Common use of Xxxxxx Children Clause in Contracts

Xxxxxx Children. Xxxxxx children are children whose natural parental rights have been terminated by the state and who have been placed in an alternative living situation by the state. A child does not become a xxxxxx child when the parents voluntarily relinquish parental power to a third party. In order for a xxxxxx child to have coverage, a Member must provide confirmation of a valid xxxxxx parent relationship to Alliant. Such confirmation must be furnished at the Member’s expense. Xxxxxx children for whom a Member assumes legal responsibility are not covered automatically. If you purchased through the Health Insurance Marketplace, You must notify the Health Insurance Marketplace. If you purchased outside the Health Insurance Marketplace, you must notify Alliant in- writing by submitting an enrollment application If additional Premium is required to continue coverage beyond the 31-day period, the Member will be required to submit any additional Premium within the 31day period or the xxxxxx child will be treated as a Late Enrollee. Changing Your Coverage or Removing a Dependent When any of the following events occur: • Divorce; • Death of an enrolled family member (a different type of coverage may be necessary); • Dependent child reaches age 26 (see “When Your Coverage Terminates”); • Enrolled Dependent child becomes totally or permanently disabled. If you purchased through the Health Insurance Marketplace, You must notify the Health Insurance Marketplace. If you purchased outside the Health Insurance Marketplace: notify Customer Service at 1-800-811- 4793 and ask for the appropriate forms to complete. How Your Benefits Work for You Whether you purchased coverage through the Health Insurance Marketplace or not, there is no difference in the benefits this contract provides. Note: Te r m s s u c h as C o v e r e d S e r v i c e s , M e d i c a l N e c e s s i t y , In -Network Hospitals and Out-of-Pocket Limit are defined in the Definitions section. Introduction All Covered Services must be Medically Necessary, and coverage or certification of services that are not Medically Necessary may be denied. A Member has direct access to primary and specialty care directly from any In-Network Physician. Physicians and Hospitals participating in our Networks are compensated using a variety of payment arrangements, including capitation, fee for service, per diem, discounted fees, and global reimbursement. You also may receive care from a Physician Assistant (PA) or Nurse Practitioner (see “Definitions” section). For a list of In-Network providers and facilities, please visit XxxxxxxXxxxx.xxx or call Customer Service at 1-800-811-4793. Preferred Provider Option Your health insurance plan is a comprehensive benefit plan called a “Preferred Provider Plan.” This means that you have a choice when you go to a Physician, Hospital or other health care provider. The Contract is divided into two sets of benefits: In-Network and Out-of-network. If you choose Out-of-Network benefits, you will pay more. Each time you visit a provider, you will have that choice to make. That’s why it’s called Preferred Provider. By visiting XxxxxxxXxxxx.xxx you can choose a provider or practitioner from our network. You also may contact Alliant Customer Service at 1-800-811-4793 and a representative will help you find an In-Network Provider. After selecting a provider, you may contact the provider’s office directly to schedule an appointment. Out-of-Service-Area Provider Coverage A member who needs a medical provider, physician or facility outside of our service area, can locate an In-Network Provider by contacting Alliant Customer Service at 1-800-811-4793. Copayment or Out-of-Pocket Whether you choose In-Network or Out-of-Network benefits, you will be charged a cost-share. Cost- sharing is a Copayment or an Out-of-Pocket amount for certain services, which may be a flat-dollar amount or a percentage of the total charge. Any cost-share amounts required are shown in the Summary of Benefits and Coverage’s. If applicable, any emergency room Copayment is waived when a Member is admitted to the Hospital through the emergency room. The Calendar Year Deductible Before this plan begins to pay benefits, other than for preventive care, you must meet any Deductible required. Deductible requirements are stated in the Summary of Benefits and Coverage’s. Carry Over Deductible When insured by this health plan, Covered Services during the last three months of a calendar year applied to that year’s Deductible can carry over and also apply toward the next year’s Deductible. If a change is made during the last 3-months of a calendar year, the deductible carry-over is restricted to the time period covered under the “newest” health plan with Alliant Health Plans. Coinsurance and Out-of-Pocket Limit

