminebenefitspayable underthisplan and other plans. Wemay getthefactswe need from,or give themto,other organizationsorpersonsforthe purposeof applyingtheserulesanddeterminingbenefitspayable under thisplanand other plans coveringthepersonclaimingbenefits.We need not tell or get the consentof, any personto do this.

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CLAIMSNotice of Claim We mustreceive notice of claim within30 daysof thedatethe loss began orassoon asreasonablypossible. Noticegiven byor on behalfoftheinsuredtoAmbetter from ArkansasHealth&Wellness,OneAlliedDrive,Suite2520,LittleRock,AR,72202,withinformationsufficient toidentifythe insured,shallbe deemed noticeto us.

Claim FormsUponreceipt ofanoticeof claim, we willfurnish you withforms forfilingproofsof loss.If we donotprovide you withsuchformswithinfifteen(15)daysafter you havegiven us notice, you shallbe deemedto have compliedwiththerequirementsofthis policy asto proof of loss uponsubmitting,withinthetimerequired forfilingproofsof loss,writtenproofcoveringtheoccurrence,thecharacter,andthe extent of the loss forwhichclaimismade.

Proof of Loss We mustreceive written proof of loss withinone hundredeighty(180) days ofthe loss orassoon asisreasonably possible.

Cooperation ProvisionEach covered person,orotherperson actingonthe covered person’s behalf, mustcooperate fullyto assist usindetermining our rights andobligationsunder the policy and,asoften as may bereasonably necessary: 1. Sign,date and deliverto us authorizationstoobtainanymedicalorotherinformation,recordsor documents we deemrelevantfromanypersonor entity;

2. Obtainandfurnishto us,or our representatives,any medicalorotherinformation,recordsor documents we deem relevant;

3. Answer,underoathorotherwise,any questions we deem relevant,which we or our representatives may ask; and

4. Furnishanyotherinformation,aidorassistancethat we mayrequire,includingwithoutlimitation, assistanceincommunicatingwith anypersonorentityincluding requesting any person orentity topromptlyprovideto us,or our representative,anyinformation, recordsordocumentsrequested by us.

If any covered person,orotherpersonactingonthe covered person’sbehalf, failsto provideany ofthe itemsorinformationrequestedortotakeanyactionrequested,theclaim(s)willbeclosedandnofurtheractionwillbetaken by us unlessanduntil theitemorinformationrequestedisreceived ortherequestedactionis taken,subject tothetermsandconditionsofthe policy.

Inaddition,failureonthepartofany covered person,orother personactingonthe covered person’s behalf, toprovideanyoftheitemsorinformationrequestedorto take anyactionrequestedmayresultinthe denialoftheclaim atissuetothe member.

Time for Payment of ClaimsBenefitswill bepaidwithin 30daysafterreceipt of proof of loss.Shouldwe determine thatadditional supportingdocumentationisrequiredtoestablishresponsibilityof payment,weshallpaybenefitswithin 30days afterreceiptof additionalsupportingdocumentation.

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Wewillpay ordeny a cleanclaim within30 days ofreceiptif theclaimwas submittedelectronicallyor within45daysafterreceiptiftheclaim was submittedby othermeans.Wewillpay12%interest afterthe 61st dayofnonpayment.

Payment of ClaimsExcept asset forth inthis provision,all benefits are payable to you. Anyaccruedbenefitsunpaidat your death,or your dependent's deathmay,at our option,bepaideithertothe beneficiary orto the estate.If any benefitispayable to your or your dependent's estate,orto a beneficiary who isaminor orisotherwise notcompetentto give validrelease, we maypayupto $1,000toanyrelativewho,in our opinion,isentitledto it.

We maypayalloranypartofthe benefitsprovidedbythis policy for hospital, surgical,nursing,ormedical services,directlytothe hospital or otherperson renderingsuch services.

Anypaymentmade by us ingoodfaithunderthisprovisionshallfullydischarge our obligationto theextentofthe payment. We reservetherightto deductany overpaymentmade under this policy fromanyfuture benefitsunderthis policy.

