Common use of GUARANTEED RENEWABLE Clause in Contracts

GUARANTEED RENEWABLE. Guaranteed renewable means that this contract will renew each year on the anniversary date unless terminated earlier in accordance with contract terms. You may keep this contract in force by timely payment of the required premiums. We may decide not to renew as of the renewal date if: (1) we decide not to renew all contracts issued on this form, with the same type and level of benefits, to residents of the state where you then live; or (2) there is fraud or an intentional material misrepresentation made by or with the knowledge of a member in filing a claim for contract benefits. Rate changes are effective on a member’s annual renewal date and will be based on each member’s attained age, family structure, geographic region, tobacco usage and benefit plan at the time of renewal. We have the right to change premiums. We will notify the member in writing at least 45 days prior to the renewal date of any change in premium rates. If we discontinue offering and decide not to renew all policies issued on this form, with the same type and level of benefits, for all residents of the state where you reside, we will provide a written notice to you at least 90 days prior to the date that we discontinue coverage. At least 45 days advanced written notice of any plan to take an action or make a change permitted by this clause will be delivered to you at your last address as shown in our records. We will make no change in your premium solely because of claims made under this contract or a change in a member's health. While this contract is in force, we will not restrict coverage already in force.

GUARANTEED RENEWABLE. Guaranteed renewable means that this This contract will renew each year on the anniversary date unless terminated earlier in accordance with contract termsis guaranteed renewable. You may keep this contract in force by timely payment of the required premiums. We may decide not to renew Coverage under this contract is for an initial term of 12 months commencing as of the effective date of the member’s coverage and will automatically renew for successive terms of 12 months unless terminated or non-renewed as provided for in this contract. However, we may refuse renewal as of the anniversary of the contract effective date if: (1) we decide not refuse to renew all contracts issued on this form, with the same type and level of benefits, to residents of the state where you then live; or (2) there is fraud or an intentional material misrepresentation made by or with the knowledge of a member in filing a claim for contract benefits. Rate changes are effective on a member’s annual renewal date and will be based on each member’s attained age, family structure, geographic region, tobacco usage and benefit plan at the time of renewal. We have the right to change premiums. We will notify the member in writing at least 45 days prior to the renewal date of any change in premium rates. If we discontinue offering and decide not refuse to renew all policies issued on this form, with the same type and level of benefits, for all residents of the state where you reside, we will provide a written notice to you at least 90 days prior to the date that we discontinue coverage. At least 45 days advanced written notice of any plan to take an action or make a change permitted by this clause will be delivered to you at your last address as shown in our records. We will make no change in your premium solely because of claims made under this contract or a change in a member's health. While this contract is in force, we will not restrict coverage already in force.

GUARANTEED RENEWABLE. Guaranteed renewable means that this This contract will renew each year on the anniversary date unless terminated earlier in accordance with contract termsis guaranteed renewable. You may keep this contract in force by timely payment of the required premiums. We may decide not to renew Coverage under this contract is for an initial term of 12 months commencing as of the effective date of the member’s coverage and will automatically renew for successive terms of 12 months unless terminated or non-renewed as provided for in this contract. However, we may refuse renewal as of the anniversary of the contract effective date if: (1) we decide not refuse to renew all contracts issued on this form, with the same type and level of benefits, to residents of the state where you then live; or (2) there is fraud or an intentional material misrepresentation made by or with the knowledge of a member in filing a claim for contract benefits. Rate changes are effective on a member’s annual renewal date and will be based on each member’s attained age, family structure, geographic region, tobacco usage and benefit plan at the time of renewal. We have the right to change premiums. We will notify the member in writing at least 45 30 days prior to the renewal date of any change in premium rates. If we discontinue offering and decide not refuse to renew all policies issued on this form, with the same type and level of benefits, for all residents of the state where you reside, we will provide a written notice to you at least 90 days prior to the date that we discontinue coverage. At least 45 30 days advanced written notice of any plan to take an action or make a change permitted by this clause will be delivered to you at your last address as shown in our records. We will make no change in your premium solely because of claims made under this contract or a change in a member's health. While this contract is in force, we will not restrict coverage already in force.. As a cost containment feature, this contract contains prior authorization requirements. This contract may require a referral from a primary care physician for care from a specialist provider. Benefits may be reduced or not covered if the requirements are not met. Please refer to the Schedule of Benefits and the Prior Authorization Section. Sunshine State Health Plan Xxxxx Xxxxxxxx, Plan President and CEO TABLE OF CONTENTS Contract Face Page 1 Introduction 3 Member Rights and Responsibilities 4 Definitions 8 Dependent Member Coverage 22 Ongoing Eligibility 24 Premiums 26 Major Medical Expense Benefits 27 Prior Authorization 43 General Non-Covered Services and Exclusions 44 Plan Administration 47 Reimbursement 51 Coordination of Benefits 52 Claims 55 Grievance and Complaint Procedures 57 General Provisions 64 Attachment: Plan Information Page Schedule of Benefits INTRODUCTION‌ Welcome to Ambetter from Sunshine Health! This contract has been prepared by us to help explain your coverage. Please refer to this contract whenever you require medical services. It describes: How to access medical care. What health services are covered by us. What portion of the health care costs you will be required to pay. This contract, the Schedule of Benefits, the application as submitted to us and any amendments or riders attached shall constitute the entire contract under which covered services and supplies are provided or paid for by us. This contract should be read and re-read in its entirety. Since many of the provisions of this contract are interrelated, you should read the entire contract to get a full understanding of your coverage. Many words used in the contract have special meanings, are italicized and are defined for you. Refer to these definitions in the Definitions section for the best understanding of what is being stated. This contract also contains exclusions, so please be sure to read this contract carefully. How to Contact Us Ambetter from Sunshine Health 0000 Xxxxxxxxxxxxx Xxxxxxx, Xxxxx 000 Sunrise, FL 33323 Normal Business Hours of Operation 8:00 a.m. to 5:00 p.m. EST Member Services 0-000-000-0000 TDD/TTY line 0-000-000-0000 Fax 0-000-000-0000 Emergency 911 24/7 Nurse Advice Line 0-000-000-0000 (24 hour nurse advice line) Interpreter Services Ambetter from Sunshine Health has a free service to help our members who speak languages other than English. This service is very important because you and your physician must be able to talk about your medical or behavioral health concerns in a way you both can understand. Our interpreter services are provided at no cost to you. We have representatives that speak Spanish and medical interpreters to assist with other languages. Members who are blind or visually impaired and need help with interpretation can call Member Services for an oral interpretation. To arrange for interpretation services, call Member Services at 0-000 000-0000 (TDD/TTY 1-800-955- 8770). MEMBER RIGHTS AND RESPONSIBILITIES‌ We are committed to: