Attachment 12 - GIC Member Handbook Active Non Medicare.pdf

Benefit Handbook

THE HARVARD PILGRIM EXPLORER POS PLAN FOR

MASSACHUSETTS GROUP INSURANCE COMMISSION MEMBERS

MASSACHUSETTS

This benefit Plan is provided to you by the Group Insurance Commission (GIC) on a self-insured basis. Harvard Pilgrim Health Care has arranged for the availability of a Network of health care Providers and will be performing various benefit and claim administration and case management services on behalf of the GIC. Although some materials may refer to you as a Member of one of Harvard Pilgrim Health Care’s products, the GIC is the insurer of your coverage.

IMPORTANT NOTICE: This Plan includes a tiered Provider Network. In this Plan, Members pay different levels of Member Cost Sharing depending on the tier of the Provider delivering a Covered Benefit or supply.

The Explorer POS Plan Provider Directory includes Provider tiering information and is available online at www.harvardpilgrim.org/GIC or by calling Member Services at 1-844-442-7324. For TTY service, please call 711.

EFFECTIVE DATE: 07/01/2026

GIC_POS_11

INTRODUCTION

Welcome to The Harvard Pilgrim Explorer POS Plan For Massachusetts Group Insurance Commission Members (the Plan). Thank you for choosing us to help you meet your health care needs.

The health care services under this Plan are administered by Harvard Pilgrim Health Care (HPHC) through its Provider Network. The Harvard Pilgrim Explorer POS Plan is a self-insured health benefits plan for the Group Insurance Commission (GIC). The GIC is your Plan Sponsor and is financially responsible for this Plan's health care benefits. HPHC provides benefits and claims administration and case management services on behalf of the GIC as outlined in this Benefit Handbook and the Schedule of Benefits.

The Harvard Pilgrim Explorer POS Plan has been designed to offer you the coordinated care and cost advantages of Health Maintenance Organization (HMO) health coverage as well as the choice of obtaining Covered Benefits outside the HMO Provider Network.

However, your responsibilities and financial obligations differ depending upon whether you receive care In-Network or Out-of-Network.

When we use the words “we,” “us,” and “our” in this Handbook, we are referring to Harvard Pilgrim Health Care. When we use the words “you” or “your” we are referring to Members as defined in the Glossary.

In-Network Benefits Your “In-Network” benefits provide coverage at a lower out-of-pocket cost. With very limited exceptions, you must receive care from Harvard Pilgrim Explorer POS Plan Providers (Plan Providers) to obtain In-Network benefits. Plan Providers are medical Providers under contract to care for HPHC Members. They include Primary Care Providers (PCPs), specialists, hospitals and many other types of Providers. You can locate Plan Providers by calling the Member Services Department at 1-844-442-7324 or you may access the Explorer POS Plan Provider Directory online atwww.harvardpilgrim.org/GIC.

Out-of-Network Benefits Your “Out-of-Network” benefits provide coverage at a higher out-of-pocket cost.

However, your Out-of-Network benefits allow you to receive Covered Benefits from almost any medical Provider located within the United States.

You must choose a PCP for yourself and each Member of your family when you enroll in the Plan. Most care must be provided or arranged by your PCP, except as described in section I.E.2. Your PCP Manages Your Health Care.

If you choose to receive Covered Benefits from a Provider or at a facility which is not a Plan Provider your benefits will be covered at the Out-of-Network level.

Your benefits will also be covered at the Out-of-Network level if you receive services from Plan Providers in the Service Area without a Referral from your PCP, when a Referral is required.

As a Member, you can take advantage of a wide range of helpful online tools and resources at www.harvardpilgrim.org. Your secure online account offers you a safe way to help manage your health care. You are able to check your Schedules of Benefits and

BENEFIT HANDBOOK | i http://www.harvardpilgrim.org

Benefit Handbook, look up benefits, Copayments, claims history, and Deductible status, and view Prior Approval and referral activities. You can also learn how your Plan covers preventive care and conditions such as asthma, diabetes, COPD and high blood pressure.

HPHC’s cost transparency tool allows you to compare cost and quality on many types of health care services including surgical procedures and office visits. The cost transparency tool provides estimated costs only. Your Member Cost Sharing may be different.

To access information, tools and resources online, visit www.harvardpilgrim.org and select the Member Login button (first time users must create an account and then log in). To access the cost transparency tool once you’re logged in, click on the “Tools and Resources” link from your personalized Member dashboard and look for the Estimate My Cost link.

You may call the Member Services Department at 1-844-442-7324 if you have any questions. Member Services staff are available to help you with questions about the following:

• Selecting a PCP

• Your Benefit Handbook

• Your benefits

• Your enrollment

• Your claims

• Provider Information

• Requesting an Explorer POS Plan Provider Directory

• Requesting a Member kit

• Requesting ID cards

• Registering a complaint

We can usually accommodate questions from non-English speaking Members. We offer language interpretation services in more than 180 languages free of charge.

Deaf and hard-of-hearing Members who use a Teletypewriter (TTY) may communicate with the Member Services Department. For TTY services, please call 711.

We value your input. We would appreciate hearing from you with any comments or suggestions that will help us further improve the quality of service we bring you.

Harvard Pilgrim Health Care, Inc.

Member Services Department 1 Wellness Way Canton, MA 02021 Phone: 1-844-442-7324 www.harvardpilgrim.org

Medical necessity Guidelines HPHC uses evidence based clinical review criteria to evaluate whether certain services or procedures are Medically Necessary for a Member’s care. Members or their practitioners may obtain a copy of the Medical Necessity Guidelines applicable to a service or procedure for which coverage is requested. Medical ii | BENEFIT HANDBOOK

Necessity Guidelines may be obtained by calling the Member Services Department at 1-844-442-7324 or going to www.harvardpilgrim.org.