Foreign Claims Incurred For Emergency CareClaimsincurredoutsideofthe UnitedStatesfor emergency careand treatmentofa covered person mustbe submittedin Englishorwithan Englishtranslation. Foreignclaimsmust includethe applicable medicalrecordsinEnglishtoshowproper proof of loss and evidence of paymentto theprovider.

Assignment We willreimbursea hospital or healthcare provider if:1. Your healthinsurance benefits are assigned by you inwriting;and2. We approve theassignment.

Anyassignmenttoa hospital orpersonprovidingthetreatment, whetherwithorwithout our approval,shallnotconferuponsuch hospital orperson,any rightorprivilegegrantedto you under the policy except fortheright toreceive benefits,ifany, that we have determinedtobedue andpayable.

Medicaid ReimbursementTheamountpayableunderthis policy willnotbechangedor limitedforreasonof a covered person being eligiblefor coverageunderthe Medicaidprogramofthestateinwhichthe member lives.

We willpay thebenefitsofthis policy to the state if:1. A covered person iseligiblefor coverageunderthe state'sMedicaidprogram; and 2. We receiveproper proof of loss andnoticethatpaymenthasbeen made for covered expenses underthatprogram.

Our payment tothe state willbelimited tothe amountpayable underthis policy for the covered expenses forwhichreimbursementis due.Paymentunder this provisionwillbe made in goodfaith.It willsatisfy ourresponsibilitytotheextentofthatpayment.

Insurance With Other InsurersIf you are eligibleto receive benefits underthis policy andany basic hospital,medical‐surgical,major medicalplan,thenthe policy withthe earliest effective date istheprimary policy ofcoverage andthe other policy isthesecondary policy. You must obtain benefits from your primary policy before you can obtain benefits fromthesecondary policy.This policy doesnotpay benefits forany benefits you receiveunderanyprimary policy.

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Insurance With MedicareIfapersonis alsoaMedicarebeneficiary,Medicareisalways the primary plan. This means that benefits paidfor eligible expenses by your plan willbereducedby the amountthat Medicarepays.

Custodial ParentThisprovisionappliesiftheparentsofacovered eligible child aredivorcedorlegallyseparatedandboth thecustodial parent andthenon‐custodialparentaresubjecttothesamecourtoradministrativeorderestablishingcustody.Thecustodialparent,whoisnota covered person,willhave the rightsstated belowif we receiveacopyoftheorderestablishingcustody.

Uponrequestby thecustodialparent, we will:1. Providethecustodialparentwithinformationregardingtheterms,conditions,benefits,exclusionsandlimitationsof the policy;

2. Acceptclaim formsand requests forclaimpaymentfrom the custodialparent;and3. Makeclaimpaymentsdirectlytothecustodialparentforclaims submitted bythe custodialparent. Payment ofclaimsto the custodialparent,which aremade under thisprovision,willfullydischarge our obligations.

Acustodialparentmay,with our approval,assignclaimpaymentstothe hospital or medical practitioner providingtreatmenttoan eligible child.

Physical Examination We shallhave the right andopportunityto examine a covered person whileaclaimispendingorwhilea disputeover theclaim is pending. Theseexaminationsare made at our expenseandas often as we mayreasonablyrequire.

Legal ActionsNosuitmay bebroughtby you on aclaimsooner thansixty(60)days aftertherequired proof of loss isgiven.Nosuit maybebroughtmorethanthreeyearsafter thedate proof of loss isrequired.

Noaction at laworin equitymay be brought against us under the policy foranyreasonunlessthe covered person firstcompletes allthestepsinthe complaint/grievance proceduresmadeavailabletoresolve disputesin your stateunderthe policy.After completingthat complaint/grievance proceduresprocess,if you wantto bringlegalactionagainst us on thatdispute, you mustdosowithinthreeyearsofthe date wenotified you ofthefinal decisionon your complaint/grievance.

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INTERNAL CLAIMS AND APPEALS PROCEDURES AND EXTERNAL REVIEW

Overview

If you need help: If you do not understand your rights or if you need assistance understanding your rights or you do not understand some or all of the information in the following provisions, you may contact Ambetter from Arkansas Health & Wellness, at the Member Services Department, Post Office Box 25538, Little Rock, Arkansas 72221, by telephone at 1‐877‐617‐0390, by fax at 1‐877‐617‐0393 orAmbetter.ARHealthWellness.com.

