Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc., and underwritten by Matthew Thornton Health Plan, Inc., independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Anthem Bronze Pathway HMO 5500/20% POLICY What You need to know about Your Individual health Policy. IMPORTANT NOTICE THIS POLICY REFLECTS THE KNOWN REQUIREMENTS FOR COMPLIANCE UNDER THE AFFORDABLE CARE ACT AS PASSED ON MARCH 23, 2010. AS ADDITIONAL GUIDANCE IS FORTHCOMING FROM THE US DEPARTMENT OF HEALTH AND HUMAN SERVICES, AND THE NEW HAMPSHIRE INSURANCE DEPARTMENT, THOSE CHANGES WILL BE INCORPORATED INTO YOUR HEALTH INSURANCE POLICY. IF THIS POLICY IS PROVIDED TO YOU AS A NEW SUBSCRIBER, YOU MAY, AT ANY TIME WITHIN THIRTY (30) DAYS AFTER ITS RECEIPT, RETURN IT TO US BY DELIVERING IT OR MAILING IT TO ANTHEM BLUE CROSS AND BLUE SHIELD. IMMEDIATELY UPON SUCH DELIVERY OR MAILING, THE POLICY WILL BE DEEMED VOID FROM THE BEGINNING, AND ANY PREMIUM PAID WILL BE REFUNDED LESS ANY CLAIMS PAID. THE BENEFITS DESCRIBED IN THIS POLICY ARE PROVIDED IN ACCORDANCE WITH THE REQUIREMENTS OF THE NEW HAMPSHIRE STATUTES APPLICABLE TO ACCIDENT AND HEALTH INSURANCE AND UNDER THE JURISDICTION OF THE NEW HAMPSHIRE INSURANCE COMMISSIONER. This product is administered by Anthem Health Plans of New Hampshire, Inc., operating as Anthem Blue Cross and Blue Shield, a stock corporation and licensed Accident and Health insurer in the State of New Hampshire. Benefits are underwritten by Matthew Thornton Health Plan, Inc. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of New Hampshire, Inc. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Si necesita ayuda en español para entender este documento, puede solicitarla sin costo adicional, llamando al número de servicio al cliente que aparece al dorso de su tarjeta de identificación y aqui abajo. If You need Spanish-language assistance to understand this document, You may request it at no additional cost by calling the Customer Service number below or on Your Identification Card. Our toll-free telephone number is 1-855-330-1102 Anthem Blue Cross and Blue Shield is located at: 1155 Elm Street, Suite 200, Manchester, New Hampshire 03101-1505 NH_OFFHIX_HM_HS_20160101 1GP8 Welcome! Welcome to Anthem Blue Cross and Blue Shield! This Policy has been prepared by Us to help explain Your coverage. Please refer to this Policy whenever You require medical services. It describes how to access medical care, what health services are covered by Us, and what portion of the health care costs You will be required to pay. This Policy shall constitute Your entire health benefit plan under which Covered Services and supplies are provided by Us. This Policy should be read and re-read in its entirety. Since many of the provisions of this Policy are interrelated, You should read the entire Policy to get a full understanding of Your coverage. Many words used in the Policy have special meanings and start with a capital letter and are defined for You. Refer to the definitions in the Definitions section for the best understanding of what is being stated. This Policy also contains “Limitations and Exclusions,” so please be sure to read it carefully. Please contact Our office whenever You have questions, concerns or suggestions. Our Customer Service Representatives are available during business hours to assist You. A representative will ask for the identification number listed on Your Identification Card so that We can locate Your important records and assist You without delay. How to Get Language Assistance Anthem is committed to communicating with Our Members about their health coverage, no matter what their language is. Anthem employs a language line interpretation service for use by all of Our Customer Service call centers. Simply call the Customer Service phone number on the back of Your Identification Card and a representative will be able to help You. Translation of written materials about Your benefits can also be asked for by contacting Customer Service. TTY/TDD services also are available by dialing 711. A special operator will get in touch with Us to help with Your needs. Si necesita ayuda en español para entender este documento, puede solicitarla sin costo adicional, llamando al número de servicio al cliente que aparece al dorso de su tarjeta de identificación y aqui abajo. If You need Spanish-language assistance to understand this document, You may request it at no additional cost by calling the Customer Service number below or on Your Identification Card. Please call Anthem Blue Cross and Blue Shield at 1-855-330-1102 or Fax Customer Service at 1-855-414-9998. You can write to Us at this address: Anthem Blue Cross and Blue Shield 1155 Elm Street Suite 200 Manchester, New Hampshire 03101-1505 Please visit