Essential Plan -EP 2 - Contract Coverage 2025 - Certificate of Coverage

Sep 27, 2026

Uploaded by Mary Man

Certificate of Coverage for Metroplus Health Plan’s Essential Plan EP 2 for 2025 outlines the contract agreement and the full terms that govern an individual’s coverage. It explains return rights within ten days of receipt, automatic renewability on the renewal date, and special pregnancy and postpartum coverage timing. The certificate emphasizes in-network benefits, primary care physician coordination, preauthorization requirements, and responsibilities when using non-participating providers, except for emergencies and urgent care.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages125

Reading Time5 h 15 min

AccessFree to download

Section I. Definitions

Section II. How Your Coverage Works

Participating Providers

The Role of Primary Care Physicians

Services Subject to Preauthorization

Medical Necessity

Important Telephone Numbers and Addresses

Section III. Access to Care and Transitional Care

Section IV. Cost-Sharing Expenses and Allowed Amount

Section V. Who is Covered

Section VI. Preventive Care

Section VII. Ambulance and Pre-Hospital Emergency Medical Services

Section VIII. Emergency Services and Urgent Care

Section IX. Outpatient and Professional Services

Section X. Additional Benefits, Equipment and Devices

Section XI. Inpatient Services

Section XII. Mental Health Care and Substance Use Services

Section XIII. Prescription Drug Coverage

Section XIV. Wellness Benefits

Section XV. Vision Care

Section XVI. Dental Care

Section XVII. Exclusions and Limitations

Section XVIII. Claim Determinations

Section XIX. Grievance Procedures

Section XX. Utilization Review

Section XXI. External Appeal

Section XXII. Termination of Coverage

Section XXIII. Temporary Suspension Rights for Armed Forces’ Members

Section XXIV. General Provisions

CERTIFICATE OF COVERAGE METROPLUSHEALTH MARKETPLACE Essent ia l P lan-EP 2 2025 This is Your ESSENTIAL PLAN CONTRACT Issued by Metroplus Health Plan This is Your individual Contract for the Essential Plan coverage issued by Metroplus Health Plan. This Contract, together with the attached Schedule of Benefits, applications and any amendment or rider amending the terms of this Contract constitute the entire agreement between You and Us. You have the right to return this Contract. Examine it carefully. If You are not satisfied, You may return this Contract to Us and ask Us to cancel it. Your request must be made in writing within ten (10) days from the date You receive this Contract. Renewability. The renewal date for this Contract is twelve months from the effective date of coverage. This Contract will automatically renew each year on the renewal date, unless otherwise terminated by Us as permitted by this Contract or by You upon 30 days’ prior written notice to Us. If You become pregnant while covered under this Contract, You will have coverage for the duration of the pregnancy, along with one year of postpartum coverage. The 12-month postpartum coverage period will start on the last day of Your pregnancy and end on the last day of the 12th month. In-Network Benefits. This Contract only covers in-network benefits. To receive in-network benefits You must receive care exclusively from Participating Providers who are located within Our Service Area. Care Covered under this Contract (including Hospitalization) must be provided, arranged or authorized in advance by Your Primary Care Physician and, when required, approved by Us. In order to receive the benefits under this Contract, You must contact Your Primary Care Physician before You obtain the services , except for services to treat an Emergency Condition described in the Emergency Services and Urgent Care section of this Contract. Except for care for an Emergency Condition described in the Emergency Services and Urgent Care section of this Contract , You will be responsible for paying the cost of all care that is provided by Non-Participating Providers. READ THIS ENTIRE CONTRACT CAREFULLY. IT IS YOUR RESPONSIBILITY TO UNDERSTAND THE TERMS AND CONDITIONS IN THIS CONTRACT. This Contract is governed by the laws of New York State. Talya Schwartz, MD Metroplus HealthPlan President & Chief Executive Officer If You need foreign language assistance to understand this Contract, You may call Us at the number on Your ID card. TABLE OF CONTENTS Section I. Definitions ................................................................................................ 4 Section II. How Your Coverage Works .................................................................... 10 Participating Providers ................................................................................................. 10 The Role of Primary Care Physicians .......................................................................... 11 Services Subject to Preauthorization ........................................................................... 12 Medical Necessity ........................................................................................................ 13 Important Telephone Numbers and Addresses ........................................................... 15 Section III. Access to Care and Transitional Care ................................................. 17 Section IV. Cost-Sharing Expenses and Allowed Amount.................................... 20 Section V. Who is Covered ...................................................................................... 22 Section VI. Preventive Care ..................................................................................... 23 Section VII. Ambulance and Pre-Hospital Emergency Medical Services............. 27 Section VIII. Emergency Services and Urgent Care.....................................

FAQs

Are benefits limited to in-network providers?

Yes. The contract covers only in-network benefits, requiring care to be received exclusively from participating providers within the service area, with exceptions for emergency conditions and urgent care as described in the contract.

Sep 27, 2026

Uploaded by Mary Man