Internal Claims and Appeals Procedures: When a healthinsuranceplan denies aclaim fora treatment orservice(a claimforplanbenefits, you havealreadyreceived (post‐service claim denial) ordenies yourrequesttoauthorizetreatmentorservice(pre‐service claim denial), you,orsomeone you have authorized tospeakon your behalf(an authorized representative),canrequestan appeal ofthe plan’sdecision.Iftheplan rescinds your coverage or denies your applicationforcoverage, you may also appealthe plan’sdecision. Whenthe planreceives your appeal,it isrequiredtoreviewits owndecision.When the planmakesa claimdecision,itisrequiredto notify you (providenoticeofan adverse benefit determination):

Thereasonsfortheplan’sdecision;

Your rightto file appealtheclaim decision;

Your rightto requestan external review; and

The availabilityofa ConsumerServicesDivision atTheArkansasDepartmentofInsurance.

NOTE:If you donotspeak English, you may beentitledtoreceive appeals’information in your nativelanguage uponrequest.

When you request an internal appeal,theplanmustgive you itsdecisionassoonaspossible,but nolater than:

72hoursafterreceiving your requestwhen you are appealing thedenialof a claim forurgent care.(If your appealconcerns urgentcare, you may be ableto havetheinternal appeal and externalreviewstake place at the same time.)

30daysforappealsof denialsofnon‐urgent care you have not yetreceived.

60 daysforappeals of denials of services you have alreadyreceived(post‐servicedenials).

Noextensionsofthe maximum time limitsarepermittedunless you consent.

Continuing Coverage: The plan cannot terminate your benefits until all of the appeals have been exhausted. However, if the plan’s decision is ultimately upheld, you may be responsible for paying any outstanding claims or reimbursing the plan for claims’ payments it made during the time of the appeals.

Cost and Minimums for Appeals: Thereisnocost to you to file an appeal andthere isno minimum amountrequiredtobein dispute.

Defined terms: Any termsappearingin italics are defined.

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Emergency medical services: Ifthe plandenies aclaim foran emergency medical service, your appealwillbehandled asan urgent appeal. The plan will advise you at the time it denies the claim that you can file an expedited internal appeal. If you have filed for an expedited internal appeal, you may also file for an expedited external review (see “Simultaneous urgent claim, expedited internal review and external review”).

Your rights to file an appeal of denial of health benefits: You or your authorized representative, such as your healthcare provider, may file the appeal for you, in writing, either by mail or by facsimile (fax). For an urgent request, you may also file an appeal by telephone:

Ambetter from Arkansas Health & Wellness, at the Appeals Unit, One Allied Drive, Suite 2520, Little Rock, AR 72202, by telephone at 1‐877‐617‐0390, by fax at 1‐866‐811‐3255 or Ambetter.ARHealthWellness.com.

Pleaseincludein your writtenappeal orbepreparedtotellusthefollowing:Name,addressandtelephonenumberofthe insuredperson;

Theinsured’shealthplan identificationnumber;

Nameof healthcare provider,addressandtelephonenumber;

Date the healthcarebenefitwasprovided(ifa post‐claimdenialappeal)

Name,addressandtelephonenumberofan authorized representative (if appealis filed by a person otherthantheinsured);and

Acopyofthenoticeof adverse benefit determination.

Rescission of coverage: Iftheplan rescinds your coverage, you may file an appealaccordingtothe followingprocedures.Theplancannotterminate your benefits until alloftheappealshave been exhausted. Sincea rescission meansthatno coverageever existed,ifthe plan’sdecision to rescindis upheld, you willberesponsibleforpaymentofallclaimsfor your healthcareservices.

Time Limits for filing an internal claim or appeal: You must filetheinternalappealwithin180 days ofthereceiptofthenoticeofclaimdenial(an adverse benefit determination). Failureto file withinthistime limitmayresultinthecompany’sdecliningtoconsidertheappeal.

In general,thehealthplanmay unilaterallyextend thetime for providingadecisionon both pre‐service and post‐service claims for15 daysafter the expirationofthe initialperiod,ifthe plandeterminesthatsuch anextension is necessary for reasonsbeyondthe controloftheplan.Thereisnoprovision forextensionsin thecase ofclaimsinvolvingurgentcare.

