Coverage summary and criteria — top-level coverage summary, exclusions, Table of Contents references
Top-level coverage summary, member protections, enrollment and administrative rules, major medical benefits, and key operational provisions are summarized below. See referenced sections for details.
Introduction: This contract (together with your Schedule of Benefits, enrollment application, and any riders) constitutes the entire agreement explaining how to access medical care, which services are covered, and member cost sharing obligations. Many defined terms appear in the Definitions section and must be reviewed to understand coverage.
Protection from Balance Billing and Non-Network Services: Federal balance-billing protections (per the No Surprises Act) prohibit non-network providers from balance billing members for services subject to those protections; when protections apply, you are only responsible for member cost share calculated as if services were provided by a network provider and based on the recognized amount as defined by law. Non-emergency services from non-network providers generally require prior authorization and may be subject to different eligible expense calculations; if no network provider is available within a reasonable distance, prior authorization may be granted to obtain non-network care at no greater cost than network care. Emergency services are covered without prior authorization and include evaluation and stabilization; follow-up care is not emergency care and may require authorization.
Medical Necessity: Covered services must be medically necessary as defined: consistent with symptoms/diagnosis; provided per accepted standards of practice; not custodial; not solely for convenience; not experimental/investigational unless allowed; appropriate in scope/duration/intensity; cost-effective compared to alternatives; and, for hospital confinement, not safely provided as outpatient. Charges for services not medically necessary are not eligible expenses.
Dependent Coverage, Newborns and Adopted Children: An eligible newborn or newly placed adopted child is automatically covered from birth or placement through the 31st calendar day. No deductible or cost sharing applies during that initial 31-day period. To continue coverage beyond 31 days, you must notify the insurer and pay any additional premium as required: timely notification and premium deadlines differ for newborns and adopted children (see sections). Dependent eligibility rules, including continuation for certain disabled dependents beyond age limits, are in the Dependent Member Coverage section.
Enrollment Periods and Special Enrollment: Annual open enrollment dates and effective date rules are set forth in the Schedule of Benefits and Enrollment section. Special Enrollment may be available for qualifying events (loss of other coverage, marriage, birth/adoption/placement, move, domestic abuse, Medicaid/CHIP eligibility changes, COBRA cessation, and others). Qualified individuals generally have 60 calendar days to report qualifying events to request Special Enrollment.
Premiums, Grace Period and Reinstatement: Premiums are due in advance monthly; initial premium must be paid before coverage effective date. There is a 60-calendar-day premium grace period during which coverage remains in force but claims may pend. Reinstatement after lapse for nonpayment requires a written application within one year and payment of required premium; conditional receipts and timelines for automatic reinstatement apply.
Third-Party Payments: Members are expected to pay premiums; third-party premium payments are accepted only from specified sources (Ryan White program, Indian tribes/organizations, certain government programs, qualifying tax-exempt organizations, family members, certain employers under ICHRA/QSEHRA). Payments from other parties may be rejected.
Cost Sharing Features: Benefits are subject to deductible, copayments, coinsurance, and maximum out-of-pocket as shown in your Schedule of Benefits. Deductible applies as defined; copayments are due at time of service and do not count toward deductible but apply to MOOP. Each claim is adjudicated separately.
Prior Authorization and Utilization Management: Many services require prior authorization (see Schedule of Benefits). Examples include non-emergency non-network services, certain diagnostic tests, inpatient admissions, injectable drugs, specific surgeries, transplant services, nutritional supplements, pain management, and others. Prior authorization timing rules (e.g., elective admissions, home health, clinical trials) and exceptions for emergencies are noted.
Major Medical Expense Benefits Summary: Essential health benefits are provided (ambulatory services, emergency services, hospitalization, maternity/newborn care, MH/SUD, prescription drugs, rehabilitative/habilitative services, lab, preventive, chronic disease management, pediatric services). All covered services are subject to conditions, limitations, exclusions, and medical necessity requirements. Specific benefit highlights below cover common categories and notable limitations.
Emergency and Ambulance Services: Emergency services (evaluation and stabilization) are covered without prior authorization; if admitted, notify insurer within 48 hours or as soon as reasonably possible. Emergency air and ground ambulance are covered when emergency condition exists; non-emergency air and ground ambulance require prior authorization. You should not be balance billed for covered emergency air or ground ambulance services when balance billing protections apply.
Acquired Brain Injury: Services for acquired brain injury (cognitive rehabilitation, neuropsych testing, neurofeedback, post-acute transition and community reintegration services) are covered when medically necessary; custodial and long-term nursing care are excluded.