Exclusions or Limitations for Preexisting Conditions. The Plan does not impose any restrictions, limitations or exclusions related to preexisting conditions on your Covered Benefits.

Prescription Drug Coverage

Your outpatient prescription drug coverage is not administered by HPHC. Please see your CVS Caremark Prescription Drug Plan brochure or call CVS Caremark at 1-877-876-7214 for information on coverage of outpatient prescription drugs.

Regardless of whether the CVS Caremark brochure is specifically noted in a handbook section, any reference to outpatient drugs found within this handbook is governed by the CVS Caremark Prescription Drug Plan brochure.

Employee Assistance Program (EAP)

If you have a question about Employee Assistance Program benefits Optum 1-844-263-1982 supportfinder.optum.com/mass4you (Website Access Code: Mass4You)

• What your Employee Assistance Program (EAP) benefits are

• The status of (or a question about) an EAP claim

BENEFIT HANDBOOK | iii iv | BENEFIT HANDBOOK

BENEFIT HANDBOOK | v vi | BENEFIT HANDBOOK

TABLE OF CONTENTS

Benefit Handbook

I. HOW THE PLAN WORKS

A. HOW TO USE THIS BENEFIT HANDBOOK

B. HOW TO USE YOUR HARVARD PILGRIM EXPLORER POS PLAN PROVIDER DIRECTORY

C. EXPLORER POS PLAN TIERED NETWORK

D. MEMBER OBLIGATIONS

E. HOW TO OBTAIN CARE

F. MEMBER COST SHARING

G. PRIOR APPROVAL

H. SERVICES PROVIDED BY A DISENROLLED NON-PLAN PROVIDER

I. MEDICAL NECESSITY GUIDELINES

J. PROVIDER FEES FOR SPECIAL SERVICES (CONCIERGE SERVICES)

K. CARE MANAGEMENT PROGRAMS

II. GLOSSARY

III. COVERED BENEFITS

IV. EXCLUSIONS

V. STUDENT DEPENDENT COVERAGE

A. STUDENTS INSIDE THE SERVICE AREA

B. STUDENTS OUTSIDE THE SERVICE AREA

VI. REIMBURSEMENT AND CLAIMS PROCEDURES

A. BILLING BY PROVIDERS

B. REIMBURSEMENT FOR BILLS YOU PAY

C. THE LIMITS ON FILING CLAIMS

D. TIME LIMITS FOR THE REVIEW OF CLAIMS

E. PAYMENT LIMIT

F. MISCELLANEOUS CLAIMS PROVISIONS

VII. APPEALS AND COMPLAINTS

A. BEFORE YOU FILE AN APPEAL

BENEFIT HANDBOOK | vii

B. MEMBER APPEAL PROCEDURES

C. WHAT YOU MAY DO IF YOUR APPEAL IS DENIED

D. THE FORMAL COMPLAINT PROCESS

VIII. ELIGIBILITY

A. MEMBER ELIGIBILITY

B. HOW YOU’RE COVERED IF MEMBERSHIP BEGINS WHILE YOU’RE HOSPITALIZED

IX. ABOUT ENROLLMENT AND MEMBERSHIP

A. About Enrollment and Membership

X. TERMINATION AND TRANSFER TO OTHER COVERAGE

A. TERMINATION BY THE SUBSCRIBER

B. TERMINATION FOR LOSS OF ELIGIBILITY

C. MEMBERSHIP TERMINATION FOR CAUSE

D. CONTINUATION OF COVERAGE FOR SURVIVORS

E. CONTINUATION OF COVERAGE AFTER A CHANGE IN MARITAL STATUS

F. CONTINUATION OF COVERAGE REQUIRED BY LAW

G. CONTINUATION OF DEPENDENT COVERAGE UNDER HPHC

XI. WHEN YOU HAVE OTHER COVERAGE

A. BENEFITS IN THE EVENT OF OTHER INSURANCE

B. PROVIDER PAYMENT WHEN PLAN COVERAGE IS SECONDARY

C. WORKERS’ COMPENSATION/GOVERNMENT PROGRAMS

D. SUBROGATION AND REIMBURSEMENT

E. MEDICAL PAYMENT POLICIES

F. MEMBER COOPERATION

G. THE PLAN'S RIGHTS

H. MEMBERS ELIGIBLE FOR MEDICARE

XII. PLAN PROVISIONS AND RESPONSIBILITIES

A. IF YOU DISAGREE WITH RECOMMENDED TREATMENT

B. LIMITATION OF LEGAL ACTIONS

C. ACCESS TO INFORMATION

D. SAFEGUARDING CONFIDENTIALITY

E. NOTICE

F. MODIFICATION OF THIS BENEFIT HANDBOOK

G. OUR RELATIONSHIP WITH PLAN PROVIDERS

H. IN THE EVENT OF A MAJOR DISASTER

I. EVALUATION OF NEW TECHNOLOGY

J. UTILIZATION REVIEW PROCEDURES

K. QUALITY ASSURANCE PROGRAMS

viii | BENEFIT HANDBOOK

L. PROCEDURES USED TO EVALUATE EXPERIMENTAL/INVESTIGATIONAL DRUGS, DEVICES

OR TREATMENTS

M. PROCESS TO DEVELOP MEDICAL NECESSITY GUIDELINES AND UTILIZATION REVIEW

CRITERIA

N. NON-ASSIGNMENT OF BENEFITS

O. NEW TO MARKET DRUGS

P. PAYMENT RECOVERY

XIII. MEMBER RIGHTS & RESPONSIBILITIES

XIV. INDEX

APPENDIX A: GROUP HEALTH CONTINUATION COVERAGE UNDER COBRA GENERAL

NOTICE

APPENDIX B: IMPORTANT NOTICE ABOUT YOUR PRESCRIPTION DRUG COVERAGE AND

MEDICARE

APPENDIX C: NOTICE OF GROUP INSURANCE COMMISSION PRIVACY PRACTICES

APPENDIX D: THE UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS

ACT (USERRA)

APPENDIX E: MEDICAID AND THE CHILDREN’S HEALTH INSURANCE PROGRAM NOTICE

(CHIP)

BENEFIT HANDBOOK | ix x | BENEFIT HANDBOOK

THE HARVARD PILGRIM EXPLORER POS PLAN FOR MASSACHUSETTS GROUP INSURANCE

COMMISSION MEMBERS - MASSACHUSETTS

I. How the Plan Works This section describes how to use your Benefit Handbook and how your coverage works under The Harvard Pilgrim Explorer POS Plan For Massachusetts Group Insurance Commission Members (the Plan).