Time Limits for an External Appeal: You have 120daysto file foran external review afterreceiptoftheplan’s final adverse benefit determination.

Your Rights to a Full and fair review. The plan mustallow you toreview theclaim file andto present evidence and testimony aspart of theinternalclaimsand appealsprocess.Theplanmustprovide you,freeof charge,with anynew oradditionalevidenceconsidered,reliedupon,or generated bythe plan (or at thedirection ofthe plan) inconnection withtheclaim; suchevidence mustbeprovidedassoon as possibleand sufficiently in advance of thedate on whichthe noticeoffinalinternal adverse benefit determination isrequired to give you a reasonable opportunity torespondpriortothatdate; and

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o

o

o



Before the plan can issuea final internal adverse benefit determination based onaneworadditionalrationale, you must be provided,free ofcharge,withthe rationale;therationale must be providedas soonaspossibleandsufficientlyin advanceof the dateon which thenoticeof final internal adverse benefit determination isrequiredto be providedto give you a reasonable opportunityto respondpriortothat date.

The adverse determination mustbewritteninamannerunderstoodby you,orifapplicable, your authorized representative andmustincludeall of the following:

Thetitlesandqualifyingcredentialsofthepersonorpersons participatingin thefirstlevelreviewprocess(thereviewers); Informationsufficient to identifytheclaiminvolved, includingthedateofservice,the healthcare provider;and Astatement describingtheavailability,upon request,ofthediagnosiscodeanditscorresponding meaning,and thetreatmentcode anditscorrespondingmeaning.

Asa general matter,theplan may deny claims at anypointin theadministrativeprocessonthebasis thatitdoesnothave sufficient information;sucha decision;however,willallow you toadvanceto thenext stageofthe claimsprocess.

Other Resources to help youDepartment of Insurance: Forquestionsabout your rightsorforassistance you mayalsocontact the ConsumerServicesDivisionatThe ArkansasDepartmentofInsurance (800)852‐5494.

Language services are available from the health benefitplan.

Your rights to appeal and the instructions for filing an appeal are described in the provisions following this Overview.

INTERNAL CLAIMS AND APPEALS

Non‐urgent, pre‐service claim denial Foranon‐urgent pre‐service claim, theplanwillnotify you ofitsdecisionassoonaspossiblebutno laterthan 30 days afterreceiptofthe claim.

Ifthe plan needsmoretime,itwillcontact you,inwriting,telling you the reasonswhy it needs moretime andthedatewhenitexpectstohaveadecisionfor you,whichshouldbe no laterthan 30 days.

Ifthe planneedsadditionalinformationfrom you beforeit can makeitsdecision,itwillprovideanoticeto you,describingthe information needed. You will have 45days fromthedate oftheplan’snoticeto provide theinformation.If you donot provide the additionalinformation,the plan candeny your claim.Inwhich case, you may file an appeal.

Urgent Pre‐service Care claim denial If your claim for benefits is urgent, you or your authorized representative, or your healthcare provider (physician) may contact us with the claim, orally or in writing.

Ifthe claim forbenefitsisone involving urgent care,wewillnotify you ofourdecisionassoonaspossible,butnolaterthan 72 hours afterwe receive your claimprovided you have given usinformation sufficienttomake a decision.

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If you have not given us sufficient information,wewillcontact you assoonaspossiblebutno morethan24 hoursafter wereceive your claimtolet you know thespecific informationwe willneedtomake adecision. You mustgive usthespecificinformationrequestedassoon as you can but nolaterthan 48 hours afterwe haveasked you fortheinformation.

Wewillnotify you ofourdecisionassoonaspossiblebutno laterthan48hours afterwehave receivedthe neededinformation or theendofthe 48 hours you hadto providetheadditionalinformation.

Toassure you receive noticeofourdecision,wewillcontact you by telephoneor facsimile(fax) orby anothermethodmeant toprovidethedecisionto you quickly.

