Leading our Community to Improved Health

Transcription

1 Provider Manual A Reference Guide for Healthcare Providers Credentialed in the PrimeTime Health Plan Network Revised October, 2016 Leading our Community to Improved Health

2 Table of Contents Introduction 3 CMS Regulations. 3 Information About the MA Program.. 3 CMS Marketing Provisions. 3 Access to Services.. 7 Federal Disaster Policy... 8 Physician Incentive Plans: Requirements and Limitations. 9 Contract Provisions Special Needs Policy Contact List. 12 Provider Manual. 13 PrimeTime Health Plan (PTHP). 13 Summary or Product Lines.. 13 Member Confidentiality 13 Introduction. 13 Statement of HIPAA Portability Rights.. 13 Purpose Of This Notice.. 14 Our Privacy Policies And Practices 15 Uses And Disclosures Of Your Protected Health Information 16 Rights That You Have. 18 For Further Information. 18 Effective Date 18 Provider Relations. 19 Provider Relations Department.. 19 Telephone/Fax Numbers:.. 19 PrimeTime Website 20 Grievance &Appeals. 13 Process:.. 20 PrimeTime Health Plan Contact Information 21 Service Center.. 21 Enrollee Rights and Responsibilities.. 21 You have a Right to: 21 You have a Responsibility to:.. 22 Service Department Overview 22 Eligibility 22 Eligibility and Benefit Verification 23 Claims 23 Introduction.. 23 Claim Tips 23 Mailed Claims.. 23 Timeframes.. 24 Timely Filing 24 Pharmacy 24 Pharmacy Program Pharmacy and Therapeutics Committee Formulary Structure 24 Exceptions I Prior Authorizations. 24 Medication Therapy Management (MTM) Mail Order I Extended Day Supply Retail Pharmacies. 25 Credentialing.. 25 Credentialing Overview 25 Who Establishes Credentialing Policy 25 Credentialing Policies.. 25 Confidentiality. 26 Initial Credentialing 26 1

3 Table of Contents (continued) Who is Credentialed When Credentialed/Re-credentialed. 27 Credentialing Tips 27 Practitioner Rights in the Credentialing Process.. 27 Updating Information Change Forms.. 28 Credentialing Site Visits. 28 Standards.. 29 Non-Discrimination. 29 Member Medical Record Standards 29 Medical Record Scoring.. 30 Advance Directives. 30 What is CAQH. 30 Why CAQH. 30 How to start process 30 No Internet Access.. 30 Needed Items to Complete Process. 30 Disclosure Requirements 31 Participation Procedures. 31 Utilization Management 31 Mission Statement and Purpose. 31 Pre-Certification / Prior Authorization / Pre-Approval.. 31 How to Submit a request for Pre-Certification Prior Authorization Requirements.. 32 Referral Process 33 Clinical Guidelines. 34 Clinical Practice Guidelines Disease and Case Management Programs Disease Management Program.. 37 Case Management Program 37 Health Maintenance Programs 37 AultLine.. 38 Quality Management Quality Management and Performance Improvement.. 38 Quality Management Goals 38 Program Focus.:.. 38 Compliance/Fraud, Waste & Abuse.. 41 Glossary.. 43 A.. 43 B-C. 44 D-E F-J. 46 M-P 47 R-S. 48 T-W 49 2

4 Introduction CMS Regulations PrimeTime Health Plan is a Medicare Advantage Plan with a Point-of-Service Option (HMO-POS). PrimeTime Health Plan has established this section to address compliance with the laws and regulations governing the delivery of health care services as a Medicare Advantage Organization (MAO) as set forth by the Centers for Medicare and Medicaid Services (CMS). All regulations are required to be communicated to all Providers through policies, standards, and manuals. Providers are responsible for implementing and adhering to all CMS regulations outlined in the manual, policies and contract. As per the executed provider contract, all providers must abide by the Health Plan s policies and procedures, and manuals. Please refer to your contract or call our office for further requirements and/or information. Information About the MA Program (42 CFR , (a)(4): (f)(2)) PrimeTime Health Plan provides, on an annual basis, and in a format using standard terminology specified by CMS, the information necessary to enable CMS to provide to current and potential beneficiaries the information they need to make informed decisions with respect to the available choices for Medicare coverage. PrimeTime Health Plan provides this information to all members on an annual basis. PrimeTime Health Plan will disclose to CMS all information necessary to (1) Administer & evaluate the program (2) Establish and facilitate a process for current and prospective beneficiaries to exercise choice in obtaining Medicare services. CMS Marketing Provisions (42 CFR ) In conducting marketing activities, as a Medicare Advantage Organization (MAO), PrimeTime Health Plan may not Provide cash or other monetary rebates as an inducement for enrollment or otherwise. Offer gifts to potential enrollees, unless the gifts are of nominal (as defined in the CMS Marketing Guidelines) value, are offered to all potential enrollees without regard to whether or not the beneficiary enrolls, and are not in the form of cash or other monetary rebates. Engage in any discriminatory activity such as, for example, attempts to recruit Medicare beneficiaries from higher income areas without making comparable efforts to enroll Medicare beneficiaries from lower income areas. Solicit door-to-door for Medicare beneficiaries or through other unsolicited means of direct contact, including calling a beneficiary without the beneficiary initiating the contact. Engage in activities that could mislead or confuse Medicare beneficiaries, or misrepresent the MA organization. MAO may not claim it is recommended or endorsed by CMS or Medicare or that CMS or Medicare recommends that the beneficiary enroll in MAO. It may, however, explain that the organization is approved for participation in Medicare. 3

