WIXLIB

BMC HealthNet PlanCommonwealth CareEvidence of CoverageThis health plan meets Minimum Creditable Coverage standards and will satisfythe individual mandate that you have health insurance.Please see page 4 for additional information.Boston Medical Center Health Plan, Inc.Two Copley Place Suite 600 Boston, Massachusetts 02116Effective Date: July 1, 2013 Date of Issue: July 1, 2013 Form No. BMCHP-CC-11-Rev.

TRANSLATION SERVICES2

TRANSLATION SERVICES (Cont.)3

INTRODUCTIONWelcome to BMC HealthNet Plan Commonwealth Care.Boston Medical Center Health Plan, Inc., also known as BMC HealthNet Plan (“BMCHP”) is a not-for-profitMassachusetts managed care organization. We arrange for the provision of health care services to members through contractswith network providers (doctors, other health care professionals, and hospitals). All network providers are located in ourservice area. As a member, you agree to receive all your health care from network providers (except in certain situations, suchas emergencies, described in this Evidence of Coverage booklet). When you become a member, you will need to choose aPrimary Care Provider (PCP) to manage your care. Your PCP is a network doctor or nurse practitioner. Your PCP willprovide you with primary care services and, if the need arises, may refer you to other network providers for additional care.The Commonwealth Care Health Insurance Program (“Commonwealth Care”) is a special state-subsidized healthinsurance program. Commonwealth Care is overseen by the Commonwealth Health Insurance Connector Authority (the“Connector”).BMC HealthNet Plan Commonwealth Care. Through an arrangement with the Connector, BMCHP offers BMC HealthNetPlan Commonwealth Care, referred to in this Evidence of Coverage (EOC) as the “plan.” Individuals meeting the Connector’seligibility requirements for Commonwealth Care can enroll in our plan. In exchange for a premium that we receive from theConnector, we agree to provide the coverage described in this EOC to enrolled members for the time period covered by thepremium. By submitting a signed membership application, and by paying any applicable premiums to the Connector, youagree to all the terms of this EOC.This EOC is an important legal document that describes the relationship between you and BMCHP. It describes your rightsand obligations as a member in the plan. It tells you how the plan works, covered services to which members are entitled,services that are not covered services, certain limits and conditions related to covered services, and copayments you must paywhen you receive covered services. It also describes other important information related to membership in the plan. We hopeyou will read this EOC and save it for future use. The Table of Contents will help you find what you need to know. Italicizedwords in this EOC have meanings that are explained in the Definitions section (Appendix A) toward the end of theEOC. If you need any help understanding this EOC, please contact us. We’re here to help!MINIMUM CREDITABLE COVERAGE AND MANDATORY HEALTH INSURANCEREQUIREMENTSMASSACHUSETTS REQUIREMENT TO PURCHASE HEALTH INSURANCE:As of January 1, 2009, the Massachusetts Health Care Reform Law requires that Massachusetts residents, eighteen (18)years of age and older, must have health coverage that meets the Minimum Creditable Coverage standards set by theCommonwealth Health Insurance Connector, unless waived from the health insurance requirement based onaffordability or individual hardship. For more information call the Connector at 1-877-MA-ENROLL or visit theConnector website (www.mahealthconnector.org ).Minimum Creditable Coverage Standards. This health plan meets applicable Minimum Creditable Coverage standardsthat are effective as of January 1, 2011 as part of the Massachusetts Health Care Reform Law. If you purchase this plan, youwill satisfy the statutory requirement that you have health insurance meeting these standards.THIS DISCLOSURE IS FOR MINIMUM CREDITABLE COVERAGE STANDARDS THAT ARE EFFECTIVE January 1,2011. BECAUSE THESE STANDARDS MAY CHANGE, REVIEW YOUR HEALTH PLAN MATERIAL EACH YEARTO DETERMINE WHETHER YOUR PLAN MEETS THE LATEST STANDARDS.If you have questions about this notice, you may contact the Division of Insurance by calling (617) 521-7794 or visitingits website at www.mass.gov/doi.4

BMC HEALTHNET PLANCOMMONWEALTH CAREADDRESS AND TELEPHONE DIRECTORYPHONE NUMBERSMember Services Department: 1-877-957-5300 (toll-free) Monday – Friday 8 a.m. – 6 p.m. We’re Here to Help: The Member Services Department is available to help answer questions about how the planworks, selecting a Primary Care Provider (PCP), benefits, pharmacy, enrollment, eligibility, claims, network providerinformation, requesting a Provider Directory, ID cards, registering a concern, billing and change of addressnotification. We strive to provide excellent services. Calls to the Member Services Department are monitored bysupervisors to ensure quality service to our members. Member Satisfaction Process: For information about Grievances or Appeals, call Member Services. Utilization Review Information: Call Member Services if you want to find out the status of utilization review(medical necessity review) decision involving your benefits. Members with total or partial hearing loss: You may communicate with Member Services by calling our TTYmachine at 1-866-765-0055. Non-English Speaking Members: A free language translation service is available to members upon request to helpwith questions about plan administrative procedures. This service provides you with access to interpreters who cantranslate over 140 languages. Call Member Services toll-free at 1-877-957-5300.Nurse Advice Line: 1-800-765-7344 (24 hours and toll free)Members can call and speak to a nurse over the phone and get answers to health related questions. Call any day at anytime. A specially trained registered nurse will assist you. After you explain your symptoms, the nurse may give youadvice about how to take care of yourself at home, or suggest you go to an emergency room or call your doctor. All callsare confidential.To Obtain Emergency Medical Care: In an emergency, seek care at the nearest emergency facility. If needed, call 911for emergency medical assistance. (If 911 services are not available in your area, call the local number for emergencymedical services.)To Obtain Routine or Urgent Medical Care: For routine and urgent care inside the service area, always call your PCP.To Obtain Mental Health and Substance Abuse Services: The plan contracts with Beacon Health Strategies, LLC, tomanage all mental health and substance abuse services.If you need mental health or substance abuse services, you may do any of the following: Call the toll-free 24-hour mental health/substance abuse telephone line at 1-877-957-5600 for help finding a networkprovider Go directly to a network provider who provides mental health or substance abuse services Call your PCP for help finding a network provider Visit our website (www.bmchp.org) to look up network providersTo Obtain Durable Medical Equipment, Prosthetics, Orthotics or Medical Supplies: The plan contracts withNorthwood, Inc. to manage most of these services. Some equipment and supplies will still be managed by the plan. If youneed these services, you may do any of the following: Contact our Member Services Department at 1-877-957-5300 (toll free) Monday – Friday 8 a.m. – 6 pm Call your PCP for help finding a network provider Visit our website (www.bmchp.org) to look up network providersTo Obtain Pharmacy Services: For information about covered pharmacy services and network pharmacies, includingretail, specialty and mail order pharmacies, do any of the following: Contact Member Services (see above) Visit our website (www.bmchp.org) Contact our Pharmacy Benefits Manager (PBM) at:Catamaran2441 Warrenville Road Suite 610Attention: Customer Care5