Indeterminingwhether a claim involvesurgent care,the plan mustapplythejudgmentofaprudentlaypersonwhopossesses anaverageknowledgeofhealthandmedicine. However, if a physician with knowledge of your medical condition determines that a claim involves urgent care, or an emergency, the claim must be treated as an urgent care claim.

Simultaneous urgent claim and expedited internal review: Inthe caseof a claim involving urgent care, you or your authorized representative may also request an expeditedinternalreview.Arequest for expedited internal review maybe submitted orallyorinwriting bythe claimant; and allnecessaryinformation,includingthe plan’sbenefitdeterminationon review,shall betransmittedbetween theplanandtheclaimant bytelephone, facsimile,orotherexpeditiousmethod.

The physician,ifthe physician certifies,inwriting,that you havea medical condition where the time frame forcompletionofanexpeditedreview of an internalappealinvolving an adverse benefit determination wouldseriouslyjeopardizethe lifeor healthof you orjeopardize your ability to regainmaximum function, you may file arequest for an expedited externalreviewto be conductedsimultaneouslywiththeexpedited internalappeal.

Simultaneous urgent claim, expedited internal review and external review: You,or your authorized representative,may requestan expeditedexternalreview if both the following apply

1.You havefiledarequestforanexpeditedinternal review; and 2.Aftera final adverse benefit determination,ifeither ofthe following applies:

a. Your treating provider certifies that the adverse benefit determination involves a medical condition that could seriously jeopardize the life or health of you, or would jeopardize your ability to regain maximum function, if treated after the time frame ofastandardexternalreview;

b. The final adverse benefit determination concerns an admission, availability of care,continued stay, or healthcare service for which you received emergency services, but hasnot yetbeen dischargedfrom a facility.

Concurrent care decisions Reduction or termination of ongoing plan of treatment: If wehave approved anongoingplan or courseoftreatmentthatwillcontinueover aperiodoftimeoracertainnumberof treatments andwenotify youthatwehave decidedtoreduceor terminatethetreatment,we willgiveyou noticeofthatdecisionallowingsufficient timeto appeal thedetermination andtoreceive adecisionfromusbeforeanyinterrupti onof careoccurs.

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Request to extend ongoing treatment: If you havereceivedapproval for anongoing treatmentand wish to extend the treatment beyondwhat hasalreadybeen approved,wewillconsider your appealas arequest forurgent care.If you requestanextensionof treatment at least24hoursbeforethe end ofthetreatment period,wemustnotify you soon aspossiblebut no laterthan 24 hoursafter receiptoftheclaim.

Anappealofthisdecisionisconductedaccordingtotheurgent careappeals procedures.

Concurrent urgent care and extension of treatment: Under theconcurrentcareprovisions,any request thatinvolvesboth urgent careandthe extension of acourse of treatmentbeyondthe periodoftimeor numberoftreatmentspreviously approvedbythe planmustbe decidedassoonaspossible,takingintoaccountthemedicalurgencies,andnotificationmustbeprovidedtothe claimant within 24 hours after receiptoftheclaim, providedtherequestismade atleast24 hourspriorto the expirationof the prescribed periodoftime or number oftreatments.

Non‐urgent request to extend course of treatment or number of treatments:Ifarequesttoextenda courseoftreatment beyondtheperiodoftime or numberof treatmentspreviously approvedbythe plan doesnot involveurgentcare,the request may be treated asa new benefit claimand decidedwithinthe timeframe appropriateto the type of claim,e.g.,as a pre‐service claim or a post‐service claim. If the request is not made at least 24 hours prior to the expiration of the prescribed period of time or number of treatments,therequestmustbetreatedasa claim involving urgent care anddecided inaccordancewiththeurgentcare claimtimeframes, e.g.,assoon aspossible,takingintoaccountthemedical emergencies,butnotlater than 72 hoursafterreceipt.