5 CMS Marketing Provisions-Continued Market non-health care related products to prospective enrollees during any MA or Part D sales activity or presentation. This is considered cross-selling and is prohibited. Market any health care related product during a marketing appointment beyond the scope agreed upon by the beneficiary, and documented by the plan, prior to the appointment (48 hours in advance, when practicable). Market additional health related lines of plan business not identified prior to an individual appointment without a separate scope of appointment identifying the additional lines of business to be discussed. Distribute marketing materials for which, before expiration of the 45-day period, MAO receives from CMS written notice of disapproval because it is inaccurate or misleading, or misrepresents MAO, its marketing representatives, or CMS. Use providers or provider groups to distribute printed information comparing the benefits of different health plans unless the providers, provider groups, or pharmacies accept and display materials from all health plans with which the providers, provider groups, or pharmacies contract. The use of publicly available comparison information is permitted if approved by CMS in accordance with the Medicare marketing guidance. Conduct sales presentations or distribute and accept MAO enrollment forms in provider offices or other areas where health care is delivered to individuals, except in the case where such activities are conducted in common areas in health care settings. Conduct sales presentations or distribute and accept plan applications at educational events. Employ MAO plan names that suggest that a plan is not available to all Medicare beneficiaries. This prohibition shall not apply to MA plan names in effect on July 31, Display the names and/or logos of co-branded network providers on the organization's member identification card, unless the provider names, and/or logos are related to the member selection of specific provider organizations (for example, physicians, hospitals). Other marketing materials (as defined in ) that include names and/or logos of provider co-branding partners must clearly indicate that other providers are available in the network. Engage in any other marketing activity prohibited by CMS in its marketing guidance. Provide meals for potential enrollees, which is prohibited, regardless of value. Use a plan name that does not include the plan type. The plan type should be included at the end of the plan name. PrimeTime Health Plan does not distribute any marketing materials or election forms, or make such materials or forms available to individuals eligible to elect an MA plan, For at least 45 days (or 10 days if using marketing materials that use, without modification, proposed model language as specified by CMS) following the date on which the MA organization submitted the material or form to CMS for review under CMS guidelines. If the MA plan has file and use certification as submitted to CMS, the MA plan may distribute designated marketing materials 5 days following their submission to CMS. 4

6 CMS Marketing Provisions-Continued Or if CMS disapproves the distribution of the new material or form. Marketing materials include any informational materials targeted to Medicare beneficiaries which: Promote the MA organization, or any MA plan offered by the MA organization; Inform Medicare beneficiaries that they may enroll, or remain enrolled in, an MA plan offered by the MA organization; Explain the benefits of enrollment in an MA or rules that apply to enrollees; Explain how Medicare services are covered under an MA plan, including conditions that apply to such coverage. Examples of marketing materials include, but are not limited to: General audience materials such as general circulation brochures, newspapers, magazines, television, radio, billboards, yellow pages, or the Internet. Marketing representative materials such as scripts or outlines for telemarketing or other presentations. Presentation materials such as slides and charts. Promotional materials such as brochures or leaflets, including materials for circulation by third parties (e.g., physicians or other providers). Membership communication materials such as membership rules, subscriber agreements (evidence of coverage), member handbooks, and wallet card instructions to enrollees. Letters to members about contractual changes, changes in providers, premiums, benefits, plan procedures, etc. Membership or claims processing activities (e.g., materials on rules involving non-payment of premiums, confirmation of enrollment or disenrollment, or annual notification information). In reviewing marketing material or election forms, CMS determines if the marketing materials: Provide, in a format (and, where appropriate, print size) that is, and using standard terminology that may be, specified by CMS, the following information to Medicare beneficiaries interested in enrolling: Adequate written description of rules (including any limitations on the providers from whom services can be obtained), procedures, basic benefits and services, and fees and other charges. Adequate written description of any supplemental benefits and services. Adequate written explanation of the grievance and appeals process, including differences between the two, and when it is appropriate to use each. Any other information necessary to enable beneficiaries to make an informed decision about enrollment. Notify the general public of its enrollment period (whether time-limited or continuous) in an appropriate manner, through appropriate media, throughout its service and continuation area. Include notice that the MA organization is authorized by law to refuse to renew its contract with CMS, that CMS also may refuse to renew the contract, and that termination or non-renewal may result in termination of the beneficiary's enrollment in the plan. Are not materially inaccurate or misleading or otherwise make material misrepresentations. For markets with a significant non-english speaking population, provide materials in the language of these individuals. PrimeTime Health Plan does not distribute any marketing materials or election forms, or make such materials or forms available to individuals eligible to elect an MA plan, 5

