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CERTIFICATE OF GROUP HEALTH CARE COVERAGE

DEFINITIONS

II. GROUP HEALTH CARE COVERAGE

FOR YOUR AND YOUR DEPENDENTS
1. In General
2. Primary Care Physician (PCP) Selection
3. OB/GYN Selection
4. Changing Your Primary Care Physician
COVERED SERVICES AND SUPPLIES
1. In General
2. Member Financial Responsibility
3. Covered Services
4. Limitations
5. Exclusions

FOR YOU AND YOUR DEPENDENTS
1. In General: This Coverage provides benefits for many of the services and supplies needed for care and treatment of Your or Your Qualified Dependents' Illnesses and Injuries, or to maintain Your or Your Qualified Dependents' good health, as determined by Your Qualified Dependents’ respective Primary Care Physician. Not all services and supplies are eligible; some are eligible only to a limited extent.
2. Primary Care Physician (PCP) Selection: Once You have chosen Community First, Your next choice is to select who will provide the majority of Your and Your Qualified Dependents’ health care services. Your Primary Care Physician will be the one You call when You need medical advice, when You are ill and when You need preventive care such as immunizations. Each Covered Person may select his or her own Primary Care Physician from the Community First Participating Provider directory. Primary medical care includes the following medical specialties: internal medicine, general, pediatrics and family practice. If Your PCP is also part of a Limited Provider Network, or association of health professionals who work together to provide a full range of health care services, You may also be choosing a specific group of specialists, hospitals and/or ancillary providers who are part of Your PCP’s network. In such a case, You may not be allowed to receive services from any physician or health care professional that is not also part of Your PCP’s network. All of Your care will be provided within the network to which Your PCP belongs, so make sure that Your PCP’s network includes the specialists and hospitals that You prefer.
  
  Should You have a chronic, disabling, or Life-Threatening Illness, You may apply to Community First's Medical Director to utilize a Participating Specialty Physician as a Primary Care Physician, provided that (1) the request includes information specified by Community First, including certification of medical need, and is signed by You and Participating Specialty Physician interested in serving as the Primary Care Physician; (2) the Participating Specialty Physician meets, and agrees to abide by the Community First requirements for Primary Care Physicians; and (3) the Participating Specialty Physician is willing to accept the coordination of all of Your health care needs.
  
  If such request is denied, You may Appeal the decision through Community First's established Complaint and Appeals process. Should such request be approved, the new designation shall not be retroactive and shall in no way reduce the amount of compensation owed to the original Primary Care Physician prior to the date of the new designation.
3. OB/GYN Selection. A woman entitled to coverage shall be permitted direct access to the health care services of a participating obstetrician or gynecologist without a referral by the woman's Primary Care Physician or pre-authorization or precertification by Community First to include, but not be limited to, the following:
4. Changing Your Primary Care Physician: Community First believes that a strong Primary Care Physician/Member relationship is critical. However, we also realize that there may be a need for a Member to change his/her Primary Care Physician. If You must change Your Primary Care Physician, You may do so by calling Community First’s Member Services Department. Requests for changes received on or before the 15th of the month will take effect on the first day of the following month. Requests for changes received after the 15th will take effect the first day of the second month following the change request.
  For example, if You request a change on or before August 15th, the change will become effective September 1st. If You request a change on or after August 16th, the change will become effective October 1st.
  Many of the terms used below are defined in the “Definitions” section shown on a separate page.
COVERED SERVICES AND SUPPLIES
1. In General: Community First will arrange or provide for benefits for the Covered Services and Supplies set forth in Section 3 of this Part B. A written referral and/or Pre-authorization by the Primary Care Physician and/or Community First is required for payment of most Covered Services and/or Supplies rendered by other Participating Providers and all Non-Participating Providers, except in the case of a Medical Emergency, or when accessing the services of a properly credentialed, participating obstetrician or gynecologist or behavioral health Provider.
  
  Pre-authorization is granted on the condition that the Member is eligible for Covered Services at the time the Covered Services are received. Pre-authorization will be denied if the requested supply or service is not a Covered Service or Supply. If You have any questions about whether a Covered Service or Supply requires Pre-authorization, contact Your Primary Care Physician or Community First’s Member Services Department.
  1. Covered Services: All Covered Services must be furnished to a Member:
    1. by a Primary Care Physician;
    2. by another Participating Provider and authorized by a Primary Care Physician or Community First;
    3. by a Non-Participating Provider if referred by a PCP and pre-authorized by Community First;
    4. by a Participating Specialty Care Physician approved by Community First's Medical Director to perform the services of a Primary Care Physician pursuant to a request of a Member with a chronic, disabling or Life-Threatening illness; or
    5. by a participating obstetrician or gynecologist as described in II.A.3. above or a participating behavioral health provider as described in II.B.1. above.
    It is Your responsibility to secure a referral from Your Primary Care Physician to see specialists and to undergo Hospitalizations, outpatient surgery, and diagnostic procedures. Written referral is required for payment of services and supplies rendered by other Participating Providers.
    
    If Medically Necessary Covered Services are not available through a Participating Provider, Community First will, at the request of a Participating Provider, and within a reasonable time period allow referral to a Non-Participating Provider and shall fully reimburse the Non-Participating Provider at the usual and customary rate or at a negotiated rate. Before such a requested referral can be denied, Community First must have the request reviewed by a specialist of the same or similar specialty as the Physician or provider to whom the referral is requested.
  2. After Hours Care: Illnesses and Injuries often do not happen during normal office hours. You may call Your Primary Care Physician’s office 24 hours a day and You should contact him or her if You need after hours care. If the call is not placed during office hours, You will be assisted by an answering service that will notify the physician on call and advise You on how to proceed. If You are not able to reach Your Primary Care Physician or an answering service, please contact Community First’s nurse advice/triage service described in the following paragraph. Please inform the nurse who answers that You were unable to reach Your Primary Care Physician.
  3. Urgent Care Services: In the event of an urgent situation (Illness or Injury) that is severe or painful enough to require assessment and/or treatment within 24 hours, You should contact Your Primary Care Physician who will direct You based on the symptoms. Additionally, Members may call Community First’s 24-hour nurse/triage service. You may reach this service by calling 210-358-6262 or 1-877-698-7032.
    
    Exceptions to these requirements for Covered Services furnished in connection with Emergency Care for medical conditions occurring inside or outside the Service Area are set forth below. All Covered Services must be furnished while a person is a Member.
  4. Medical Emergency: Services for a Medical Emergency are covered anywhere in the world 24 hours a day. If a Medical Emergency occurs, Members should go to the nearest participating or non-participating medical facility.
    
    Necessary Emergency Care services will be provided to Members, including the treatment and stabilization of a Medical Emergency, and any medical screening examination or other evaluation required by state or federal law which is necessary to determine if a Medical Emergency exists.
    
    If it is determined that a Medical Emergency does not exist (i.e., Emergency Care is not rendered), the Covered Person will be required to contact his/her Primary Care Physician in order to arrange any non-Emergency Care needed. If a Member chooses to use the emergency room for non-emergency treatment, he or she will be responsible for all billed charges. You can use Community First’s Complaint and Appeals Process to resolve a dispute regarding Emergency Care.
    
    If You have any questions regarding whether a situation constitutes a Medical Emergency, please contact Your Primary Care Physician who will direct You based on symptoms. Additionally, Members may call Community First’s 24-hour nurse advice/triage service. You may reach this service by calling 210-358-6262 or 1-877-698-7032.
    
    If it is determined that a Medical Emergency does exist, Community First will pay for Emergency Care services performed by non-Participating Providers at negotiated or usual and customary rates for the services performed. Community First will approve or deny coverage of post-stabilization care, as requested by a treating provider, within the timeframe appropriate to the circumstances, but in no case to exceed one hour.
    
    Community First will have Pre-authorization staff on duty at phones during regular business hours. If You have received Emergency Care and the Provider who treated You indicates that you will need follow-up care to complete the treatment, the follow-up care must be rendered by the Member's Primary Care Physician, not by the Provider who treated You for the Medical Emergency. The Member, or someone acting on the Member’s behalf, should contact the Member’s Primary Care Physician within 24 hours, or as soon as reasonably possible, so that he or she may arrange for follow-up care.
2. Member Financial Responsibility. As explained below, when accessing authorized Covered Services from a Participating Provider, You will only owe a Co-payment to that Provider. If you receive a bill from any provider, please notify Community First’s Member Services Department immediately.
3. Covered Services: The Covered Services are those that are in the list below. Section 4 of this Part B (“Limitations”) describes any modification of these Covered Services for certain Illnesses. A service or supply is not a Covered Service or Supply if excluded. It is excluded to the extent it falls outside any limits described in Section 4 of this Part B (“Limitations”) or is described in Section 5 of this Part B (“Exclusions”). Some Covered Services and/or Supplies below may require medical review for Medical Necessity and/or appropriateness prior to Pre-authorization.
4. Limitations: This Section 4 describes limits for the Covered Services under Section 3 above. It also describes any modifications of those Covered Services for certain Illnesses.
  1. Major Disaster or Epidemic. Community First will consistently make a good faith effort to provide or arrange for Covered Services, taking into account existing conditions and events. If there is a major disaster or an epidemic, Community First will provide or arrange for Covered Services to the extent possible or practical according to its best judgment. In doing this, Community First will take into account the facilities and personnel that are then available to provide Covered Services. Neither Community First nor any Participating Provider will have any liability or obligation on account of delay or failure to provide or arrange for Covered Services if:
    1. such delay or failure is due to lack of available facilities or personnel; and
    2. such lack is the result of such major disaster or such epidemic.
  2. Circumstances Beyond the Control of Community First or Participating Providers. Due to circumstances not within the control of Community First or Participating Providers, there may be a delay in providing or arranging for Covered Services, or it may not be practical or possible to do so. In that event, neither Community First nor any Participating Provider will have any liability or obligation on account of delay or failure to provide or arrange for Covered Services if a good faith effort has been made to do so. Some examples of such circumstances are: complete or partial destruction of facilities because of war, riot, or civil insurrection; the disability of a significant number of Participating Providers; and other similar causes.
  3. Continuity of Treatment in the Event of the Termination of a Primary Care Physician. Community First will notify You no less than thirty (30) days in advance if a Participating Physician or other provider treating You is going to be leaving the Community First network. If the Physician or other provider is treating You under a "special circumstance” and the treating Physician or provider makes the request, then Community First will continue to compensate the Physician or other provider, on Your behalf, for up to ninety (90) days. "Special circumstance" means a condition such that Your Physician or provider reasonably believes discontinuation of care could cause harm to You. Examples include:
    1. A person who has a disability;
    2. A person with an acute condition;
    3. A person with a Life-Threatening Illness.
    4. A person who is past the twenty-fourth