Post‐service appeal of a claim denial (retrospective)If your appealisfor a post‐service claim denial,wewillnotify you ofourdecisionassoonaspossiblebutno laterthan 30 days afterwehave received your appeal.Ifwe need more time, wewillcontact you,telling you about the reasonswhywe need moretime andthedate whenweexpecttohaveadecisionfor you,whichshould benolaterthan15 days,providedthatthewe determinethatsuchan extensionisnecessary duetomattersbeyondourcontrol,and wenotify youpriorto theexpirationofthe initial30daysperiod.If thereason weneed more timeto make adecision is because you havenotgivenusnecessaryinformation, you willhave 45 days fromthedate wenotify you togiveustheinformation.Wewilldescribetheinformation neededto make ourdecisioninthe noticewe send you.Thisis alsoknown as a “retrospective review.”Theplanwillnotify you ofitsdeterminationas soon aspossiblebutnolaterthan5days afterthe benefit determination ismade.

Theplanwilllet you knowbefore the endofthe first30‐dayperiod,explainingthe reasonforthedelay, requesting anyadditionalinformationneeded,andadvising you when a finaldecisionis expected.If moreinformationisrequested, you haveat least 45 days tosupplyit. The claim then mustbedecidednolater than15days after you supplytheadditionalinformationorthe periodgivenbytheplan todoso ends, whichevercomesfirst.Theplanmustget your consentifitwantsmore time afterits firstextension.The planmustgive you notice that your claimhasbeen deniedinwholeorinpart (paying less than 100% ofthe claim)beforethe endofthetime allottedfor thedecision.

EXTERNAL REVIEW Right to External ReviewUndercertain circumstances, you have arightto request an externalreview ofour adversebenefitdecision byan independent review organization orby the Insurance Commissioner,orboth.

If you havefiledinternal claimsandappealsaccordingwiththe procedures ofthisplan, andthe plan has deniedorrefusedtochangeitsdecision,orifthe planhas failed,because ofits actionsor its failure toact,

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toprovide you witha final determination of your appealwithin thetime permitted,orif theplanwaives,in writing,the requirement toexhausttheinternalclaimsand appealsprocedures, you may makea request for an external reviewofan adverse benefit determination.

Allrequestsforan external review mustbe made within120 daysof the dateof the noticeofthe plan’s final adverse benefit determination.Standardrequestsforan externalreview mustbeprovided in writing;requests for expeditedexternalreviews,including experimental/investigational,maybesubmittedorallyorelectronically.Whenanoralorelectronicrequestforreview is made,writtenconfirmationof the request mustbesubmittedto the plan no laterthan 5days aftertheinitialrequestwasmade.

You may file the request for an external review by contacting the Arkansas Insurance Department External Review Division, Arkansas Insurance Department at 1200 West 3rd Street, Little Rock, AR 72201 orvia emailto: [email protected] externalreviewsis alsoavailableontheDepartment’swebsite: http://insurance.arkansas.gov/csd.htm.

Non‐urgent request for an external reviewUnlesstherequestis for anexpedited externalreview,theplanwillinitiateanexternalreviewwithin5 daysafterit receives your writtenrequestif your request iscomplete. Theplanwillprovide you withnoticethatithasinitiatedtheexternalreviewthatincludes:(a)Thenameandcontactinformationfor theassigned independent review organization ortheInsuranceCommissioner,asapplicable,for thepurposeof submitting additionalinformation;and (b)Except for when an expeditedrequestismade, astatementthat you may,with10businessdaysafterthedate ofreceiptof the notice,submit,inwriting, additionalinformation foreither the independent review organization ortheInsuranceCommissionerto considerwhen conductingthe external review.

If the plan denies your request for an external review because you have failed to exhaust the Internal Claims and Appeals Procedure, you mayrequest a writtenexplanation,whichtheplan will provideto you within 10 daysof receiptof your request,explainingthe specificreasonsforitsassertion that you werenot eligible for an external review because you didnotcomplywiththe requiredprocedures.

If the Arkansas Department of Insurance upholds the plan’s decision:If you filearequestforanexternalreviewwiththe ArkansasDepartmentof Insurance,and ifthe InsuranceCommissionerupholds theplan’sdecisiontodenythe external review because you didnotfollowthe plan’s internalclaimsand appealsprocedures, you must resubmit your appealaccordingtotheplan’sinternalclaimsand appeals procedureswithin10daysofthedateof your receiptoftheInsuranceCommissioner’s decision.Theclock willbeginrunningonallofthe requiredtime periodsdescribedinthe internal claimsandappeals procedures when you receivethisnoticefrom theInsuranceCommissioner.

If the plan’s failure to comply with its obligations under the internal claims and appeals procedures was considered (i) de minimis,(ii)not likelyto causeprejudiceorharm to you (claimant),(iii)because we had a good reason orour failurewascaused by mattersbeyondourcontrol(iv)inthecontext of anongoinggood‐faithexchangeofinformationbetween the plan and you (claimant)or your authorized representative and (v) notpart ofapattern orpracticeofour notfollowingtheinternal claimsandappeals procedures, then you will notbe deemed to have exhaustedtheinternal claimsandappealsrequirements. You may requestanexplanation of the basis forthe plan’s assertingthatitsactionsmeetthisstandard.

Expedited external review : You may have an expeditedexternalreviewif your treating provider certifiesthatthe adverse benefit determinationinvolvesa medical condition thatcouldseriouslyjeopardizethelifeorhealthof you (claimant),orwouldjeopardize your abilityto regain maximum functionif treatedafterthe time frame fora standard external review;orthe final adverse benefit determination concernsanadmission, 62141AR010 75

http://insurance.arkansas.gov/csd.htm

mailto:[email protected]



availabilityofcare,continued stay, or healthcareservice for which you received emergency services,buthave not yet beendischarged from a facility.

Expedited external review for experimental or investigational treatment: You may requestan externalreviewof an adverse benefit determination basedontheconclusion thatarequestedhealthcare serviceis experimental or investigational,exceptwhentherequestedhealthcareservice isexplicitlylistedasanexcludedbenefit underthetermsofthehealthbenefitplan.

To be eligible foranexternalreview underthisprovision, your treating provider shallcertifythatoneofthefollowingsituationsis applicable:

(1)

Standardhealthcareserviceshave notbeeneffectivein improving your condition; (2) Standardhealthcareservices are notmedically appropriate for you;or(3) There is no available standardhealthcareservicecoveredbythehealthplanissuerthatismorebeneficialthanrequestedhealthcareservice.

If the request for an expedited external review is complete and eligible, theplanwill immediately provideortransmitallnecessary documentsandinformation consideredinmakingthe adverse benefit determination inquestion totheassigned independent review organization (IRO) bytelephone,facsimileor other availableexpeditiousmethod.

If the request is not complete, we will notify you immediately, including what is needed to make the request complete.

Independent Review Organization: An external review is conducted by an independent review organization (IRO) selectedonarandombasisas determinedinaccordancewithArkansaslaw. The IROwillprovide you withawrittennoticeofitsdecision toeither upholdorreversetheplan’s adverse benefit determination within 30 daysof receiptofa standard external review (not urgent).

If an expedited external review (urgent)wasrequested,the IRO willprovideadeterminationas soon aspossibleor within72 hoursofreceiptofthe expeditedrequest.The IRO’s decisionisbindingonthe company.Ifthe IRO reverses the health benefit plan’s decision, the plan will immediately provide coverage forthehealthcareservice orservicesinquestion.

Ifthe InsuranceCommissioneror IRO requiresadditionalinformationfrom you or your healthcare provider,theplanwilltell you what isneededto maketherequestcomplete.

If the plan reverses its decision: If theplandecidestoreverseitsadverse determinationbeforeor duringtheexternalreview,theplanwillnotify you,the IRO, and the Insurance Commissionerwithinonebusinessdayof the decision.

After receipt of healthcare services:Noexpeditedreview isavailablefor adverse benefit determinationsmade afterreceiptofthe healthcare service or services in question.

Emergency medical services: If plan denies coverage foran emergency medicalservice,theplanwillalso adviseatthetimeofdenialthat you requestanexpeditedinternaland external review oftheplan’sdecision.

If the IRO and InsuranceCommissioner uphold the plan’s decision, you may have a right to file a lawsuit inanycourthavingjurisdiction.

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GENERAL PROVISIONSEntire ContractThis policy, withtheapplication,istheentirecontractbetween you and us. Noagentmay:1. Changethis policy;2. Waive anyof theprovisionsofthis policy;3. Extendthe time forpaymentof premiums; or 4. Waiveanyof our rightsor requirements.