7 CMS Marketing Provisions-Continued For at least 45 days (or 10 days if using marketing materials that use, without modification, proposed model language as specified by CMS) following the date on which the MA organization submitted the material or form to CMS for review under CMS guidelines. If the MA plan has file and use certification as submitted to CMS, the MA plan may distribute designated marketing materials 5 days following their submission to CMS. Or if CMS disapproves the distribution of the new material or form. Marketing materials include any informational materials targeted to Medicare beneficiaries which: Promote the MA organization, or any MA plan offered by the MA organization; Inform Medicare beneficiaries that they may enroll, or remain enrolled in, an MA plan offered by the MA organization; Explain the benefits of enrollment in an MA or rules that apply to enrollees; Explain how Medicare services are covered under an MA plan, including conditions that apply to such coverage. Examples of marketing materials include, but are not limited to: General audience materials such as general circulation brochures, newspapers, magazines, television, radio, billboards, yellow pages, or the Internet. Marketing representative materials such as scripts or outlines for telemarketing or other presentations. Presentation materials such as slides and charts. Promotional materials such as brochures or leaflets, including materials for circulation by third parties (e.g., physicians or other providers). Membership communication materials such as membership rules, subscriber agreements (evidence of coverage), member handbooks, and wallet card instructions to enrollees. Letters to members about contractual changes, changes in providers, premiums, benefits, plan procedures, etc. Membership or claims processing activities (e.g., materials on rules involving non-payment of premiums, confirmation of enrollment or disenrollment, or annual notification information). In reviewing marketing material or election forms, CMS determines if the marketing materials: Provide, in a format (and, where appropriate, print size) that is, and using standard terminology that may be, specified by CMS, the following information to Medicare beneficiaries interested in enrolling: Adequate written description of rules (including any limitations on the providers from whom services can be obtained), procedures, basic benefits and services, and fees and other charges. Adequate written description of any supplemental benefits and services. Adequate written explanation of the grievance and appeals process, including differences between the two, and when it is appropriate to use each. Any other information necessary to enable beneficiaries to make an informed decision about enrollment. Notify the general public of its enrollment period (whether time-limited or continuous) in an appropriate manner, through appropriate media, throughout its service and continuation area. 6

8 CMS Marketing Provisions-Continued Include notice that the MA organization is authorized by law to refuse to renew its contract with CMS, that CMS also may refuse to renew the contract, and that termination or non-renewal may result in termination of the beneficiary's enrollment in the plan. Are not materially inaccurate or misleading or otherwise make material misrepresentations. For markets with a significant non-english speaking population, provide materials in the language of these individuals. Access to Services (42 CFR ) An MA organization that offers an MA coordinated care plan or network MA MSA plan may specify the networks of providers from whom enrollees may obtain services if the MA organization ensures that all covered services, including additional or supplemental services contracted for, by (or on behalf of) the Medicare enrollee, are available and accessible under the plan. To accomplish this, PrimeTime Health Plan meets the following requirements: Maintains and monitors a network of appropriate providers that is supported by written agreements and is sufficient to provide adequate access to covered services to meet the needs of the population served. These providers are typically used in the network as primary care providers (PCPs), specialists, hospitals, skilled nursing facilities, home health agencies, ambulatory clinics, and other providers. Establishes the panel of PCPs from which the enrollee may select a PCP. If an MA organization requires its enrollees to obtain a referral in most situations before receiving services from a specialist, the MA organization must either assign a PCP for purposes of making the needed referral or make other arrangements to ensure access to medically necessary specialty care. Provides or arranges for necessary specialty care, and in particular give women enrollees the option of direct access to a women's health specialist within the network for women's routine and preventive health care services provided as basic benefits. The MA organization arranges for specialty care outside of the plan provider network when network providers are unavailable or inadequate to meet an enrollee's medical needs. If seeking a service area expansion for an MA plan, demonstrate that the number and type of providers available to plan enrollees are sufficient to meet projected needs of the population to be served. Demonstrates to CMS that its providers in an MA plan are credentialed through the process set forth. Ensures that: The hours of operation of its MA plan providers are convenient to the population served under the plan and do not discriminate against Medicare enrollees; and Plan services are available 24 hours a day, 7 days a week, when medically necessary. Ensures that services are provided in a culturally competent manner to all enrollees, including those with limited English proficiency or reading skills, and from diverse cultural and ethnic backgrounds. Provides coverage for ambulance services, emergency and urgently needed care services, and post-stabilization care services Ensures that its contracted provider network have the information required for effective and continuous patient care and quality review, including procedures to ensure that-- MAO will make a "best-effort" attempt to conduct an initial assessment of each enrollee's health care needs, including following up on unsuccessful attempts to contact an enrollee, within 90 days of the effective date of enrollment; Maintain procedures to inform members of follow-up care or provide training in selfcare as necessary; 7

