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HCR-GF-2010
This Rider changes provisions in, or adds provisions to, your Certificate of Insurance, including any affected riders, endorsements or other
amendments thereto, (hereinafter collectively “Policy) issued by Group Health Incorporated as required by the federal Patient Protection
and Affordable Care Act. Except as otherwise provided in this Rider, the provisions herein apply to all persons covered under the Policy
(“Members”). All of the terms, conditions, and limitations of the Policy to which this Rider is attached also apply to this Rider, except where
they are specifically changed by this Rider. This Rider shall take effect on your Policy renewal date on or after September 23, 2010.
1. Grandfathered Plan. We believe this Policy is a “grandfathered health plan” under the Patient Protection and Affordable Care
Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health
coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that this Policy may
not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the
provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other
consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits.
Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause
a plan to change from grandfathered health plan status can be directed to Customer Service by calling (212) 501-4444 or visiting
our Web site at www.emblemhealth.com. You may also contact the U.S. Department of Health and Human Services at
www.healthreform.gov. Your group must notify us if the group or the plan sponsor changes the premium contribution rate that
applies to your coverage under this Policy at any point during the plan year.
2. Annual Limits. Any annual dollar limit under the Policy that applies to Essential Benefits, whether such annual limit applies only
to a covered Essential Benefit or includes covered Essential Benefits and other covered services, is hereby deleted. “Essential Benefits”
include ambulatory care; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder
services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative care; laboratory services; preventive
and wellness services and chronic disease management; pediatric services including oral and vision care; and any other services set
forth in regulations issued pursuant to the Patient Protection and Affordable Care Act. Not all Essential Benefits may be covered under
your Contract and/or Certificate. Only the Essential Benefits listed as covered services in your Contract or Certificate are covered. Note
that annual dollar limits may remain in effect for specific covered services other than Essential Benefits. Also, if you have prescription
drug coverage and you have a separate annual dollar limit on certain covered items that are not prescription drugs, such as enteral
formulas and modified solid food products, that annual dollar limit will continue to apply.
3. Pre-Existing Conditions. Under this Rider, the provision, if any, in the Policy that allows us to exclude or otherwise limit coverage
for Pre-Existing Conditions until a Member has been continuously covered under the Policy for a stated period is hereby deleted in its
entirety with respect to all Members under the age of 19.
4. Lifetime Dollar Limits Deleted. Any lifetime dollar limit under the Policy that applies to Essential Benefits, whether such
lifetime limit applies only to an Essential Benefit or includes covered Essential Benefits and other covered services, is hereby deleted in
its entirety. “Essential Benefits” include ambulatory care; emergency services; hospitalization; maternity and newborn care; mental
health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative
care; laboratory services; preventive and wellness services and chronic disease management; pediatric services, including oral and
vision care; and any other services set forth in regulations issued pursuant to the Patient Protection and Affordable Care Act. Not all
Essential Benefits may be covered under your Certificate. Only the Essential Benefits listed as covered services in your Certificate are
covered. Note that lifetime dollar limits for specific covered services other than Essential Benefits remain in effect.
5. Dependent Children Covered to Age 26. If the Policy makes coverage of dependents available, this Rider applies to coverage
of children as follows:
A. If you selected other than individual coverage, your children who are under the age of 26 may be covered under the Policy.
Coverage lasts until the end of the month in which the child turns 26 years of age. Your children need not be financially dependent
upon you for support or claimed as dependents on your tax return; residents of your household; enrolled as students; or unmarried.
Children-in-law (spouses of children) and grandchildren are not covered under this Rider. If your children are eligible for
employer-sponsored coverage on their own, then they are not eligible for dependent coverage to age 26. Coverage for these children
ceases on the date otherwise specified under the Policy.