Certificate of Coverage Sparrow PHP Silver 4000 Exclusive Individual Policy SNN04400-RX08E520 TABLE OF CONTENTS TABLE OF CONTENTS .................................................................................................. 2 INDIVIDUAL POLICY ...................................................................................................... 5 Individual Policy. .......................................................................................................... 5 Changes to the Document. .......................................................................................... 5 Right to Cancel Coverage. ........................................................................................... 5 Other Information You Should Have. ........................................................................... 5 Execution of Contract. .................................................................................................. 5 Meaningful Access. ...................................................................................................... 6 INTRODUCTION ............................................................................................................. 8 How to Use this Document. .......................................................................................... 8 Defined Terms. ............................................................................................................ 8 How to Contact Us. ...................................................................................................... 8 The Affordable Care Act (ACA). ................................................................................... 8 YOUR RESPONSIBILITIES ............................................................................................ 9 Be Enrolled and Pay Required Premium. ..................................................................... 9 Not All Health Care Services Are Covered. .................................................................. 9 Choose Your Health Care Providers. ........................................................................... 9 Pay Your Share. ........................................................................................................... 9 Show Your ID Card. ..................................................................................................... 9 File Claims with Complete and Accurate Information. ................................................ 10 Statement of Your Rights and Responsibilities. ......................................................... 10 OUR RESPONSIBILITIES ............................................................................................ 12 Determine Benefits..................................................................................................... 12 Pay for Our Portion of the Cost of Covered Health Services. ..................................... 12 Review and Determine Benefits Following our Reimbursement Policies. .................. 12 WHAT IS COVERED ..................................................................................................... 13 Accessing Benefits. .................................................................................................... 13 Prior Approval. ........................................................................................................... 13 Utilization Review. ...................................................................................................... 16 When Medicare or Other Coverage is Primary. ......................................................... 16 BENEFITS AND COVERAGE ....................................................................................... 17 Information About Your Cost Share. .......................................................................... 17 Your Annual Deductible. ............................................................................................ 17 Your Annual Out-of-Pocket Maximum. ....................................................................... 17 What You Pay When Using Network Health Care Providers. .................................... 17 What You Pay When Using Non-Network Health Care Providers. ............................. 20 Description of Covered Health Services. .................................................................... 20 GENERAL EXCLUSIONS AND LIMITATIONS ............................................................ 47 NETWORK BENEFITS ................................................................................................. 51 PHP Exclusive SNN04400-RX08E520, effective 1/1/20 [2] Table of Contents Network Benefits. ....................................................................................................... 51 Emergency Health Services. ...................................................................................... 53 Continuing Care when Physician Leaves Network. .................................................... 53 WHEN COVERAGE BEGINS ....................................................................................... 54 How to Enroll. ............................................................................................................. 54 Genetic Information. ................................................................................................... 54 Who is Eligible for Coverage. ..................................................................................... 54 When to Enroll and When Coverage Begins. ............................................................. 55 End Stage Renal Disease (ESRD). ............................................................................ 58 HOW TO FILE A CLAIM ............................................................................................... 60 Payment of Clean Claims. .......................................................................................... 60 Covered Health Services from a Network Health Care Provider. ............................... 60 Covered Health Services from a Non-Network Health Care Provider. ....................... 61 Filing Deadline for Claims. ......................................................................................... 62 Benefit Determinations. .............................................................................................. 63 PREMIUMS ................................................................................................................... 66 Payment of Premiums. ............................................................................................... 66 Adjustments to Premiums. ......................................................................................... 66 Grace Period. ............................................................................................................. 66 Special Grace Period for Members Receiving Advanced Payment of Tax Credits (APTC). ...................................................................................................................... 66 Reinstatement. ........................................................................................................... 67 QUESTIONS, GRIEVANCES, APPEALS AND COMPLAINTS .................................... 68 Terms Used in This Process. ..................................................................................... 68 What to Do First. ........................................................................................................ 69 How to Request a Formal Grievance. ........................................................................ 69 Grievance Process – Step 1. ..................................................................................... 69 Grievance Process – Step 2. ..................................................................................... 70 Grievance Determinations. ......................................................................................... 70 External Review Rights. ............................................................................................. 71 COORDINATION OF BENEFITS .................................................................................. 72 Benefits When You Have Coverage under More than One Plan. .............................. 72 When Coordination of Benefits Applies. ..................................................................... 72 Definitions. ................................................................................................................. 72 Order of Benefit Determination Rules. ....................................................................... 74 Effect on the Benefits of this Plan. ............................................................................. 76 Right to Receive and Release Needed Information. .................................................. 77 Payments Made. ........................................................................................................ 77 Right of Recovery. ..................................................................................................... 77 WHEN COVERAGE ENDS ........................................................................................... 78 General Information. .................................................................................................. 78 Events Ending Your Coverage. .................................................................................. 78 Other Events Ending Your Coverage. 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