Xxxxxx Children. Xxxxxx children are children whose natural parental rights have been terminated by the state and who have been placed in an alternative living situation by the state. A child does not become a xxxxxx child when the parents voluntarily relinquish parental power to a third party. In order for a xxxxxx child to have coverage, a Member must provide confirmation of a valid xxxxxx parent relationship to Alliant. Such confirmation must be furnished at the Member’s expense. Xxxxxx children for whom a Member assumes legal responsibility are not covered automatically. If you purchased through the Health Insurance Marketplace, You must notify the Health Insurance Marketplace. If you purchased outside the Health Insurance Marketplace, you must notify Alliant in- writing by submitting an enrollment application If additional Premium is required to continue coverage beyond the 31-day period, the Member will be required to submit any additional Premium within the 31day period or the xxxxxx child will be treated as a Late Enrollee. Changing Your Coverage or Removing a Dependent When any of the following events occur: •  Divorce; •  Death of an enrolled family member (a different type of coverage may be necessary); •  Dependent child reaches age 26 (see “When Your Coverage Terminates”); •  Enrolled Dependent child becomes totally or permanently disabled. If you purchased through the Health Insurance Marketplace, You must notify the Health Insurance Marketplace. If you purchased outside the Health Insurance Marketplace: notify Customer Service at 1-800-811- 4793 and ask for the appropriate forms to complete. If you purchased coverage through the Health Insurance Marketplace, see “Reporting life & income changes to the Marketplace” at the end of this document for additional information. Eligibility How Your Benefits Work for You Whether you purchased coverage through the Health Insurance Marketplace or not, there is no difference in the benefits this contract provides. Note: Te r m s s u c h as C o v e r e d S e r v i c e s , M e d i c a l N e c e s s i t y , In -Network Hospitals and Out-of-Pocket Limit are defined in the Definitions section. Introduction All Covered Services must be Medically Necessary, and coverage or certification of services that are not Medically Necessary may be denied. A Member has direct access to primary and specialty care directly from any In-Network Physician. Physicians and Hospitals participating in our Networks are compensated using a variety of payment arrangements, including capitation, fee for service, per diem, discounted fees, and global reimbursement. You also may receive care from a Physician Assistant (PA) or Nurse Practitioner (see “Definitions” section). For a list of In-Network providers and facilities, please visit XxxxxxxXxxxx.xxx or call Customer Service at 1-800-811-4793. Preferred Provider Option Your health insurance plan is a comprehensive benefit plan called a “Preferred Provider Plan.” This means that you have a choice when you go to a Physician, Hospital or other health care provider. The Contract is divided into two sets of benefits: In-Network and Out-of-network. If you choose Out-of-Network benefits, you will pay more. Each time you visit a provider, you will have that choice to make. That’s why it’s called Preferred Provider. By visiting XxxxxxxXxxxx.xxx you can choose a provider or practitioner from our network. You also may contact Alliant Customer Service at 1-800-811-4793 and a representative will help you find an In-Network Provider. After selecting a provider, you may contact the provider’s office directly to schedule an appointment. Out-of-Service-Area Provider Coverage A member who needs a medical provider, physician or facility outside of our service area, can locate an In-Network Provider by contacting Alliant Customer Service at 1-800-811-4793. Copayment or Out-of-Pocket Whether you choose In-Network or Out-of-Network benefits, you will be charged a cost-share. Cost- sharing is a Copayment or an Out-of-Pocket amount for certain services, which may be a flat-dollar amount or a percentage of the total charge. Any cost-share amounts required are shown in the Summary of Benefits and Coverage’s. If applicable, any emergency room Copayment is waived when a Member is admitted to the Hospital through the emergency room. The Calendar Year Deductible Before this plan begins to pay benefits, other than for preventive care, you must meet any Deductible required. Deductible requirements are stated in the Summary of Benefits and Coverage’s. Carry Over Deductible When insured by this health plan, Covered Services during the last three months of a calendar year applied to that year’s Deductible can carry over and also apply toward the next year’s Deductible. If a change is made during the last 3-months of a calendar year, the deductible carry-over is restricted to the time period covered under the “newest” health plan with Alliant Health Plans. Coinsurance and Out-of-Pocket Limit