Anthem’s website at www.anthem.com. Lisa M. Guertin Kathleen S. Kiefer President and General Manager Corporate Secretary New Hampshire NH_OFFHIX_HM_HS_20160101 1GP8 3 MEMBER RIGHTS AND RESPONSIBILITIES As a Member, You have rights and responsibilities when receiving health care. As Your health care partner, We want to make sure Your rights are respected while providing Your health benefits. That means giving You access to Our Network of health care Providers and the information You need to make the best decisions for Your health. As a Member, You should also take an active role in Your care. You have the right to: · Speak freely and privately with Your health care Providers about all health care options and treatment needed for Your condition, no matter what the cost or whether it is covered under Your Policy. · Work with Your Doctors to make choices about Your health care. · Be treated with respect and dignity. · Expect Us to keep Your personal health information private by following Our privacy policies, and state and Federal laws. · Get the information You need to help make sure You get the most from Your health plan, and share Your feedback. This includes information on: o Our company and services. o Our Network of health care Providers. o Your rights and responsibilities. o The rules of Your health plan. o The way Your health plan works. · Make a complaint or file an Appeal about: o Your health plan and any care You receive. o Any covered service or benefit decision that Your health plan makes. · Say no to care, for any condition, sickness or disease, without it having an effect on any care You may get in the future. This includes asking Your Doctor to tell You how that may affect Your health now and in the future. · Get the most up-to-date information from a health care Provider about the cause of Your illness, Your treatment and what may result from it. You can ask for help if You do not understand this information. · Get help at any time, by calling the Customer Service number located on the back of Your Identification Card (1-855-330-1102) or by visiting www.anthem.com. Or contact Your local insurance department: NEW HAMPSHIRE Phone: 1-800-852-3416 Write: Life, Accident and Health Consumer Affairs Coordinator New Hampshire Insurance Department 21 South Fruit Street, Suite 14 Concord, NH 03301 NH_OFFHIX_HM_HS_20160101 MEMBER RIGHTS AND RESPONSIBILITIES 4 You have the responsibility to: · Read all information about Your health benefits and ask for help if You have questions. · Follow all health plan rules and policies. · Choose a Network Primary Care Physician, also called a PCP, if Your health plan requires it. · Treat all Doctors, health care Providers and staff with respect. · Keep all scheduled appointments. Call Your health care Provider’s office if You may be late or need to cancel. · Understand Your health problems as well as You can and work with Your health care Providers to make a treatment plan that You all agree on. · Inform Your health care Providers if You don’t understand any type of care You’re getting or what they want You to do as part of Your care plan. · Follow the health care plan that You have agreed on with Your health care Providers. · Give Us, Your Doctors and other health care Providers the information needed to help You get the best possible care and all the benefits You are eligible for under Your Policy. This may include information about other health insurance benefits You have along with Your coverage with Us. · Inform Customer Service if You have any changes to Your name, address or family members covered under Your plan. If You would like more information, have comments, or would like to contact Us, please go to www.anthem.com and select Customer Support > Contact Us. Or call the Customer Service number on the back of Your Identification Card (1-855-330-1102). We want to provide high quality benefits and customer service to Our Members. Benefits and coverage for services given under the plan are overseen by Your Policy, Outline of Coverage or Cost-Sharing Schedule and not by this Member Rights and Responsibilities statement. NH_OFFHIX_HM_HS_20160101 TABLE OF CONTENTS COST-SHARING SCHEDULE .................................................................................................................................7 Section 1: OVERVIEW – HOW YOUR PLAN WORKS...................................................................................... 17 Section 2: COST SHARING TERMS...................................................................................................................... 19 Section 3: NETWORK BENEFITS..........................................................................................................................21 I.