Allridersorendorsementsaddedtothe policy after the date of issue orat reinstatementor renewal whichreduceoreliminatebenefitsorcoverageinthe policy shallrequiresignedacceptancebytheinsured.After dateof policy issue,anyriderorendorsement whichincreases benefitsor coveragewithaconcomitant increaseinpremiumduringthe policy term mustbeagreedtoin writingsignedby the insured,exceptifthe increasedbenefits orcoverageisrequiredbylaw.

Non‐WaiverIf we or you failto enforce orto insiston strictcompliancewith any oftheterms,conditions,limitationsor exclusions ofthe policy thatwillnot beconsideredawaiverofanyrightsunderthe policy.Apastfailuretostrictlyenforcethe policy willnotbeawaiverofanyrights inthefuture,eveninthesamesituation or setoffacts.

RescissionsNomisrepresentationof factmaderegardinga covered person duringthe applicationprocessthat relatestoinsurabilitywillbeusedtovoid/rescindtheinsurance coverageordeny aclaimunless: 1. Themisrepresentedfact iscontainedinawrittenapplication, includingamendments,signedbya

covered person;2. Acopyoftheapplication,andanyamendments,hasbeenfurnishedtothe covered person(s), or totheirbeneficiary;and

3. Themisrepresentationoffact wasintentionallymade andmaterialto our determinationtoissuecoveragetoany covered person. A covered person's coveragewillbevoided/rescindedandclaimsdeniedifthatpersonperformsanactorpracticethatconstitutesfraud.“Rescind”hasa retroactiveeffect and meansthecoveragewasneverin effect.

Repayment for Fraud, Misrepresentation or False InformationDuringthe firsttwoyears a covered person isinsuredunderthe policy,ifa covered person commitsfraud, misrepresentation or knowingly providesfalseinformationrelatingtothe eligibility of any covered person underthis policy orinfilingaclaimfor policy benefits, we have theright to demandthat covered person paybackto us allbenefitsthat we paidduringthetimethe covered person wasinsuredunderthe policy.

Conformity with State LawsAnypartofthis policy in conflictwiththelawsofArkansasonthis policy's effective date or onany premium duedateischangedtoconformto the minimumrequirements ofArkansas statelaw.

Conditions Prior To Legal ActionOnoccasion, we mayhave adisagreementrelatedtocoverage,benefits,premiums,orotherprovisions underthis policy.Litigationisanexpensiveand time‐consumingwaytoresolve thesedisagreementsand shouldbethelastresortin a resolutionprocess.Therefore,withaviewtoavoidinglitigation, you mustgive writtennoticeto us of your intenttosue us asaconditionpriorto bringinganylegal action. Your notice must:

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1. Identifythe coverage, benefit,premium,orotherdisagreement; 2. Refertothespecific policy provision(s) atissue;and 3. Includeallrelevantfactsand informationthatsupport your position.

Unlessprohibitedbylaw, you agreethat you waiveanyactionforstatutoryorcommonlawextra‐contractual orpunitivedamagesthat you may have if the specified contractualclaims arepaid,ortheissues giving riseto thedisagreement areresolvedorcorrected,within thirty(30)days after we receive yournoticeofintentionto sue us.

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62141AR010 79

Statement of Non-Discrimination

Ambetter from Arkansas Health & Wellness complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Ambetter from Arkansas Health & Wellness does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Ambetter from Arkansas Health & Wellness:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:

Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:

Qualified interpreters Information written in other languages

If you need these services, contact Ambetter from Arkansas Health & Wellness at 1-877-617-0390 (TTY/TDD 1-877-617-0392).

If you believe that Ambetter from Arkansas Health & Wellness has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Ambetter from Arkansas Health & Wellness Appeals Unit, One Allied Drive, Suite 2520, Little Rock, AR 72202, 1-877-617-0390 (TTY/TDD 1-877-617-0392), Fax 1-866-811-3255. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Ambetter from Arkansas Health & Wellness is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.


TDD/TTY1‐877‐617‐0392 Log on to:

Ambetter.ARHealthWellness.com

80


http://www.hhs.gov/ocr/office/file/index.html

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

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2018 Evidence of Coverage - Arkansas · Anand Shukla SVP, Individual Health. Arkansas Health &...

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