Xxxxxx Children. Xxxxxx children are children whose natural parental rights have been terminated by the state and who have been placed in an alternative living situation by the state. A child does not become a xxxxxx child when the parents voluntarily relinquish parental power to a third party. In order for a xxxxxx child to have coverage, a Member must provide confirmation of a valid xxxxxx parent relationship to Alliant. Such confirmation must be furnished at the Member’s expense. Xxxxxx children for whom a Member assumes legal responsibility Children are not covered automaticallyautomatically added to Your policy. For Coverage to begin, an application form to add the child as a Dependent and a payment of any applicable Premium must be received by Us within thirty-one (31) days from the date of legal assumption. The Premium shall include the first thirty-one (31) days of coverage. If you the application and Premium are not received by Us within thirty-one (31) days from the date of legal assumption, Coverage will terminate at the end of the thirty-one (31) day period. If the application and Premium are received by Us after the thirty-one (31) day period, but within sixty (60) days from the date of legal assumption, Coverage will be reinstated retroactively with no break in Coverage. If You purchased through the Health Insurance Marketplace, You must notify the Health Insurance Marketplace. If you purchased outside the Health Insurance Marketplace, you must notify Alliant in- writing by submitting an enrollment application If additional Premium is required to continue coverage beyond the 31-day period, the Member will be required to submit any additional Premium within the 31day period or the xxxxxx child will be treated as CHANGING YOUR COVERAGE (removing a Late Enrollee. Changing Your Coverage or Removing a Dependent dependent) When any of the following events occur: • Divorce; • Death of an enrolled family member (a different type of coverage may be necessary); • Dependent child reaches age 26 (see “When Your Coverage Terminates”); • Enrolled Dependent child becomes totally or permanently disabled. If you You purchased through the Health Insurance Marketplace, You must notify the Health Insurance Marketplace. If you You purchased outside the Health Insurance Marketplace: , notify Customer Service at 1(000) 000-800-811- 4793 0000 and ask for the appropriate forms to complete. How Your Benefits Work for HOW YOUR BENEFITS WORK FOR YOU‌ Whether You Whether you purchased coverage through the Health Insurance Marketplace or not, there is no substantial difference in the benefits this contract Contract provides. Note: Te r m s s u c h as C o v e r e d S e r v i c e s , M e d i c a l N e c e s s i t y , In -Network Hospitals and Out-of-Pocket Limit are defined in with the Definitions section. Introduction All Covered Services must be Medically Necessary, and coverage or certification exception of services that are not Medically Necessary may be denied. A Member has direct access to primary and specialty care directly from any In-Network Physician. Physicians and Hospitals participating in our Networks are compensated using a variety of payment arrangements, including capitation, fee for service, per diem, discounted fees, and global reimbursement. You also may receive care from a Physician Assistant (PA) or Nurse Practitioner (see “Definitions” section). For a list of In-Network providers and facilities, please visit XxxxxxxXxxxx.xxx or call Customer Service at 1-800-811-4793. Preferred Provider Option Your health insurance plan is a comprehensive benefit plan called a “Preferred Provider Plan.” This means that you have a choice when you go to a Physician, Hospital or other health care providerthe Grace Period. The Contract is divided into two sets of benefits: In-Network Grace Period differs based on where You purchased Your policy and Out-of-network. If you choose Out-of-Network benefits, you will pay more. Each time you visit a provider, you will have that choice to make. That’s why it’s called Preferred Provider. By visiting XxxxxxxXxxxx.xxx you can choose a provider or practitioner from our network. whether You also may contact Alliant Customer Service at 1-800-811-4793 and a representative will help you find receive an In-Network Provider. After selecting a provider, you may contact the