MARKETPLACE PLAN Evidence of Coverage and Health Insurance Contract Georgia

Care Source Health Care with Heart MARKETPLACE PLAN Evidence of Coverage And Health Insurance Contract Georgia POLMP-GA(2021) CareSource Georgia Co. 600 Galleria Parkway, Ste. 400 Atlanta, Georgia 30339 IT IS IMPORTANT THAT YOU READ YOUR POLICY. This policy is a legal contract between you and CareSource. You are allowed to return this policy within ten (10) days and have a refund of the premium paid if after examination of its content you are not satisfied with the policy for any reason. If you return this policy it shall be void and no coverage will be provided. You may return this policy to: 600 Galleria Parkway, Ste. 400, Atlanta, Georgia 30339 A Table of Contents follows, showing you where to look for information concerning specific areas. POLMP-GA(2021) CareSource Table of Contents SECTION 1 – INTRODUCTION .................................................................................................. 2 How to Use Your Evidence of Coverage ............................................................................ 3 Defined Terms .................................................................................................................... 3 Your Responsibilities .......................................................................................................... 4 Be Enrolled and Pay Required Premiums .......................................................................... 4 Choose Your Health Care Providers ................................................................................... 4 Your Financial Responsibility ............................................................................................ 4 Pay the Cost of Limited and Excluded Services ................................................................. 4 Show Your ID Card ............................................................................................................ 5 The Marketplace ................................................................................................................. 5 Eligibility Requirements ..................................................................................................... 5 Dependent Provisions ......................................................................................................... 6 Application and Enrollment for CareSource ....................................................................... 7 Confirmation of Eligibility ................................................................................................. 7 Annual Eligibility Determinations ...................................................................................... 8 Enrollment Date .................................................................................................................. 8 Ineligibility and Your Right to Appeal Eligibility Decisions ............................................. 8 Availability of Benefits After Enrollment in the Plan ........................................................ 8 Change in Eligibility Status or Personal Information ......................................................... 8 Open Enrollment ................................................................................................................. 9 Special Enrollment .............................................................................................................. 9 SECTION 2 – DEFINITIONS ...................................................................................................... 11 SECTION 3 – HOW THE PLAN WORKS ................................................................................. 27 Benefits ............................................................................................................................. 27 The Service Area ............................................................................................................... 27 Out of Service Area Dependent Child Coverage .............................................................. 27 Network Providers ............................................................................................................ 27 Covered Services From Network Providers ..................................................................... 28 Services Provided by Non-Network Providers ................................................................. 28 What You Must Pay .......................................................................................................... 29 Premium Payments ........................................................................................................... 29 Grace Period ...................................................................................................................... 29 Annual Deductible ............................................................................................................ 30 POLMP-GA(2021) i Table of Contents CareSource Eligible Expenses .............................................................................................................. 30 Coinsurance....................................................................................................................... 30 Copayment ........................................................................................................................ 31 Annual Out-of-Pocket Maximum ..................................................................................... 31 If You Receive a Bill From a Network Provider .............................................................. 31 The Plan Does Not Pay for All Health Care Services ....................................................... 32 Your Primary Care Provider ............................................................................................. 32 Choose a PCP .................................................................................................................... 32 Visit Your PCP ................................................................................................................. 32 Changing Your PCP .......................................................................................................... 33 If You Can't Reach Your PCP .......................................................................................... 33 Canceling Provider Appointments .................................................................................... 33 When You Need Specialty Care ....................................................................................... 33 Providers Who Leave the Network ................................................................................... 33 Continuity of Care ............................................................................................................. 33 Continuity of Care for Existing Covered Persons ............................................................. 34 Continuity of Care for New Covered Persons .................................................................. 34 Conditions for Coverage of Continuity of Care as Described in this Section .................. 35 Prior Authorization ........................................................................................................... 35 Benefit Determinations ..................................................................................................... 36 Types of requests for Prior Authorization and Retrospective Medical Review ............... 36 Timing of Initial Benefit Determinations ......................................................................... 37 Notification of Benefit Determinations ............................................................................ 38 SECTION 4 – IMPORTANT INFORMATION ON EMERGENCY, URGENT CARE, AND INPATIENT SERVICES ........................................................................................ 39 Emergency Health Care Services ...................................................................................... 39 Notice to Your PCP or CareSource Following Emergency Care ..................................... 40 Transfer ............................................................................................................................. 40 Coverage for Urgent Care Services Outside the Service Area ......................................... 40 Inpatient Hospital Stay ...................................................................................................... 41 Inpatient Hospital Services ............................................................................................... 41 Charges After Your Discharge from a Hospital ............................................................... 41 How Benefits are Paid ...................................................................................................... 41 SECTION 5 – YOUR COVERED SERVICES ............................................................................ 42 AMBULANCE SERVICES ............................................................................................. 42 POLMP-GA(2021) i Table of Contents CareSource AUTISM SPECTRUM DISORDER SERVICES ............................................................ 43 BEHAVIORAL HEALTH CARE SERVICES ................................................................ 45 COVERED CLINICAL TRIALS ..................................................................................... 46 DENTAL SERVICES – PEDIATRIC .............................................................................. 47 DIABETIC EDUCATION, EQUIPMENT, AND SUPPLIES

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