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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.  \nYou 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.  \nRenewability. 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.  \nIn-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.  \nREAD THIS ENTIRE CONTRACT CAREFULLY. IT IS YOUR RESPONSIBILITY TO UNDERSTAND THE TERMS AND CONDITIONS IN THIS CONTRACT.  \nThis Contract is governed by the laws of New York State.  \nTalya Schwartz, MD  \nMetroplus HealthPlan President & Chief Executive Officer  \nIf You need foreign language assistance to understand this Contract, You may call Us at the number on Your ID card.  \nTABLE OF CONTENTS  \nSection I. Definitions ................................................................................................ 4  \nSection II. How Your Coverage Works .................................................................... 10  \nParticipating Providers ................................................................................................. 10  \nThe Role of Primary Care Physicians .......................................................................... 11  \nServices Subject to Preauthorization ........................................................................... 12  \nMedical Necessity ........................................................................................................ 13  \nImportant Telephone Numbers and Addresses ........................................................... 15  \nSection III. Access to Care and Transitional Care ................................................. 17  \nSection IV. Cost-Sharing Expenses and Allowed Amount.................................... 20  \nSection V. Who is Covered ...................................................................................... 22  \nSection VI. Preventive Care ..................................................................................... 23  \nSection VII. Ambulance and Pre-Hospital Emergency Medical Services............. 27  \nSection VIII. Emergency Services and Urgent Care.....................................","cbCaikJ9lZcDnSsr","https://ap.wps.com/l/cbCaikJ9lZcDnSsr","pdf",2717923,125,"English","# Section I. Definitions\n# Section II. How Your Coverage Works\n## Participating Providers\n## The Role of Primary Care Physicians\n## Services Subject to Preauthorization\n## Medical Necessity\n## Important Telephone Numbers and Addresses\n# Section III. Access to Care and Transitional Care\n# Section IV. Cost-Sharing Expenses and Allowed Amount\n# Section V. Who is Covered\n# Section VI. Preventive Care\n# Section VII. Ambulance and Pre-Hospital Emergency Medical Services\n# Section VIII. Emergency Services and Urgent Care\n# Section IX. Outpatient and Professional Services\n# Section X. Additional Benefits, Equipment and Devices\n# Section XI. Inpatient Services\n# Section XII. Mental Health Care and Substance Use Services\n# Section XIII. Prescription Drug Coverage\n# Section XIV. Wellness Benefits\n# Section XV. Vision Care\n# Section XVI. Dental Care\n# Section XVII. Exclusions and Limitations\n# Section XVIII. Claim Determinations\n# Section XIX. Grievance Procedures\n# Section XX. Utilization Review\n# Section XXI. External Appeal\n# Section XXII. Termination of Coverage\n# Section XXIII. Temporary Suspension Rights for Armed Forces’ Members\n# Section XXIV. General Provisions","[{\"question\":\"Are benefits limited to in-network providers?\",\"answer\":\"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.\"}]","Essential Plan -EP 2 - Contract Coverage 2025 - Certificate of Coverage | PDF",1790525941,315]