provider’s office directly to schedule an appointment. Out-of-Service-Area Provider Coverage A member who needs a medical provider, physician or facility outside of our service area, can locate an In-Network Provider by contacting Alliant Customer Service at 1-800-811-4793. Copayment or Out-of-Pocket Whether you choose In-Network or Out-of-Network benefits, you will be charged a cost-share. Cost- sharing is a Copayment or an Out-of-Pocket amount for certain services, which may be a flat-dollar amount or a percentage of the total charge. Any cost-share amounts required are shown in the Summary of Benefits and Coverage’s. If applicable, any emergency room Copayment is waived when a Member is admitted to the Hospital through the emergency room. The Calendar Year Deductible Before this plan begins to pay benefits, other than for preventive care, you must meet any Deductible required. Deductible requirements are stated in the Summary of Benefits and Coverage’s. Carry Over Deductible When insured by this health plan, Covered Services during the last three months of a calendar year applied to that year’s Deductible can carry over and also apply toward the next year’s Deductible. If a change is made during the last 3-months of a calendar year, the deductible carry-over is restricted to the time period covered under the “newest” health plan with Alliant Health Plans. Coinsurance and Out-of-Pocket LimitAdvance Premium Tax Credit (APTC).

Xxxxxx Children. Xxxxxx children are children whose natural parental rights have been terminated by the state and who have been placed in an alternative living situation by the state. A child does not become a xxxxxx child when the parents voluntarily relinquish parental power to a third party. In order for a xxxxxx child to have coverage, a Member must provide confirmation of a valid xxxxxx parent relationship to Alliant. Such confirmation must be furnished at the Member’s expense. Xxxxxx children for whom a Member assumes legal responsibility Children are not covered automaticallyautomatically added to your policy. For Coverage to begin, an application form to add the child as a Dependent and a payment of any applicable Premium must be received by us within thirty-one (31) days from the date of legal assumption. The Premium shall include the first thirty-one (31) days of coverage. If the application and Premium are not received by us within thirty-one (31) days from the date of legal assumption, Coverage will terminate at the end of the thirty-one (31) day period. If the application and Premium are received by us after the thirty-one (31) day period, but within sixty (60) days from the date of legal assumption, Coverage will be reinstated retroactively with no break in Coverage. If you purchased through the Health Insurance Marketplace, You you must notify the Health Insurance Marketplace. If you purchased outside the Health Insurance Marketplace, you must notify Alliant in- writing by submitting an enrollment application If additional Premium is required to continue coverage beyond the 31-day period, the Member will be required to submit any additional Premium within the 31day period or the xxxxxx child will be treated as CHANGING YOUR COVERAGE (removing a Late Enrollee. Changing Your Coverage or Removing a Dependent dependent) When any of the following events occur: • Divorce; • Death of an enrolled family member (a different type of coverage may be necessary); • Dependent child reaches age 26 (see “When Your Coverage Terminates”); • Enrolled Dependent child becomes totally or permanently disabled. If you purchased through the Health Insurance Marketplace, You you must notify the Health Insurance Marketplace. If you purchased outside the Health Insurance Marketplace: , notify Customer Service at 1(000) 000-800-811- 4793 0000 and ask for the appropriate forms to complete. How Your Benefits Work for You HOW YOUR BENEFITS WORK FOR YOU Whether you purchased coverage through the Health Insurance Marketplace or not, there is no substantial difference in the benefits this contract Contract provides. Note: Te r m s s u c h as C o v e r e d S e r v i c e s , M e d i c a l N e c e s s i t y , In -Network Hospitals and Out-of-Pocket Limit are defined in with the Definitions section. Introduction All Covered Services must be Medically Necessary, and coverage or certification exception of services that are not Medically Necessary may be denied. A Member has direct access to primary and specialty care directly from any In-Network Physician. Physicians and Hospitals participating in our Networks are compensated using a variety of payment arrangements, including capitation, fee for service, per diem, discounted fees, and global reimbursement. You also may