Caresource Dental and Vision Evidence of Coverage and Health Insurance Contract

CareSource Dental and Vision Evidence of Coverage and Health Insurance Contract PHIX-IN002(2017)-E IN-EXCM-0260a Evidence of Individual Coverage and Health Maintenance Organization Contract Marketplace Plan CareSource Indiana, Inc. Attn: Claims Department P.O. Box 3607 Dayton, Ohio 45401 Please read this EOC carefully. If you are not satisfied, return this Evidence of Individual Coverage and Health Maintenance Organization Contract (“EOC”) to us within ten (10) calendar days after you received it. The EOC will be deemed delivered three (3) calendar days after it was deposited in the United States mail with first class postage prepaid, or when it is personally delivered, to the address shown above. Upon return, this EOC will be deemed void and any Premium will be refunded. In such event, any Health Care Services received during this ten (10) calendar day period are solely your responsibility. Information regarding this Plan may be obtained by contacting CareSource at: 1-877-806- 9284 or CareSource.com/marketplace. PHIX-IN002(2017)-E CareSource Table of Contents SECTION 1 – WELCOME .............................................................................................................1 How to Contact Us ...............................................................................................................1 How to Use Your Evidence of Coverage .............................................................................2 Defined Terms .....................................................................................................................2 Your Responsibilities ...........................................................................................................2 Be Enrolled and Pay Required Premiums ............................................................................2 Choose Your Health Care Providers ....................................................................................3 Your Financial Responsibility .............................................................................................3 Pay the Cost of Limited and Excluded Services ..................................................................3 Show Your ID Card .............................................................................................................3 The Marketplace ..................................................................................................................3 Eligibility Requirements ......................................................................................................4 Dependent Provisions ..........................................................................................................5 Application and Enrollment for CareSource ........................................................................6 Confirmation of Eligibility ..................................................................................................6 Annual Eligibility Determinations .......................................................................................6 Enrollment Date ...................................................................................................................7 Ineligibility and Your Right to Appeal Eligibility Decisions ..............................................7 Availability of Benefits After Enrollment in the Plan .........................................................7 Change in Eligibility Status or Personal Information ..........................................................7 Open Enrollment ..................................................................................................................8 Special Enrollment ...............................................................................................................8 SECTION 2 – HOW THE PLAN WORKS ....................................................................................9 Benefits ................................................................................................................................9 The Service Area..................................................................................................................9 Out of Service Area Dependent Child Coverage .................................................................9 Network Providers ...............................................................................................................9 Covered Services From Network Providers ......................................................................10 Services Provided by Non-Network Providers ..................................................................10 What You Must Pay ...........................................................................................................10 Premium Payments ............................................................................................................10 Grace Period.......................................................................................................................11 Annual Deductible .............................................................................................................11 PHIX-IN002(2017)-E i Table of Contents CareSource Eligible Expenses ...............................................................................................................12 Coinsurance........................................................................................................................12 Copayment .........................................................................................................................12 Annual Out-of-Pocket Maximum ......................................................................................12 If You Receive a Bill .........................................................................................................12 The Plan Does Not Pay for All Health Care Services .......................................................13 Your Primary Care Provider ..............................................................................................13 Choose a PCP .....................................................................................................................13 Visit Your PCP ..................................................................................................................13 Changing Your PCP ...........................................................................................................13 If You Can't Reach Your PCP ...........................................................................................14 Canceling Provider Appointments .....................................................................................14 When You Need Specialty Care ........................................................................................14 Prior Authorization ............................................................................................................14 Providers Who Leave the Network ....................................................................................15 Continuity of Care..............................................................................................................15 Continuity of Care for Existing Covered Persons..............................................................16 Continuity of Care for New Covered Persons ...................................................................16 Conditions for Coverage of Continuity of Care as Described in this Section ...................17 SECTION 3 – IMPORTANT INFORMATION ON EMERGENCY, URGENT CARE, AND INPATIENT SERVICES .........................................................................................18 Emergency Health Care Services.......................................................................................18 Notice to Your PCP or the Plan Following Emergency Care ............................................18 Transfer ..............................................................................................................................19 Coverage for Urgent Care Services Outside the Service Area ..........................................19 Inpatient Hospital Stay .......................................................................................................19 Inpatient Hospital Services ................................................................................................19 Charges After Your Discharge from a Hospital ................................................................20 How Benefits are Paid .......................................................................................................20 SECTION 4 – YOUR COVERED SERVICES.............................................................................21 1. AUTISM SPECTRUM DISORDER SERVICES – PSYCHIATRIC HEALTH CARE SERVICES FOR COVERED PERSONS .................................21 2. AUTISM SPECTRUM DISORDERS - MEDICAL HEALTH CARE SERVICES FOR COVERED PERSONS .............................................................24 3. AMBULANCE SERVICES ..................................................................................24 4. BEHAVIORAL HEALTH CARE SERVICES .....................................................25 PHIX-IN002(2017)-E ii Table of Contents CareSource 5. COVERED CLINICAL TRIALS ..........................................................................27 6. DENTAL SERVICES – PEDIATRIC ...................................................................28 7. DENTAL SERVICES - RELATED TO ACCIDENTAL INJURY

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