9 Access to Service-Continued Each provider, supplier, and practitioner furnishing services to enrollees maintains an enrollee health record in accordance with standards established by the MA organization, taking into account professional standards; and There is appropriate and confidential exchange of information among provider network components Federal Disasters Policy Getting Medical Care and Prescription Drugs in a Disaster or Emergency Area If the Governor of our member s state, the U.S. Secretary of Health and Human Services, or the President of the United States declares a state of disaster or emergency in his/her geographic area, they are still entitled to care from us. PrimeTime Health Plan will temporarily change our rules for affected member s medical care and prescription drugs during an emergency or disaster as described below: Medical Care Allow members to see certain doctors or go to certain hospitals that accept Medicare patients, even if the doctor or hospital isn t in our network and your health care isn t an emergency. Waive referral rules for out-of-network services. Reduce plan-approved out-of-network cost-sharing to in-network cost-sharing amounts. Pharmacy Access (Plans with Part D coverage) Lift the refill-too-soon edits on prescriptions if they had to leave their home without them or they were lost or damaged due to the emergency or disaster. Allow members to obtain the maximum extended-day supply of their medication, if requested and available at the time of refill, at one of our extended-day supply pharmacies. Allow access to covered Part D drugs dispensed at out-of-network pharmacies when they cannot obtain their covered drugs at a network pharmacy. Members may have to pay more at an out-of-network pharmacy. If they pay full cost for their medications at an out-of-network pharmacy, they may submit their receipt for reimbursement consideration. Replacing lost or damaged durable medical equipment or supplies (wheelchair, walker, diabetic supplies, etc.) Equipment and supplies normally covered under the plan will be replaced at the network level of benefits if they are lost or damaged due to the disaster. Replacing a lost plan member identification card Contact our Service Center at the phone numbers listed below to replace a lost or damaged member identification card. 8

10 Federal Disaster Policy-Continued Paying plan premium If the member s plan has a monthly plan premium and they pay us directly, they can sign up for premium withholding from their Social Security check or pay by electronic funds transfer through their bank. Contact our Service Center at the phone numbers listed below for additional information. Contact information To get more information about getting care from doctors or other providers and prescription drugs during an emergency or disaster, please contact us: Call: or TTY users: or Call Center Hours: Monday through Friday 8:00 a.m. to 8:00 p.m. (October 1 February 14, we are available 7 days a week, 8:00 a.m. to 8:00 p.m.) Website: Physician Incentive Plans: Requirements and Limitations (42 CFR ) The requirements in this section apply to an MA organization and any of its subcontracting arrangements that utilize a physician incentive plan in their payment arrangements with individual physicians or physician groups. Subcontracting arrangements may include an intermediate entity, which includes but is not limited to, an individual practice association that contracts with one or more physician groups or any other organized group. Any physician incentive plan operated by an MA organization must meet the following requirements: The MA organization makes no specific payment, directly or indirectly, to a physician or physician group as an inducement to reduce or limit medically necessary services furnished to any particular enrollee. Indirect payments may include offerings of monetary value (such as stock options or waivers of debt) measured in the present or future. If the physician incentive plan places a physician or physician group at substantial financial risk for services that the physician or physician group does not furnish itself, the MA organization must assure that all physicians and physician groups at substantial financial risk have either aggregate or per-patient stop-loss and conduct periodic surveys. For all physician incentive plans, the MA organization provides all information requested to CMS. 9

11 Contract Provisions (42 CFR ) PrimeTime Health Plan agrees to comply with all the applicable requirements and conditions set forth in this part and in general instructions. PrimeTime Health Plan agrees: To provide: The basic benefits and, to the extent applicable, supplemental benefits. Access to benefits as required. In a manner consistent with professionally recognized standards of health care, all benefits covered by Medicare. To disclose information to beneficiaries in the manner and the form prescribed by CMS. To operate a quality improvement program and have an agreement for external quality review as required. To comply with the reporting requirements for submitting encounter data/risk adjustment to CMS. The CEO, CFO, or an individual delegated the authority to sign on behalf of one of these officers, and who reports directly to such officer, must certify that each enrollee for whom the organization is requesting payment is validly enrolled in an MA plan offered by the organization and the information relied upon by CMS in determining payment (based on best knowledge, information, and belief) is accurate, complete, and truthful. The CEO, CFO, or an individual delegated with the authority to sign on behalf of one of these officers, and who reports directly to such officer, must certify (based on best knowledge, information, and belief) that the encounter data it submits are accurate, complete, and truthful. If such encounter data, or risk adjustment data is generated by a related entity, contractor, or subcontractor of an MA organization, such entity, contractor, or subcontractor must similarly certify (based on best knowledge, information, and belief) the accuracy, completeness, and truthfulness of the data. To submit to CMS all information necessary for CMS to administer and evaluate the program and to simultaneously establish and facilitate a process for current and prospective beneficiaries to exercise choice in obtaining Medicare services. This information includes, but is not limited to: To comply with: The benefits covered under the MA plan; The MA monthly basic beneficiary premium and MA monthly supplemental beneficiary premium, if any, for the plan; Medical records and certify completeness and truthfulness; The service area and continuation area, if any, of each plan and the enrollment capacity of each plan; Plan quality and performance indicators for the benefits under the plan including: Disenrollment rates for Medicare enrollees electing to receive benefits through the plan for the previous 2 years; Information on Medicare enrollee satisfaction; Information on health outcomes. Title VI of the Civil Rights Act of 1964 as implemented by regulations at 45 CFR part 84; The Age Discrimination Act of 1975 as implemented by regulations at 45 CFR part 91; The Rehabilitation Act of 1973; The Americans With Disabilities Act; Other laws applicable to recipients of Federal funds; and All other applicable laws and rules. 10

12 Comply with Federal laws and regulations to include, but not limited to: Federal criminal law, the False Claims Act (31 U.S.C et. Seq.) and the anti-kickback statute (section 1128B(b) of the Act) To comply with: all applicable provider requirements, including provider certification requirements, anti-discrimination requirements, provider participation and consultation requirements, the prohibition on interference with provider advice, limits on provider indemnification, rules governing payments to providers, and limits on physician incentive plans and for the arrangements to be specified in the contracts between the MAO, providers, first tier and downstream entities. Special Needs Policy AultCare/PrimeTime recognizes that some enrollees have special needs or preferences that may affect the administration of their health plan or their ability to obtain medical services. If you are a provider who can address the special needs or preferences of AultCare/PrimeTime enrollees who speak a language other than English, who are visually or hearing impaired, or who have specific social/cultural needs; please notify AultCare/PrimeTime by completing the Provider Information Form located on the website Provider Tab, Ohio Provider Credentialing Forms and following the instructions on the form for submission to the AultCare Credentialing Department. AultCare Credentialing Department P.O. Box 6910 Canton, Ohio Phone: Fax: credentialing@aultcare.com The information you provide will be kept in a database and referenced when an enrollee calls us with special needs. If you are aware of an enrollee in need of special services, please advise them to contact us for assistance by calling the Customer Service phone number on their identification card. 11

13 Introduction (continued) CONTACT LIST PrimeTime Health Plan (Medicare) Fax TTY Line Monday through Friday 8:00 a.m. 8 p.m. From October 1 February 14, we are open seven days a week from 8:00 a.m. 8:00 p.m. PrimeTime Health Plan (Pharmacy) Fax PrimeTime Health Plan Provider Line Fax Provider Credentialing Fax credentialing@aultcare.com Provider Relations Fax Utilization Management Fax

14 Introduction (continued) Provider Manual PrimeTime Health Plan developed the Provider Manual for participating health care providers and business office staff. The manual provides information about claims filing procedures, provider agreements, utilization management procedures, credentialing, confidentiality and other topics that affect patient accounts and relations. PrimeTime Health Plan (PTHP) PrimeTime Health Plan offers an HMO-POS plan for individuals with Medicare. The Medicare program reimburses PrimeTime Health Plan to manage health services for people with Medicare who are members of the plan PTHP provides services through a network of Medicare-certified healthcare facilities and providers PTHP facilities and professionals are in compliance with Medicare credentialing standards. Summary of Product Lines Health Maintenance Organization (HMO-POS) HMO members are restricted to the use of in-network providers and facilities. No benefits are paid if the member elects to go out-of-network for services without prior authorization. The only exceptions are emergencies, urgently needed services when the network is not available, out-of-area dialysis services, and cases in which PrimeTime Health Plan authorizes use of out-of-network providers. Some of our plans offer a Point of Service (POS) option for services associated with preventive vision and dental. Member Confidentiality Privacy Policy Notice (as of January 2016) Introduction PrimeTime Health Plan cares about the relationship our members share with their provider and we strive to keep you informed on regulatory HIPAA requirements. Annually PrimeTime Health Plan members receive important Information regarding their privacy and PrimeTime Health Plan's Use and Disclosure of their Protected Health Information (PHI). We have included this information in the provider manual for your reference to PrimeTime Health Plan's current PHI standards. Included in the Member Confidentiality Section are the following documents: Statement of HIPAA Portability Rights Gramm-Leach - Bliley Act Notice (Privacy Practice Notice) Notice of Privacy Practices The Member Confidentiality section of this manual is devoted to privacy rights for our member per HIPAA. For further information regarding your privacy rights as a provider, please see the Credentialing Section. Statement of HIPAA Portability Rights IMPORTANT-KEEP THIS CERTIFICATE. This certificate is evidence of your coverage under this plan. Under a federal law known as HIPAA, you may need evidence of your coverage to reduce a preexisting condition exclusion period under another plan.to help you get special enrollment in another plan, or to get certain types of individual health coverage even if you have health problems. Preexisting condition exclusions. Some group health plans restrict coverage for medical conditions present before an individual's enrollment. These restrictions are known as "preexisting condition exclusions." A preexisting condition exclusion can apply only to conditions for which medical advice, diagnosis, care or treatment was recommended or received within the 6 months before your "enrollment date.' Your enrollment date is your first day of coverage under the plan, or if there is a waiting period, the first day of your waiting period (typically, your first day of work).in addition, a preexisting condition exclusion cannot last for more than 12 months after your enrollment date (18 months if you are a late enrollee).finally, a preexisting condition exclusion cannot apply to pregnancy and cannot apply to a child who Is covered under any creditable coverage within 30 days after birth, adoption, or placement for adoption and does not subsequently have a break In coverage as explained below. 13

15 If a plan imposes a preexisting condition exclusion the length of the exclusion must be reduced by the amount of your prior creditable coverage. Most health coverage is creditable coverage including group health plan coverage COBRA continuation coverage, coverage under an individual health policy, Medicare Medicaid State Children s Health insurance Program (SCHIP), and coverage through high-risk pools and the Peace Corps. Not all forms of creditable coverage are required to provide certificates like this one. you do not receive a certificate for past coverage, talk to your new plan administrator. You can add up any creditable coverage you have, including the coverage shown on this certificate. However, if at any time you went for 63 days or more without any coverage (called a break in coverage) a plan may not have to count the coverage you had before the break. Therefore, once your coverage ends you should try to obtain alternative coverage as soon as possible to avoid a 63-day break. You may use this certificate as evidence or your creditable coverage to reduce the length of any preexisting condition exclusion if you enroll in another plan. Right to get special enrollment in another plan. Under HlPAA, if you rose your group health plan coverage, you may be ab e to get into another group health plan for which you are eligible (such as a spouse's plan), even if the plan generally does not accept late enrollees, if you request enrollment within 30 days. (Additional special enrollment rights may be triggered by marriage, birth, adoption and placement for adoption). Therefore, once your coverage ends, if you are eligible for coverage in another plan (such as a spouse's plan), you should request special enrollment as soon as possible. Prohibition against discrimination based on a health factor. Under HIPAA, a group health plan may not keep you (or your dependents) out of the plan based on certain health factors.also, a group health plan may not charge you (or your dependents } more for coverage, based on those health factors,than the amount charged a similarly situated individual Right to individual health coverage. Under HIPAA, tt you are an "eligible lndividua1 "you have a right to buy certain individual health policies (or in some states, to buy coverage through a high- risk pool) without a preexisting condition exclusion. To be an eligible individual, you must meet the following requirements: You have had coverage for at least 18 months without a break in coverage of 63 days or more Your most recent coverage was under a group health plan (which can be shown by this certificate) Your group coverage was not terminated because of fraud or nonpayment of premiums Member Confidentiality Privacy Policy Notice (as of January 2016) You are not eligible for COBRA continuation coverage or you have exhausted your COBRA benefits tor continuation coverage under a similar state provision) : and You are not eligible for another group health plan, Medicare, or Medicaid, and do not have any other health insurance coverage. The right to buy individual coverage is the same whether you are laid off, fired, or quit your job. Therefore, if you are interested in obtaining Individual coverage and you meet the other criteria to be an eligible individual. You should apply for this coverage as soon as possible to avoid losing your eligible individual status due to a 63-day break. State flexibility. This certificate describes minimum HIPAA protections under federal law. States may require Insurers and HMOs to provide additional protections to individuals in that state. For more information. If you have questions about your HIPAA rights you may contact your state insurance department or the U.S Department of Labor (DOL), Employee Benefits Security Administration (EBSA) toll free at (for free HIPAA publications ask for publications concerning changes in health care laws}. You may also contact the CMS pub1lcation hotline at (ask for "Protecting Your Health Insurance Coverage"). These publications and other useful information are also available on the Internet at the DOL's interactive web pages - Health Elaws. or http /lwww.cms.hhs.gov/hipaa1 PURPOSE OF THIS NOTICE Title V of the Gramm-Leach-BIiiey Act (GLBA) and the laws of the State of Ohio generally require us to provide you with this notice of our privacy policies and practices before we may share any non-public personal information about you with any unaffiliated third-party. This notice describes the type of information we may collect about you and the categories of persons or entities to whom we may disclose that information. In compliance with the GLBA and the laws of the State of Ohio, we are providing you with this notice of the privacy policies and practices of the AultCare Health Insuring Corporation,which also does business under the trade name PrimeTime Health Plan, AultCare Insurance Company which also does business under the trade names AultCare HMO, and Aultra,and which is part of an Organized Health Care Arrangement with AultCare Corporation and Aultra Administrative Group, which are affiliated entities (herein after."the Company") The laws of the State of Ohio also requires that we tell you that we may not share your personal information with a nonaffiliated third-party for any purpose that is not specifically authorized by law without your permission. 14

16 OUR PRIVACY POLICIES AND PRACTICES 1. Information that we may collect A. Categories of Information Collected and Sources from Which We Collect It We may collect non-public personal information about you from the following sources: Information we receive from you on applications or other forms. Examples of the information include name, address. Social Security number, date of birth, gender, marital status, dependent information, employment information, and medical Information; Information about your transactions with us, our affiliates, or others (for example, health care providers, third-party administrators, or other insurers). Examples of this information include information concerning health and life claims, policy coverage, eligibility, payments. medical history, and coordination of benefits: Information we receive from Independent agents or brokers, consultants. employers.or benefit plan sponsors regarding products or services purchased; Information we receive from medical records or medical professionals; Unless specifically stated in an amended Privacy Policy Notice, we do not collect any additional Information about you. B. Persons from Whom Information is Collected. We may collect non-public protected health information from individuals other than those proposed for coverage. 2. Information we may disclose to third-parties: In the course of general business practices of the Company, we may disclose the information we collect, as described above, about you or others without your permission to the following types of institutions for the reasons described. Member Confidentiality Privacy Policy Notice (as of January 2016) To a third-party to enable that party to perform a business. professional, or Insurance function for the Company : To an insurance institution, agent, or credit reporting agency in order to detect or prevent criminal activity,fraud,or misrepresentation In connection with an insurance transaction; To an insurance Institution, agent. or credit reporting agency for either the Company or the entity to whom we cf1sclose the information to perform a function in connection with an insurance transaction involving you; To a medical care institution or medical professional in order to verify coverage or benefits, or In order for us to conduct an audit that verifies treatment To an Insurance regulatory authority, law enforcement or other governmental authority in order to protect our interests in preventing or prosecuting fraud, or as required by law, To the group policyholder for the purpose of reporting claims experience or conducting an audit of our performance : To an actuarial or research organization for purposes of conducting actuarial or research studies 3. Your right to access and amend your personal information: You have the right to request access to protected health information that we have about you. This right includes the right to know the source of the information and the identities of the persons, institutions or types of institutions to whom we have disclosed such information within two (2) years prior to your request. You also have the right to view such Information and copy it in person, or request that we send you a copy of it by mail. You may be charged a reasonable fee to cover our costs if you request a copy by mail. You also have the right to request amendments or deletions of incorrect information in our possession. You must follow the It.st of procedures to request access to or amendment of your information. To obtain access to your information : You must submit a written request to the Privacy Coordinator, AultCare Insurance Company, PO Box 6029,Canton,Oho You must Include your name, address, Social Security number, telephone number, and the recorded information that you would like to access. Your request should state whether you wish to receive this information by mail. We will contact you within 30 days of your request. 15

17 To amend or delete any of your information: You must submit a written request to the Privacy Officer, AultCare Insurance Company, PO Box 6029, Canton, Ohio You must include your name, address, Social Security number, telephone number, the specific information in dispute, and the identity of the document or record that contains the disputed information. We will contact you within 30 days of your request to notify you whether we have made the amendment or deletion, or that we refuse to do so and the reasons for our refusal, which you may challenge. 4. Our practices regarding information confidentiality and security: The Company restricts access to non-public personal information about you to those employees who need that information to provide services or products to you. We maintain adequate physical, electronic, and organizational safeguards to protect information about you. These safeguards that protect against unauthorized access and use apply regardless of whether you are a current or former customer. Finally, the Company reserves the right to change their privacy policies and practices and apply the revised policies and practices to information previously created or obtained. The Company will send a notice informing you of the changes in its policies and practices, as required by law. Member Confidentiality Privacy Policy Notice (as of January 2016) THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. The terms of this Notice of Privacy Practices apply to the Covered Entity known as Au!tCare Health Insuring Corporation, which also does business under the trade name PrimeTime Health Plan, AultCare Insurance Company, which also does business under the trade name AultCare HMO, Aultra, and which is part of an Organized Health Care Arrangement with AultCare Corporation and Aultra AdmInistrative Group, which are affiliated entities. The organization will share protected health information of members as necessary to carry out treatment payment and health care operations as permitted by law. We are required by law to maintain the privacy of our members' protected health information and to provide members with notice of our legal duties and privacy practices with respect to their protected health Information We are required to abide by the terms of this Notice so long as it remains in effect. We reserve the right to change the terms of this Notice of Privacy Practices as necessary and to make the new Notice effective for all protected health information maintained by us. Copies of revised notices will be mailed to all members then covered by the plan and copies may be obtained by mailing a request to: Privacy Coordinator, P.O. Box 6029, Canton Ohio USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION Your Authorization. Except as outlined below, we will not use or disclose your protected health information for any purpose unless you have signed a form authorizing the use or disclosure.you have the right to revoke that authorization in writing unless we have taken any action in reliance on the authorization Disclosures for Treatment. We will make disclosures of your protected health information as necessary for your treatment. For instance, a doctor or health facility involved in your care may request your protected health information that we hold in order to make decisions about your care. Uses and Disclosures for Payment. We will make uses and disclosures of your protected health information as necessary for payment purposes. For instance, we may use Information regarding your medical procedures and treatment to process and pay claims, to determine whether services are medically necessary or to otherwise pre-authorize or certify services as covered under your health benefits plan. We may also forward such information to another health plan which may also have an obligation to process and pay claims on your behalf. Uses and Disclosures for Health Care Operations. We will use and disclose your protected health Information as necessary, and as permitted by law, for our health care operations which include credentialing health care providers, peer review, business management, accreditation and licensing, utilization review and management, quality Improvement and assurance, enrollment, underwriting, reinsurance, compliance, auditing, rating, and other functions related to your health benefits plan. We may also disclose your protected health Information to another health care facility, health care professional, or health plan for such things as quality assurance and case management, but only that facility, professional, or plan also has or had a patient relationship with you. Family and Friends Involved In Your Care. With your approval, we may from time to time disclose your protected health Information to designated family.friends, and others who are involved in your care or in payment for your care in order to facilitate that person's involvement In caring for you or paying for your care. If you are unavailable, incapacitated, or facing an emergency medical situation, and we determine that a limited disclosure may be in your best Interest, we may share limited protected health information with such individuals without your approval. For members of PrimeTime Health Plan only if you have designated a person to receive Information regarding payment of the premium on your Medicare MCO 16

18 policy, we will inform that person when your premium has not been paid. We may also disclose limited protected health Information to a public or private entity that is authorized to assist in disaster relief efforts in order for that entity to locate a family member or other persons that may be involved in some aspect of caring for you. Business Associates. Certain aspects and components of our services are performed through contracts with outside persons or organizations, such as auditing, accreditation, actuarial services, legal services, etc. At times it may be necessary for us to provide certain of your protected health information to one or more of these outside persons or organizations who assist us with our health care operations. All Business Associates are required to safe guard the privacy of information by Federal law. In all cases, we require these business associates to appropriately safeguard the privacy of your information. Communications with you. We may communicate with you regarding your claims, premiums, or other things connected with your health plan. You have the right to request and we will accommodate reasonable requests by you to receive communications regarding your protected health information from us by alternative means or at alternative locations. For instance, if you wish messages to not be left on voice mail or sent to a particular address, we will accommodate reasonable requests. You may request such confidential communication in writing and may send your request to Privacy Coordinator, P.O. Box 6029, Canton, Ohio Other Health-Related Products or Services. We may, from time to time, use your protected health information to determine whether you might be Interested in or benefit from treatment alternatives or other health-related programs, products or services which may be available to you as a member of the health plan. For example, we may use your protected health information to Identify whether you have a particular illness, and contact you to advise you that a disease management program to help you manage your illness better is available to you as a health plan member. We will not use your Information to communicate with you about products or services which are not health-related without your written permission. Research. In limited circumstances, we may use and disclose your protected health information for research purposes. For example, a research organization may wish to compare outcomes of patients by payer source and will need to review a series of records that we hold. In all cases where your specific authorization has not been obtained, your privacy will be protected by strict confidentiality requirements applied by an Institutional Review Board or privacy board which oversees the research or by representations of the researchers that limit their use and disclosure of member Information. Other Uses and Disclosures. We are permitted or required by law to make certain other uses and disclosures of your protected health information without your authorization. We may release your protected health information for any purpose required by law; We may release your protected health information for public health activities such as required reporting of disease, Injury, and birth and death, and for required public health investigations; We may release your protected health information as required by law if we suspect child abuse or neglect; we may also release your protected health information as required by law if we believe you to be a victim of abuse, neglect, or domestic violence; We may release your protected health information to the Food and Drug Administration if necessary to report adverse events, product defects, or to participate in product recalls; We may release your protected health information to your plan sponsor; provided, however. your plan sponsor must certify that the information provided will be maintained in a confidential manner and not used for employment related decisions or for other employee benefit determinations or in any other manner not permitted by law, We may release your protected health information if required by law to a government oversight agency conducting audits, investigations, or civil or criminal proceedings; We may release your protected health information if required to do so by a court or administrative ordered subpoena or discovery request; in most cases you will have notice of such release; We may release your protected health information to law enforcement officials as required by law to report wounds and injuries and crimes; We may release your protected health information to coroners and/or funeral directors consistent with law: We may release your protected health Information if necessary to arrange an organ or tissue donation from you or a transplant for you; We may release your protected health information for certain research purposes when such research is approved by an institutional review board with established rules to ensure privacy; We may release your protected health Information if you are a member of the military as required by armed forces services.we may also release your protected health Information if necessary for national security or intelligence activities, We may release your protected health information to workers' compensation agencies if necessary for your workers' compensation benefit determination. 17