A. HOW TO USE THIS BENEFIT HANDBOOK

1. Why This Benefit Handbook is Important This Benefit Handbook and the Schedule of Benefits make up the agreement stating the terms of the Plan.

The Benefit Handbook describes how your membership works. It explains what you must do to obtain coverage for services and what you can expect under the Plan. It is also your guide to the most important things you need to know, including:

• Covered Benefits

• Exclusions

• The requirements for In-Network and Out-of-Network coverage

You can view your Benefit Handbook and Schedule of Benefits online by using your secure online account at www.harvardpilgrim.org.

2. Words With Special Meaning Some words in this Benefit Handbook have a special meaning. These words are capitalized and are defined in the Glossary.

3. How To Find What You Need To Know This Handbook’s Table of Contents will help you find the information you need. The following is a description of some of the important sections of the Handbook.

We put the most important information first. For example, this section explains important requirements for coverage. By understanding Plan rules, you can avoid denials of coverage.

Benefit details are described in section III. Covered Benefits and also in your Schedule of Benefits. You must review section III. Covered Benefits and your Schedule of Benefits for a complete understanding of your benefits.

Your CVS Caremark prescription drug coverage is not administered by HPHC. For details on your prescription drug benefit, please refer to your CVS Caremark Prescription Drug Plan brochure or call CVS Caremark at 1-877-876-7214 for information on coverage of outpatient prescription drugs.

B. HOW TO USE YOUR HARVARD PILGRIM EXPLORER

POS PLAN PROVIDER DIRECTORY

To be eligible for In-Network coverage under the Plan, all services, except care in a Medical Emergency, must be received from Plan Providers. You can find Plan Providers by using the Harvard Pilgrim Explorer POS Plan Provider Directory.

The Explorer POS Plan Provider Directory lists the Plan Providers you must use to obtain In-Network coverage. It lists Plan Providers by state and town, specialty, and languages spoken. You may view the Explorer POS Plan Provider Directory online at our website, www.harvardpilgrim.org/GIC.

The online Explorer POS Plan Provider Directory enables you to search for Providers by name, gender, specialty, hospital affiliations, languages spoken and office locations. You can also obtain information about whether a Provider is accepting new patients. Because it is updated in accordance with state and Federal laws, the information in the online directory will be more current than a paper directory.

You may also access the physician profiling site maintained by the Commonwealth of Massachusetts Board of Registration in Medicine at www.mass.gov/orgs/board-of-registration-in-medicine.

You can also get a paper copy of the Explorer POS Plan Provider Directory, free of charge, by calling the Member Services Department at 1-844-442-7324.

Please Note: Plan Providers participate through contractual arrangements that can be terminated either by a Provider or by HPHC. Under a tiered Network Plan, a Provider’s tier level may also change.

In addition, a Provider may leave the Network because of retirement, relocation or other reasons. This means that we cannot guarantee that the Plan Provider you choose will continue to be listed under the same tier or participate in the Network for the duration of your membership. If your PCP leaves the Network for any reason, we will make every effort to notify you at least 30 days in advance, and will help you find a new Plan Provider. Under certain circumstances, you may be eligible for transition services if your Provider leaves the Network (please see section I.H. SERVICES PROVIDED BY A DISENROLLED NON-PLAN PROVIDER for details).

BENEFIT HANDBOOK | 1

C. EXPLORER POS PLAN TIERED NETWORK

For In-Network services, this Plan has a Network of Providers in which hospitals and physicians have been placed into 3 benefit levels or “tiers.” HPHC determined its tiers by using standard analytical techniques to evaluate Network PCPs, specialists, and hospitals. Based on this evaluation, Providers are grouped into three levels: Tier 1, Tier 2, and Tier 3.

Plan Providers are under contract to provide Covered Benefits to Members of the Plan.

Tiering of In-Network Providers is determined by cost efficiency standards and nationally recognized quality of care benchmarks. Cost efficiency is evaluated by comparing how much it costs doctors and hospitals to treat patients for similar conditions. Quality of care is evaluated based on standards derived from clinical guidelines for care. The tier associated with a hospital or physician determines your Member Cost Sharing for Covered Benefits. Tier 1 is the lowest-cost tier. Tier 2 is the medium-cost tier. Tier 3 is the highest-cost tier.

Harvard Pilgrim evaluated PCPs and specialists based on the performance of the physician’s medical group and their associated hospital(s). Providers are defaulted to Tier 2 if: (1) they are not affiliated with a medical group; (2 ) they are in Harvard Pilgrim's national network and not located in Massachusetts, Maine, or NewHampshire; or (3) there was insufficient data to assign a tier.

