Contract Holder Group Agreement Effective Date: January 01, 2016
HMO and Contract Holder agree to provide Covered Benefits under this plan as described below and subject to
the provisions of this Rider. The Member may obtain certain Covered Benefits from Participating Providers without a Referral from their selected PCP.
Item A under the HMO Procedure section of the Certificate is amended to delete the following sentence: Until a PCP is selected, benefits will be limited to coverage for Medical Emergency care.
Item B under the HMO Procedure section of the Certificate is deleted and replaced with the following: A. The Primary Care Physician (PCP).
The PCP provides services for the treatment of routine illnesses, injuries, well baby and preventive care services which do not require the services of a Specialist and for non-office hour Urgent Care services under this plan. The Member’s selected PCP or that PCP’s covering Physician is required to be available 7 days a week, 24 hours a day for Urgent Care services.
A Member is encouraged to select a PCP for themselves and for each of their Covered Dependents at the time of enrollment, however this is not a plan requirement. If a Member selects a PCP, the Member may change their PCP at any time by contacting HMO.
A Member will be subject to the PCP Copayment listed on the Schedule of Benefits when a Member obtains Covered Benefits from any Participating PCP.
Certain PCP offices are affiliated with integrated delivery systems or other provider groups (i.e., Independent Practice Associations and Physician-Hospital Organizations), and Members who select these
PCPs will generally be referred to Specialists and Hospitals within that system or group. However, if the
group does not include a Provider qualified to meet the Member’s medical needs, the Member may request to have services provided by nonaffiliated Providers.
If the Member’s PCP performs, suggests, or recommends a Member for a course of treatment that includes services that are not Covered Benefits, the entire cost of any such non-covered services will be the Member’s responsibility.
The Covered Benefits section of the Certificate is amended to include the following provisions:
• Self-Referred Services.
Except as described in the Exclusions and Limitations section of this Rider, the Certificate, any amendments and/or riders are hereby revised to remove the requirement that a Member must obtain a
Referral from their PCP prior to accessing Covered Benefits from Participating Providers.
Under this provision, a Member may directly access Participating Specialists, ancillary Providers and facilities for Covered Benefits without a PCP Referral, subject to the terms and conditions of the
Certificate and any cost-sharing requirements set forth in the Schedule of Benefits. Participating Providers will be responsible for obtaining pre-authorization of services from HMO.
Except as described in this Rider, the Covered Benefits section and the Exclusions and Limitations section of the Certificate remain unchanged and the ability of a Member to directly access Participating
Providers does not alter any other provisions of the Certificate. Except for Emergency Services and out-
of-area Urgent Care services, a Member must access Covered Benefits from Participating Providers and facilities or benefits will not be covered under this Certificate and a Member will be responsible for all expenses incurred unless HMO has pre-authorized the services to a non-participating Provider.
The Exclusions and Limitations section of the Certificate is amended to delete the following exclusion:
• Unauthorized services, including any service obtained by or on behalf of a Member without a prior written
Referral issued by the Member’s PCP or pre-authorized by HMO. This exclusion does not apply in a Medical Emergency, in an Urgent Care situation, or when it is a direct access benefit.
The Exclusions and Limitations section of the Certificate is amended to include the following exclusion:
• Unauthorized services obtained by the Member that require pre-authorization by HMO including but not limited to Hospital admissions and outpatient surgery. Participating Providers are responsible for obtaining pre-authorization of Covered Benefits from HMO.
The Exclusions and Limitations section of the Certificate is amended to include the following limitations:
• Comprehensive Infertility Services are not covered without pre-authorization from HMO’s Infertility case management unit, if such benefits are covered under the Member’s plan. A Member or their
Participating Physician may contact the Infertility case management unit to apply for eligibility. A Member who is eligible will be subject to case management, have access to a select network of Participating Providers and will be required to utilize Participating Providers from this select network
to receive Covered Benefits.
• Upon pre-authorization, other treatment plans may be subject to case management and a Member may be directed to specific Participating Providers for Covered Benefits including, but not limited to transplants and other treatment plans.
• Supplemental plans provided under a separate contract or policy in addition to an HMO health benefit plan, including but not limited to dental plans and behavioral health plans, are not subject to the provisions of this Rider and a Member is required to abide by the terms and conditions of the separate contract or policy. The Continuation and Conversion section of the Certificate is amended to include the following provision: