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SECTION 4 - SCHEDULE OF BENEFITS

What this section includes:

· How Do You Access benefits?
· Prior Authorization requirements;
· Benefits;
· Annual deductible;
· Deductible carryover from prior carrier
· Out-of-pocket limit;
· Covered Health Care Services and;
· Provider network.

How Do You Access Benefits?

You can choose to receive Network Benefits or Out-of-Network Benefits.
Network Benefits apply to Covered Health Care Services that are provided by a Network Physician or other
Network provider. For facility services, these are Benefits for Covered Health Care Services that are provided at a
Network facility under the direction of either a Network or Out-of-Network Physician or other provider. Network
Benefits include Physician services provided in a Network facility by a Network or an Out-of-Network
anesthesiologist, assistant surgeon, hospitalist, pathologist and radiologist, subject to our reimbursement policy.
Emergency services received at an Out-of-Network Hospital are covered at the Network level, subject to our
reimbursement policy.
Emergency Health Care Services are always paid as Network Benefits. Emergency Health Care Services and
Emergency ambulance transportation provided by an out-of-Network provider will be reimbursed as set forth
under Allowed Amounts as described in the Summary Plan Description. As a result, you will responsible for
the difference between the amount billed by the out-of-Network provider and the amount we determine to
be the Allowed Amount for reimbursement. The payments you make to out-of-Network providers for
charges above the Allowed Amount do not apply towards any applicable Out-of-Pocket limit.

Covered Health Care Services that are provided at a Network facility by an out-of-Network facility based
Physician, when not Emergency Health Care Services, will be reimbursed as set forth under Allowed Amounts as
described in the Summary Plan Description. As a result, you will be responsible for the difference between
the amount billed by the out-of-Network facility based Physician and the amount we determine to be the
Allowed Amount for reimbursement. The payments you make to out-of-Network facility based Physicians
for charges above the Allowed Amount do not apply towards any applicable Out-of-Pocket Limit.

Out-of-Network Benefits apply to Covered Health Care Services that are provided by an out-of-Network
Physician or other out-of-Network provider, or Covered Health Care Services that are provided at an out-of-
Network facility.
Depending on the geographic area and the service you receive, you may have access through our Shared
Savings Program to Out-of-Network providers who have agreed to discount their billed charges for Covered
Health Care Services. Refer to the definition of Shared Savings Program in Section 15: Glossary for details about
how the Shared Savings Program applies.

You must show your identification card (ID card) every time you request health care services from a Network
provider. If you do not show your ID card, Network providers have no way of knowing that you are enrolled under
this plan. As a result, they may bill you for the entire cost of the services you receive.

If there is a conflict between this Schedule of Benefits and any summaries provided to you by the QUEEN CITY
SKILLED CARE LLC, this Schedule of Benefits will control.

Additional information about the Network of providers and how your Benefits may be affected appears at the end
of this Schedule of Benefits.
Prior Authorization Requirements
We require prior authorization for certain covered expenses. In general, when services or supplies are received
from a network provider, the network provider is responsible for obtaining the prior authorization. You may want
to contact us to verify that the Hospital, Physician and other providers have obtained the required prior
authorization.

Page 8 Section 4 - Schedule of Benefits
HSA - 2017