• Tier 1 Providers – Includes PCPs, specialists and acute hospitals that met both Harvard Pilgrim’s cost efficiency and quality benchmarks

• Tier 2 Providers – Includes PCPs, specialists and acute hospitals that fall into one of these categories: (1) met the quality benchmark and have a moderate cost efficiency benchmark score;

(2) met the cost efficiency benchmark but may not have met other benchmarks; (3) PCPs and specialists that are not affiliated with a medical group; (4) Providers in Harvard Pilgrim’s national network; or (5) Providers for whom there was insufficient data available

• Tier 3 Providers – Includes PCPs, specialists, and acute hospitals with the lowest cost efficiency benchmark scores

Because Member Cost Sharing is dependent upon the tier placement of a doctor or hospital, you will have lower out-of-pocket costs when you select Providers from the lower tiers. You should consider a Provider’s tier and where the Provider has hospital admitting privileges before selecting a PCP or specialist. For example, if you require hospital care and your Tier 1 PCP refers you to a Tier 1 hospital, you will pay the lower out-of-pocket costs for both your physician and hospital care. However, if your Tier 1 PCP were to refer you to a Tier 3 hospital, you would pay the lowest out-of-pocket costs for physician services but the highest out-of-pocket costs for hospital care.

Only acute care hospitals, PCPs and medical specialists that are Plan Providers are assigned to one of three tiers. Certain Covered Benefits, including mental health and substance use disorder treatment, are not assigned a Provider Tier. Please see your Schedule of Benefits for the specific Member Cost Sharing amounts that apply to all your Covered Benefits.

A Provider’s tier level may be changed if there is a change that impacts the criteria used to evaluate and determine tier placement as indicated above.

Plan Providers and their tier placements are listed in the Explorer POS Plan Provider Directory at www.harvardpilgrim.org/GIC. You may also call Harvard Pilgrim’s Member Services Department at 1-844-442-7324 to check a Provider’s status and tier placement or to request a paper copy of the directory, free of charge.

2 | BENEFIT HANDBOOK

IMPORTANT POINTS TO REMEMBER

Under the Plan, your out-of-pocket costs will vary depending on whom you see and where you go for care. Please review and consider the following when seeking coverage under the Plan:

• You can lower your out-of-pocket cost by selecting Plan Providers and hospitals in the lowest cost tier.

• When you choose a PCP, it is important to consider the tier of the hospital that your PCP uses. For example, a Tier 1 PCP may admit patients to a Tier 2 or Tier 3 hospital.

• A Plan Provider may practice at multiple locations and have a different tier assigned to each location. Different out-of-pocket costs may apply to the same Plan Provider based on where you are treated by that Provider.

• Some Plan Providers have multiple offices and may be a Plan Provider at one location, and a Non-Plan Provider at another. For In-Network coverage, you must check with Harvard Pilgrim to make sure the services you seek are covered as In-Network for that specific Plan Provider at that specific location.

• For certain Covered Benefits Member Cost Sharing is not tiered. The Member Cost Sharing for these Covered Benefits is listed in your Schedule of Benefits.

In summary, it is important to be aware that Providers are affiliated with many health insurers that offer different plan options with a variety of networks. In order to be certain that your Provider participates in the Harvard Pilgrim Explorer POS Plan, you must check with Harvard Pilgrim itself, either online at www.harvardpilgrim.org/GIC or by calling Member Services at 1-844-442-7324, to confirm whether a particular Provider is included in the Network.

D. MEMBER OBLIGATIONS

1. Choose a Primary Care Provider (PCP) To obtain In-Network coverage in the Service Area, you must choose a PCP for yourself and each of your family Members when you enroll in the Plan. If you do not choose a PCP when you first enroll, or if the PCP you select is not available, we will assign a PCP to you. The Plan Service Area includes the states of Massachusetts, New Hampshire, Maine, Rhode Island and Vermont.

A PCP may be a physician, a physician assistant or a nurse practitioner specializing in one or more of the following specialties: internal medicine, adult medicine, adolescent medicine, geriatric medicine, pediatrics, family practice, or gynecology and reproductive health. PCPs are listed in the Explorer POS Plan Provider Directory. You can access our website at www.harvardpilgrim.org/GIC or call the Member Services Department at 1-844-442-7324 to confirm that the PCP you select is available.

When you choose a PCP, it is important to consider the tier of the hospital that your PCP uses. For example, a Tier 1 PCP may admit patients to a Tier 2 or Tier 3 hospital. If your Tier 1 PCP were to refer you to a Tier 2 or Tier 3 hospital, you would pay the lowest out-of-pocket costs for physician services but the higher out-of-pocket costs for hospital care.

If you have not seen your PCP before, we suggest you call your PCP for an appointment. Please do not wait until you are sick to call your PCP. Your PCP can take better care of you when he or she is familiar with your health status.

You may change your PCP at any time. Just choose a new PCP from the Explorer POS Plan Provider Directory. You can change your PCP online by using your secure online account at www.harvardpilgrim.org/GIC or by calling the Member Services Department at 1-844-442-7324.

The change is effective immediately.

2. Obtaining Referrals to In-Network Specialists In order to be eligible for In-Network coverage by the Plan, most care you receive in the Service Area must be provided or arranged by your PCP. For more information, please see section I.E. HOW TO OBTAIN

CARE.

If you need to see a specialist in the Service Area, you must contact your PCP for a Referral prior to the appointment For exceptions, see I.E.9. Services That Do Not Require a Referral. In most cases, a Referral will be given to a Plan Provider who is affiliated with the same hospital as your PCP or who has a working relationship with your PCP. Referrals to Plan Providers must be given in writing.

You do not need a Referral from your PCP when you receive care outside of the Service Area (the Service Area includes the states of Massachusetts, New Hampshire, Maine, Rhode Island and Vermont).

However, except in a Medical Emergency, you must obtain care from a Plan Provider to obtain In-Network coverage under this Benefit Handbook.

BENEFIT HANDBOOK | 3

3. Show Your Identification Card You should show your identification (ID) card every time you request health services. If you do not show your ID card, the Provider may not bill HPHC for Covered Benefits, and you may be responsible for the cost of the service. You can order a new ID card online by using your secure online account at www.harvardpilgrim.org or by calling the Member Services Department at 1-844-442-7324.

4. Share Costs You are required to share the cost of the Covered Benefits provided under the Plan. Your Member Cost Sharing may include one or more of the following:

• Copayments

• Coinsurance

• Deductibles

For In-Network services, Member Cost Sharing amounts for Covered Benefits provided by PCPs, specialists or hospitals are dependent upon the tier placement of the Provider and where you receive services.

Your Plan has an Out-of-Pocket Maximum that limits the amount of Member Cost Sharing you are required to pay. Your Member Cost Sharing responsibilities are listed in your Schedule of Benefits. See the Glossary for more information on Copayments, Coinsurance, Deductibles and the Out-of-Pocket Maximums.

5. Obtain Prior Approval You are required to obtain Prior Approval before receiving certain Covered Benefits. Please see section I.G. PRIOR APPROVAL for more information on these requirements.

6. Be Aware that your Plan Does Not Pay for All Health Services There may be health products or services you need that are not covered by the Plan. Please review section IV. Exclusions for more information. In addition, some services that are covered by the Plan are limited.

Such limitations are needed to maintain reasonable premium rates for all Members. Please see your Schedule of Benefits for any specific limits that apply to your Plan.

E. HOW TO OBTAIN CARE

IMPORTANT POINTS TO REMEMBER

1) You and each enrolled Member of your family who lives in the Service Area must select a

PCP.

2) The Service Area includes the states of Massachusetts, New Hampshire, Maine, Rhode Island and Vermont.

3) You have two types of Covered Benefits, known as “In-Network” and “Out-of-Network.”

4) In order to receive In-Network Covered Benefits in the Service Area, your care must be provided or arranged by your PCP through Plan Providers, except as noted below.

5) Your Plan has a tiered Network comprised of Tier 1, Tier 2 and Tier 3 Providers.

6) Plan Providers that are PCPs, specialists and acute hospitals are placed into three tiers; Tier 1, Tier 2 and Tier 3.

7) For In-Network tiered services, Member Cost Sharing is lowest for Tier 1 Providers and highest for Tier 3 Providers.

8) Out-of-Network Covered Benefits are available when received from Non-Plan Providers located within the United States.

9) Some services require Prior Approval by the Plan.

10) In the event of a Medical Emergency, you should go to the nearest emergency facility or call 911 or other local emergency number.

You do not need a Referral for services in a Medical Emergency.

In-Network and Out-of-Network

The Plan offers two different levels of coverage, referred to in this document as “In-Network” and “Out-of-Network” coverage.

To receive In-Network coverage you must use Plan Providers. Plan Providers have agreed to participate in the Plan and accept the Plan payment minus Member Cost Sharing as payment in full. Since we pay Plan Providers directly, if you show your Member ID card you should not have to file a claim when you use your In-Network coverage.

You receive Out-of-Network coverage when Covered Benefits are provided from Non-Plan Providers or Plan Provider without a Referral when one is required.

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Although your Member Cost Sharing is generally higher for Out-of-Network benefits, you may obtain Covered Benefits from the Provider of your choice.

To find out if a Provider is a Plan Provider, see the Explorer POS Plan Provider Directory. The Explorer POS Plan Provider Directory is available online at www.harvardpilgrim.org/GIC or by calling our Member Services Department at the telephone number listed on your ID card.

Your coverage is described further below.

Some services require Prior Approval by the Plan.

Please see the section titled I.G. PRIOR APPROVAL for information on the Prior Approval Program.

Please see your Schedule of Benefits for the specific Member Cost Sharing that applies to In-Network and Out-of-Network benefits.

1. How Your In-Network Benefits Work To obtain In-Network coverage in the Service Area, you must choose a PCP who is a Plan Provider and receive Covered Benefits in one of the following ways:

• The service must be provided by your PCP;

• The service must be provided by a Plan Provider upon Referral from your PCP;

• The service must be one of the special services that do not require a Referral listed in section I.E.9.

Services That Do Not Require a Referral, and be received from a Plan Provider;

• In the case of mental health and substance use disorder treatment, the service must be provided by a Plan Provider;

• The service must be provided in a medical emergency. In a Medical Emergency, including an emergency mental health condition, the Plan provides In-Network coverage for ambulance and hospital emergency room services. You do not need to use a Plan Provider and you do not need a Referral from your PCP.

To obtain In-Network coverage outside the Service Area, you must receive Covered Benefits through the Plan’s national Provider Network. To find a Plan Provider, see the Explorer POS Plan Provider Directory. The Explorer POS Plan Provider Directory is available online at www.harvardpilgrim.org/GIC or by calling our Member Services Department at 1-844-442-7324.

When obtaining In-Network benefits, some services require Prior Authorization by the Plan. Please see section I.G. PRIOR APPROVAL for information on the Prior Approval Program.

2. Your PCP Manages Your Health Care When you need care in the Service Area, call your PCP. The Service Area includes the states of Massachusetts, New Hampshire, Maine, Rhode Island and Vermont.

In order to be eligible for In-Network coverage in the Service Area, most services must be provided or arranged by your PCP. The only exceptions are:

• Care in a Medical Emergency

• Mental health and substance use disorder treatment

• Special services that do not require a Referral that are listed in section I.E.9. Services That Do Not Require a Referral

Either your PCP or a covering Plan Provider is available to direct your care 24-hours a day. Talk to your PCP and find out what arrangements are available for care after normal business hours. Some PCPs may have covering physicians after hours and others may have extended office or clinic hours.

You may change your PCP at any time. Just choose a new PCP from the Explorer POS Plan Provider Directory. You can change your PCP online by using your secure online account at www.harvardpilgrim.org/GIC or by calling the Member Services Department at 1-844-442-7324.

The change is effective immediately. If you select a new PCP, all Referrals from your prior PCP become invalid.

Your new PCP will need to assess your condition and provide new Referrals.

3. Referrals for Hospital and Specialty Care When you need hospital or specialty care inside the Service Area, you must first call your PCP. Your PCP will coordinate your care. Your PCP generally uses one hospital for inpatient care. This is where you will need to go for coverage, unless it is Medically Necessary for you to get care at a different hospital.

When you need specialty care, your PCP will refer you to a Plan Provider who is affiliated with the hospital your PCP uses. This helps your PCP coordinate and maintain the quality of your care. Please ask your PCP about the Referral Network that he or she uses.

If the services you need are not available through your PCP’s Referral Network, your PCP may refer you to any Plan Provider. If you or your PCP has

BENEFIT HANDBOOK | 5

difficulty finding a Plan Provider who can provide the services you need, we will assist you. For help finding a medical, mental health or substance use disorder treatment Provider, please call the Member Services Department at 1-844-442-7324. If no Plan Provider has the professional expertise needed to provide the Medically Necessary Covered Benefit, we will assist you in finding an appropriate Non-Plan Provider. In this instance, Prior Approval is required to receive In-network coverage for services from a Non-Plan Provider. The Plan will cover the approved services and you will be responsible for the applicable Member Cost Sharing that would apply if the covered service was provided by a Plan Provider.

Plan Providers with recognized expertise in specialty pediatrics are covered with a Referral from your PCP.

Your PCP may authorize a standing Referral with a specialty care Provider when:

1) The PCP determines that the Referral is appropriate;

2) The specialty care Provider agrees to a treatment plan for the Member and provides the PCP with necessary clinical and administrative information on a regular basis; and

3) The services provided are Covered Benefits as described in this Handbook and your Schedule of Benefits.

There are certain specialized services for which you will be directed to a Center of Excellence for care.

Please see section I.E.5. Centers of Excellence for more information.

Certain specialty services may be obtained without involving your PCP. For more information, please see section I.E.9. Services That Do Not Require a Referral.

When you need hospital or specialty care outside the Service Area, you may obtain Covered Benefits from the Provider of your choice. You do not need a Referral for services received outside of the Service Area.

However, you must receive Covered Benefits through a Plan Provider to receive In-Network coverage.

4. Using Plan Providers Covered Benefits must be received from a Plan Provider to be eligible for In-Network coverage.

Covered Benefits from a provider who is not a Plan Provider are covered In-network benefit level only if one of the following exceptions below applies.

Unless (1) below applies, you must obtain Prior Approval before receiving care from a Non-Plan Provider. You may request Prior Approval by calling

1-800-708-4414. The Non-Plan Provider may seek Prior Approval on your behalf. The Plan will cover the approved services and you will be responsible for the applicable Member Cost Sharing that would apply if the covered service was provided by a Plan Provider.

1) The service was received in a Medical

Emergency from an emergency room or for ambulance transport. Please see section I.E.6.

Medical Emergency Services for information on your coverage in a Medical Emergency.

2) No Plan Provider has the professional expertise needed to provide the Medically Necessary Covered Benefit. Unless 1) above applies, services by a Non-Plan Provider must be approved by us in advance.

3) Your physician is disenrolled as a Plan Provider or you are a newMember of the Plan, and one of the exceptions stated in section I.H. SERVICES

PROVIDED BY A DISENROLLED NON-PLAN

PROVIDER applies. Please refer to that section for the details of these exceptions.

To find out if a Provider is in the Plan Network, see the Explorer POS Plan Provider Directory. The Explorer POS Plan Provider Directory is available online at www.harvardpilgrim.org/GIC or by calling our Member Services Department at 1-844-442-7324.

5. Centers of Excellence Plan Providers with special training, experience, facilities or protocols for certain specialized services are designated as “Centers of Excellence.” Centers of Excellence are selected by us based on the findings of recognized specialty organizations or government agencies such as Medicare. Centers of Excellence are located in Massachusetts, Maine, New Hampshire and Rhode Island. To receive In-Network coverage in Massachusetts, Maine, New Hampshire, and Rhode Island you must obtain care at a designated Center of Excellence for the following service(s):

• Weight loss surgery (bariatric surgery)

Important Note: If you choose to receive care in Massachusetts, Maine, or New Hampshire for the above service at a facility other than a contracted Center of Excellence, coverage will be at the Out-of-Network benefit level.

To receive In-Network benefits for the service listed above outside of Massachusetts, Maine, New Hampshire, or Rhode Island you must obtain care at a hospital that is listed as a Plan Provider. Care received from a Non-Plan Provider will be covered at the Out-of-Network benefit level.

6 | BENEFIT HANDBOOK

A list of Centers of Excellence may be found in the Explorer POS Plan Provider Directory. The Explorer POS Plan Provider Directory is available online at www.harvardpilgrim.org/GIC or by calling our Member Services Department at 1-844-442-7324.

We may revise the list of services that must be received from a Center of Excellence upon 30 days notice to Members. Services or procedures may be added to the list when we identify services in which significant improvements in the quality of care may be obtained through the use of selected Providers. Services or procedures may be removed from the list if HPHC determines that significant advantages in quality of care will no longer be obtained through the use of a specialized panel of Providers.

6. Medical Emergency Services In a Medical Emergency, including an emergency related to a substance use disorder or mental health condition, you should go to the nearest emergency facility or call 911 or other local emergency number.

Your emergency room Member Cost Sharing is listed in your Schedule of Benefits. Please remember that if you are hospitalized for medical treatment, you must lnotify HPHC within 48 hours or as soon as you can.

If you are hospitalized for mental health or substance use disorder treatment, you must notify HPHC within 72 hours or as soon as you can. Call HPHC at 1-844-442-7324. This telephone number can also be found on your ID card. If notice of hospitalization is given to the Plan by an attending emergency physician no further notice is required.

Follow up care outside the Plan’s Network will be covered at the Out-of-Network benefit level. See the Glossary for additional information on Medical Emergency Services.

7. Covered Benefits from Our Affiliated National Network of Providers HPHC offers a comprehensive network of Plan Providers located in Massachusetts, New Hampshire, Maine, Rhode Island and Vermont. In addition, HPHC’s national provider network allows Members to obtain In-Network benefits outside of those states.

To locate one of these Providers, log onto the Plan’s online directory at www.harvardpilgrim.org/GIC or call Member Services at 1-844-442-7324.

8. Coverage for Services When You Are Outside the Service Area In-Network Coverage In-Network Coverage is available outside of the Service Area by using Plan Providers enrolled in the

Plan’s national Provider Network. You can locate Plan Providers outside of the Service Area by using the Explorer POS Plan Provider Directory described earlier in this Handbook.

If you need help locating a mental health or substance use disorder treatment Provider outside of the Service Area, contact the Plan’s Member Services Department at 1-844-442-7324.

As is the case within the Service Area, you do not need to use a Plan Provider to obtain care in a Medical Emergency, including an emergency related to a substance use disorder or mental health condition. You also do not need to obtain a Referral from your PCP.

In a medical emergency the Plan provides In-Network coverage for ambulance and hospital emergency room services.

Out-of-Network Coverage When you are outside the Service Area you may also obtain Out-of-Network coverage from Non-Plan Providers.

If you are hospitalized for medical treatment, you must notify HPHC within 48 hours, or as soon as you can.

If you are hospitalized for mental health or substance use disorder treatment, you must notify HPHC within 72 hours or as soon as you can. Call HPHC at 1-844-442-7324. This telephone number can also be found on your ID card. If notice of hospitalization is given to the Plan by an attending emergency physician, no further notice is required.

Coverage outside the United StatesWhen you are outside the United States coverage is limited to Urgent Care services and care needed in a Medical Emergency only. Please see section VI. Reimbursement and Claims Procedures for information on reimbursement of international claims.

9. Services That Do Not Require a Referral When you are inside the Service Area you will usually need a Referral from your PCP to get In-Network coverage from any other Plan Provider. However, you do not need a Referral for the services listed below.

You may obtain In-Network coverage for these services from any Plan Provider without a Referral from your PCP. Plan Providers are listed in the Explorer POS Plan Provider Directory.

i. Family Planning Services:

• Contraceptive monitoring

• Family planning consultation, including pregnancy testing

BENEFIT HANDBOOK | 7

• Tubal ligation

• Voluntary termination of pregnancy (abortion)

ii. Obstetric and Gynecology (OB/GYN) Services (excluding Assisted Reproductive Technology services)

• Annual gynecological exam, including routine pelvic and clinical breast exam

• Follow-up care for an acute or emergency OB/GYN condition

• Maternity care

iii. Other Services:

• Acupuncure for detoxification

• Chiropractic care

• Routine eye examination

• Nutritional counseling

• Urgent Care services

10. How Your Out-of-Network Coverage Works You use your Out-of-Network coverage whenever you obtain Covered Benefits from Non-Plan Providers.

This allows you to obtain Covered Benefits from any licensed health care professional. You do not need a Referral from your PCP. A wide range of health care services, including physician and hospital services are covered at the Out-of-Network benefit level.

Services will also be covered as Out-of-Network services if you receive care from a Plan Provider without a PCP Referral when one is required.

The Plan pays only a percentage of the cost of Covered Benefits you receive from Non-Plan Providers. You are responsible for paying the balance. Your Member Cost Sharing is generally higher for Out-of-Network benefits. However, you have more flexibility in obtaining care and may go to the licensed health care professional of your choice.

When obtaining Out-of-Network benefits, some services require Prior Approval by the Plan. Please see the section titled I.G. PRIOR APPROVAL for information on the Prior Approval Program.

To find out if a Provider is a Plan Provider, see the Explorer POS Plan Provider Directory. The Explorer POS Plan Provider Directory is available online at www.harvardpilgrim.org/GIC or by calling our Member Services Department at the telephone number listed on your ID card.

Payments to Plan Providers are usually based on a contracted rate between us and the Plan Provider.

Since we have no contract with Non-Plan Providers, there is no limit on what such Providers can charge.

Providers in Massachusetts are not allowed to balance bill you for charges over the Allowed Amount.

However, outside of Massachusetts, a Non-Plan Provider may balance bill you for the difference between the Allowed Amount and the provider's charges. Since the Plan does not cover balance bills, you are responsible for payment, unless it is a Surprise Bill.

To avoid being balance billed outside of Massachusetts, use Plan Providers when you need health care services. To find a Plan Provider, see the Explorer POS Plan Provider Directory. The Explorer POS Plan Provider Directory is available online at www.harvardpilgrim.org/GIC or by calling our Member Services Department at 1-844-442-7324.

Please Note: A Surprise Bill is an unexpected bill, as defined by the federal No Surprise Act of 2022, received from a Non-Plan Provider, that you did not knowingly select, who provided services to you while you were receiving covered services from a Plan Provider or facility. If you receive a Surprise Bill, you are only responsible for the applicable Member Cost Sharing that would apply if the covered service was provided by a Plan Provider, unless you had a reasonable opportunity to choose to have the service performed by a Plan Provider. See section VI. Reimbursement and Claims Procedures for additional information.

F. MEMBER COST SHARING

You are required to share the cost of Covered Benefits provided under the Plan. Your Member Cost Sharing may include Copayments, Coinsurance and Deductibles when using Plan Providers or Non-Plan Providers. Your Member Cost Sharing for medical and mental health and substance use disorder treatment is described below. The In-Network and Out-of-Network Member Cost Sharing amounts that apply to your Plan are listed in your Schedule of Benefits.

1. In-Network Member Cost Sharing Please Note: There are certain specialized services that must be received at designated Plan Providers, called “Centers of Excellence” to receive In-Network coverage. Please see section I.E.5. Centers of Excellence for further information.

i. Copayments A Copayment is a fixed dollar amount that you must pay for certain Covered Benefits. Copayments are due

8 | BENEFIT HANDBOOK

at the time of service or when billed by the Provider.

The Copayment amounts that apply to your Plan are listed in your Schedule of Benefits.

Your Plan has three levels of Copayments that apply to office visits and hospitals (Tier 1, Tier 2, and Tier 3). Your Copayment will vary depending upon which Explorer POS Plan Provider you see.

a. Inpatient Hospital Copayment There is a maximum of one Inpatient Hospital Copayment per Member during each Quarter in a Plan Year, waived if you are readmitted within 30 days in the same Plan Year. The Inpatient Hospital Copayment amounts that apply to your Plan are listed in your Schedule of Benefits.

b. Surgical Day Care Copayment The Surgical Day Care Copayment amount that applies to your Plan is listed in your Schedule of Benefits.

There is a maximum of one Copayment per visit up to a maximum of four Copayments per Member per Plan Year.

c. Emergency Room Copayment The emergency room Copayment amount that applies to your Plan is stated in your Schedule of Benefits.

The Copayment is waived if you are admitted directly to the Hospital from the emergency room, in which case you are responsible for the Inpatient Hospital Copayment. Please see Inpatient Hospital Copayment above for more information.

d. Advanced Radiology Copayment The advanced radiology Copayment amount that applies to your Plan is stated in your Schedule of Benefits. These services include, CT Scans, MRAs, MRIs, PET Scans and nuclear medicine services. There is a maximum of one Copayment per Member per day.

ii. In-Network Deductible A Deductible is a specific dollar amount that is payable by the Member for Covered Benefits each Plan Year before certain Covered Benefits are available under this Plan. Your Deductible limits, and the services to which they apply, are listed in your Schedule of Benefits.

When you use a Plan Provider, you must first satisfy the Deductible before the Plan begins paying Covered Benefits for certain In-Network services. Each Member enrolled in Individual Coverage must satisfy the per-Member annual In-Network Deductible amount each Plan Year. When Members are enrolled in Family Coverage, the Family Deductible is met once any combination of Members has paid the total Family Deductible amount; no family Member will pay more than the per-Member annual Deductible.

iii. Coinsurance Coinsurance is a percentage of the Allowed Amount or the Recognized Amount, if applicable, for certain Covered Benefits that must be paid by the Member.

Coinsurance amounts, and the services to which they apply, are listed in the Schedule of Benefits.

iv. In-Network Out-of-Pocket Maximum The In-Network Out-of-Pocket Maximum is the total amount of In-Network Copayments, Coinsurance and Deductibles a Member or family may pay in a year.

Your In-Network Out-of-Pocket Maximum limits are listed in your Schedule of Benefits.

2. Out-of-Network Member Cost Sharing

i. Deductibles Your Out-of-Network Deductible limits, and the services to which they apply, are listed in your Schedule of Benefits.

The Out-of-Network Deductible for medical and mental health and substance use disorder treatment accumulates separately from the In-Network Deductible for medical care.

ii. Copayments The emergency room Copayment amount that applies to your Plan is stated in your Schedule of Benefits.

The emergency room Copayment is waived, but the Member owes the Inpatient Hospital Copayment in the event of an emergency admission, unless the Member has already had an inpatient admission in the same Quarter of a given Plan Year or has been admitted within the last 30 days in the same Plan Year.

iii. Coinsurance Coinsurance is a percentage of the Allowed Amount or the Recognized Amount, if applicable, for certain Covered Benefits that must be paid by the Member.

Coinsurance amounts, and the services to which they apply, are listed in the Schedule of Benefits.

iv. Penalty A Penalty is applied to any Covered Benefit that requires Prior Approval when one is not received, as described in section I.G. PRIOR APPROVAL.

v. Out-of-Pocket Maximum Your Out-of-Network Out-of-Pocket Maximum limits, and the services to which they apply, are listed in your Schedule of Benefits.

BENEFIT HANDBOOK | 9

Charges above the Allowed Amount and Penalty payments never apply to the Out-of-Network Out-of-Pocket Maximum.

vi. Charges in Excess of the Allowed Amount On occasion, a Non-Plan Provider outside of Massachusetts may charge amounts in excess of the Allowed Amount. In those instances, you will be financially responsible for the difference between what the Provider charges and the amount of the Allowed Amount payable by the Plan, unless it is a Surprise Bill.

This means that you will be responsible for paying the full amount above the Allowed Amount or the Recognized Amount, if applicable. Amounts charged by a Non-Plan Provider in excess of the Allowed Amount do not count toward the Out-of-Pocket Maximum. Non-Plan Providers in Massachusetts are not allowed to charge you amounts in excess of the Allowed Amount. You may contact the Member Services Department at 1-844-442-7324 or at 711 for TTY service if you have questions about the maximum Allowed Amount that may be permitted by HPHC for a service. See section VI. Reimbursement and Claims Procedures for additional information.

3. Combined Payment Levels Under some circumstances, you may choose to receive services from both a Plan Provider and a Non-Plan Provider when receiving care. When this occurs, your entitlement to In-Network or Out-of-Network coverage always depends upon the participation status of the individual Provider. For example, you may receive treatment in a Plan Provider’s office, then choose to go to a non-plan laboratory to receive blood work. Since the payment level is dependent upon the participation status of the Provider, the Plan Provider would be paid at the In-Network coverage level and the laboratory would be paid at the Out-of-Network coverage level.

The benefit payment level that is applied to a hospital admission depends on the participation status of both the admitting physician and the hospital.