Lisle, IL 60532Telephone: 1- 800-227-7269Website: www.mycatamaranrx.comCustomer Service Hours of Operation: Available 24 hours, 7 days a week.To Obtain Dental Services (FOR PLAN TYPE I MEMBERS ONLY): Contact DentaQuest, our dental servicesvendor, for information about covered dental services and DentaQuest-participating dental services professionals. Youcan also call Member Services or visit our web site.DentaQuest1212 N. Corporate ParkwayMequon, WI 53092Telephone: 1-800-207-8147Fax: 1-262-834-3450Website: www.dentaquestgov.comCustomer Service Hours of Operation: Monday through Friday, 8 a.m. – 6 p.m.To Obtain Vision Services: For information about covered vision services, network eye doctors and VSP-participatingeye doctors, call Member Services, visit our website, or contact VSP - our vision services vendor:Vision Service Plan, Inc. (VSP)Attention: C&G Unit3333 Quality DriveRancho Cordova, CA 95670Telephone: 1-800-877-7195Fax: 916-858-5569Email: cgunit@vsp.comWebsite: www.vsp.comBMC HEALTHNET PLAN WEB SITE: www.bmchp.orgBMCHP ADDRESSES:BMCHP Corporate Headquarters:Boston Medical Center Health Plan, Inc.Two Copley PlaceSuite 600Boston, Massachusetts 02116BMCHP Local Offices: 1350 Main Street – 13th FloorOne Financial PlazaSpringfield, MA 01103Phone: 413-730-4800 Bourne Counting HouseOne Merrills WharfNew Bedford, MA 02740Phone: 508-990-2400TO CONTACT THE CONNECTOR: Information regarding Commonwealth Care eligibility, enrollment options, benefits,changing health plans and hardship waivers is available from the Connector. You may contact the Connector as follows:Commonwealth Health Insurance Connector AuthorityCommonwealth CarePO Box 120089Boston, MA 02112-9914Telephone: 1-877-MA-ENROLL (1-877-623-6765)For persons with total or partial hearing loss, please call TTY: 877-623-7773Hours of Operation: 8 a.m. – 5 p.m. Monday through FridayWebsite: www.mahealthconnector.org6

TABLE OF CONTENTSTranslation Services. 2Introduction: Minimum Creditable Coverage and Mandatory Health Insurance Requirements. 4Address and Telephone Directory . 5Chapter 1. Summary Chart of Covered Services and Copayments. 9Plan Type I. 9Plan Type II. 12Plan Type III . 15Chapter 2. How the Plan Works . 18Plan Types; Choose a PCP; Visit Your PCP; Changing Your PCP . 18Your PCP Provides and Refers You for Health Care. 18When You Need Specialty Care . 19Prior Authorization Requirements for Visits to Network Specialists. 19Care from Non-Network Providers . 20Care at Network Hospitals or Other Network Facilities . 20Plan Help With Referrals . 20If You Can’t Reach Your PCP . 20Canceling Provider Appointments . 20No Waiting Period or Pre-Existing Condition Limitations/Availability of Covered Services. 20The Provider Network. 20Emergency Services. 21Coverage for Urgent Care When You are Temporarily Traveling Outside the Service Area . 22Inpatient Hospital Care . 22Continuity of Care . 22Member ID Cards . 23Chapter 3. Covered Services . 24Introduction. 24Covered Services as of your Coverage Effective Date . 24Copayments, Hardship Waivers and Out of Pocket Copayment Maximums. 24Prior Authorization from Plan Authorized Reviewer. 25Inpatient Services. 25When Inpatient Services are Covered Services. 25Acute Hospital Care. 26Extended Care. 26Human Organ Transplants . 26Maternity Care . 26Mental Health and Substance Abuse – Inpatient and Diversionary Care Services . 27Reconstructive Surgery and Procedures. 27Outpatient Services . 27When Outpatient Services are Covered Services . 27Outpatient Care When You’re Sick or Injured . 27Allergy Testing and Treatment . 28Ambulance . 28Cardiac Rehabilitation . 28Chemotherapy and Radiation. 28Day Surgery . 28Dental Services: For Plan Type I Members Only . 29Diabetes Treatment . 29Dialysis . 29Durable Medical Equipment and Prosthetic Devices (DME) . 29Emergency Services. 31Family Planning Services . 31Home Health Care . 32Hospice Services. 32Laboratory, Radiology, X-Ray and other Diagnostic Tests . 33Maternity Services – Outpatient . 337