CERTIFICATE OF COVERAGE - Anthem Clear Choice Bronze Tiered 8000

Sep 16, 2026

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Certificate of Coverage for Anthem Clear Choice Bronze Tiered 8000, Off Marketplace, outlining guaranteed renewability subject to terms, rights, and member responsibilities. Explains coverage continuity for inpatient stays begun under an existing certificate, and cancellation steps if provided as a new member within 10 days. Details tiered network rules for Maine HMO Tiered Options, cost-sharing differences by tier, non-network coverage limits, and the need to confirm network status via the provider directory or Member Services, including language assistance information.

LanguageEnglish

CategoryLetters

FormatPDF

Pages126

Reading Time44 min

AccessFree to download

CERTIFICATE OF COVERAGE

RIGHT TO EXAMINE

IMPORTANT NOTICE ABOUT YOUR PROVIDER NETWORK AND BENEFITS

How to Obtain Language Assistance

CERTIFICATE OF COVERAGE Anthem Clear Choice Bronze Tiered 8000, Off Marketplace This Certificate is Guaranteed Renewable subject 24-A M.R.S.A. § 2850-B. RIGHT TO EXAMINE This Certificate replaces any previous Certificates issued by Us. Services provided during an Inpatient stay that started during an existing Certificate will continue to be covered by the terms of that Certificate until You are discharged or reach any of the Certificate’s limits or maximums, whichever occurs first. If this Certificate of Coverage is provided to You as a new Member, and if You decide not to accept this Certificate, return it to Our home office (Anthem Blue Cross and Blue Shield; 2 Gannett Drive; South Portland, ME 04106-6911) within 10 days after its delivery date. Please include a written request to cancel it. We will then refund any Subscription Charges less any claims paid under this Certificate. IMPORTANT NOTICE ABOUT YOUR PROVIDER NETWORK AND BENEFITS This is a tiered network Plan and the tiered Provider network is called “Maine HMO Tiered Options.” You may pay different Cost Sharing amounts (Copayments, Deductibles, Out-of-Pocket Limits and/or Coinsurance) depending on whether You receive services from a Tier 1 Network Provider or Tier 2 Network Provider. The tier of that Provider may change if the Provider changes affiliations. There are Hospitals, healthcare Facilities, doctors or other healthcare Providers that are not included in this Plan’s network. If You use a Non-Network Provider, there will be no benefits for services, unless they are for Emergency Care, ambulance services related to an Emergency for transportation to a Hospital, Urgent Care services received at an Urgent Care Center, or We have pre-authorized services from a NonNetwork Provider. You are responsible for confirming that the Provider You are seeing or have been referred to see is a Network Provider for this Plan . Please refer to the online Provider directory available at [www.anthem.com](www.anthem.com to determine)[ to determine](www.anthem.com to determine) if a particular Provider is in the Network and whether the Provider is in Tier 1 or Tier 2, or contact Member Services for assistance. Except for Emergency Care, ambulance services related to an Emergency for transportation to a Hospital, or Urgent Care services received at an Urgent Care Center, there is no benefit for services rendered by Non-Network Providers inside and outside the State of Maine unless the services are approved in advance by Anthem. There is no benefit for out-of-area nonemergency care/non-Urgent Care services, unless approved in advance by Anthem. Please see the “How Your Claims Are Paid” section for further details on out-of-area services through Our Inter-Plan program. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Maine, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. ME_OFFHIX_HMO_01-23 6VTG We are pleased that You have become a Member of Our health Plan, where it is Our mission to improve the health of the people We serve. We have designed this Certificate to give a clear description of Your benefits, as well as Our rules and procedures. This Certificate explains many of the rights and duties between You and Us. It also describes how to get healthcare, what services are covered, and what part of the costs You will need to pay. Many parts of this Certificate are related. Therefore, reading just one or two sections may not give You a full understanding of Your coverage. You should read the whole Certificate to know the terms of Your coverage. This Certificate, the application, and any amendments or riders attached shall constitute the entire Certificate under which Covered Services and supplies are provided by Us. Many words used in the Certificate have special meanings (e.g. , Covered Services, and Medical Necessity) . Th

FAQs

What does the “Right to Examine” section require if the certificate is provided as a new member?

Return the certificate to the home office within 10 days after delivery if you decide not to accept it, and include a written request to cancel. Refunds subscription charges less any claims paid under the certificate.

How does coverage differ when using Tier 1 vs Tier 2 network providers?

As a tiered network plan under “Maine HMO Tiered Options,” you may pay different cost-sharing amounts depending on whether services come from a Tier 1 or Tier 2 provider. A provider’s tier may change if affiliations change.

When are non-network provider services covered?

Non-network provider services generally have no benefits unless they are for Emergency Care, related ambulance transportation, urgent care at an urgent care center, or pre-authorized non-network services. Out-of-area nonemergency or non-urgent care services require advance approval.

Sep 16, 2026

Upload by Elsa