ASD and Developmental Services: Autism spectrum disorder services (evaluation, ABA, behavior training, speech/OT/PT, habilitation, psychiatric care, medications) are covered when prescribed; ABA has no numeric limit but is subject to prior authorization to determine medical necessity. Multiple providers on same day may result in separate cost shares.
Clinical Trials: Routine patient care costs for qualifying clinical trials for cancer or other life-threatening conditions are covered when physician determines trial may benefit the member and no clearly superior alternative exists. Coverage excludes unapproved trial drugs/devices, nonclinical costs (housing), and items provided solely for data collection.
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies: DME is covered (rental vs purchase rules, repair/replacement conditions), prosthetics and orthotics covered when medically necessary with prior authorization where noted. Non-durable medical supplies (glucometer strips, ostomy supplies, etc.) are covered per terms.
Maternity and Newborn Care: Inpatient stay minimums follow federal Newborns' and Mothers' Health Protection Act: 48 hours for vaginal delivery and 96 hours for cesarean unless attending provider discharges earlier. Maternity-related services may require prior authorization; postpartum and newborn services follow contract provisions.
Preventive Care: ACA-mandated preventive services recommended by USPSTF (A/B), ACIP immunizations, and HRSA-supported pediatric/women's preventive services are covered without member cost share when delivered by a network provider and billed as preventive. Preventive vs diagnostic billing rules apply.
Pharmacy Benefits: Prescription drug benefits include coverage for prescribed drugs, certain off-label uses supported by compendia, specialty drug limits, supply limits (34-day standard, up to 90-day maintenance at select pharmacies), formulary with utilization management (prior authorization, step therapy, exceptions) and exception processes (standard/expedited/external). Lock-in, split-fill, and balance-on-hand rules apply.
Behavioral Health: Inpatient and outpatient MH/SUD services are covered per parity requirements. Utilization management uses InterQual (mental health) and ASAM (SUD) criteria. Emergent inpatient withdrawal and emergent inpatient treatment do not require prior authorization. Covered services include inpatient psych, PHP, IOP, medication management, MAT, psychological testing, ABA, ECT, TMS, and more.
Rehabilitation, Home Health, Hospice: Home health services when physician indicates inability to travel are covered (home health aide, private duty nursing when outpatient, therapy services, IV meds, DME rental). Hospice inpatient and outpatient services covered; inpatient room-and-board limited to most common semiprivate rate of associated hospital/nursing home.
Transplant Services and Centers of Excellence: Transplants covered when candidate is accepted and preauthorized; must use designated network Centers of Excellence when required. Pre-transplant evaluation, transplant surgery, acquisition costs (when authorized), LVAD as bridge, post-transplant care, and donor services covered subject to medical management. Travel and lodging reimbursement for Center of Excellence use may be available with limits and documentation requirements; many ancillary expenses excluded.
Radiology and Diagnostics: Medically necessary imaging and diagnostics (MRI, CT, PET/SPECT, mammography, sleep studies) are covered; prior authorization may be required. Two bills may occur for technical vs professional components. Non-network providers should not balance bill members when balance billing protections apply.
Second Opinions, Telehealth and Virtual Care: Members are entitled to a second opinion for minor surgery, serious illness/injury, or unsatisfactory response to treatment; network physician selection limits member cost sharing. Telehealth services are covered when medically necessary and subject to same cost share as in-person services where applicable.
Limitations and Exclusions: General exclusions include custodial care, cosmetic treatments, many experimental/investigational services, routine adult vision (except diabetic-related), certain travel and convenience expenses, and items specifically listed in the General Limitations and Exclusions section. Pharmacy and DME exclusions are detailed in respective sections.
Claims, Notices and Appeal Rights: Notice and proof of claim timelines, claim submission processes, payment timetables (15 days electronic/30 days non-electronic for clean claims), interest on overdue claims, and appeal/grievance processes are specified. Grievance and appeal timeframes (standard and expedited) and external review processes through the state Insurance Commissioner are available; expedited pathways exist for urgent health situations.
Coordination of Benefits (COB): COB rules determine payment order when covered by multiple plans; the primary plan pays first. Secondary plan may reduce benefits so total payments do not exceed allowable expenses. Special COB rules for active vs retired employees, COBRA, and longer/shorter coverage apply.
Administrative Provisions: Contract termination, insured cancellation, non-assignment, rescissions, repayment for fraud, time limits on defenses, PHI protections (HIPAA), language assistance, and other administrative rules are included. Contract amendments or agent changes are restricted.
Operational Notes: Many benefits require prior authorization, documentation, or use of network providers to avoid higher member liability. Members and providers should consult the Schedule of Benefits and contact Member Services or Utilization Management for authorization, formulary, and network questions.