receive care from a Physician Assistant (PA) or Nurse Practitioner (see “Definitions” section). For a list of In-Network providers and facilities, please visit XxxxxxxXxxxx.xxx or call Customer Service at 1-800-811-4793. Preferred Provider Option Your health insurance plan is a comprehensive benefit plan called a “Preferred Provider Plan.” This means that you have a choice when you go to a Physician, Hospital or other health care providerthe Grace Period. The Contract is divided into two sets of benefits: In-Network Grace Period differs based on where you purchased your policy and Out-of-network. If whether you choose Out-of-Network benefits, you will pay more. Each time you visit a provider, you will have that choice to make. That’s why it’s called Preferred Provider. By visiting XxxxxxxXxxxx.xxx you can choose a provider or practitioner from our network. You also may contact Alliant Customer Service at 1-800-811-4793 and a representative will help you find receive an In-Network Provider. After selecting a provider, you may contact the provider’s office directly to schedule an appointment. Out-of-Service-Area Provider Coverage A member who needs a medical provider, physician or facility outside of our service area, can locate an In-Network Provider by contacting Alliant Customer Service at 1-800-811-4793. Copayment or Out-of-Pocket Whether you choose In-Network or Out-of-Network benefits, you will be charged a cost-share. Cost- sharing is a Copayment or an Out-of-Pocket amount for certain services, which may be a flat-dollar amount or a percentage of the total charge. Any cost-share amounts required are shown in the Summary of Benefits and Coverage’s. If applicable, any emergency room Copayment is waived when a Member is admitted to the Hospital through the emergency room. The Calendar Year Deductible Before this plan begins to pay benefits, other than for preventive care, you must meet any Deductible required. Deductible requirements are stated in the Summary of Benefits and Coverage’s. Carry Over Deductible When insured by this health plan, Covered Services during the last three months of a calendar year applied to that year’s Deductible can carry over and also apply toward the next year’s Deductible. If a change is made during the last 3-months of a calendar year, the deductible carry-over is restricted to the time period covered under the “newest” health plan with Alliant Health Plans. Coinsurance and Out-of-Pocket LimitAdvance Premium Tax Credit (APTC).

Xxxxxx Children. Xxxxxx children are children whose natural parental rights have been terminated by the state and who have been placed in an alternative living situation by the state. A child does not become a xxxxxx child when the parents voluntarily relinquish parental power to a third party. In order for a xxxxxx child to have coverage, a Member must provide confirmation of a valid xxxxxx parent relationship to Alliant. Such confirmation must be furnished at the Member’s expense. Xxxxxx children for whom a Member assumes legal responsibility are not covered automatically. If you purchased through the Health Insurance Marketplace, You must notify the Health Insurance Marketplace. If you purchased outside the Health Insurance Marketplace, you must notify Alliant in- writing by submitting an enrollment application If additional Premium is required to continue coverage beyond the 31-day period, the Member will be required to submit any additional Premium within the 31day period or the xxxxxx child will be treated as a Late Enrollee. Changing Your Coverage or Removing a Dependent When any of the following events occur: •  Divorce; •  Death of an enrolled family member (a different type of coverage may be necessary); •  Dependent child reaches age 26 (see “When Your Coverage Terminates”); •  Enrolled Dependent child becomes totally or permanently disabled. If you purchased through the Health Insurance Marketplace, You must notify the Health Insurance Marketplace. If you purchased outside the Health Insurance Marketplace: notify Customer Service at 1-800-811- 4793 and ask for the appropriate forms to complete. How Your Benefits Work for You Whether you purchased coverage through the Health Insurance Marketplace or not, there is no difference in the benefits this contract provides. Note: Te r m s s u c h as C o v e r e d S e r v i c e s , M e d i c a l N e c e s s i t y , In -Network Hospitals and Out-of-Pocket Limit are defined in the Definitions section. Introduction All Covered Services must be Medically Necessary, and coverage or certification of services that are not Medically Necessary may be denied. A Member has direct access to primary and specialty care directly from any In-Network Physician. Physicians and Hospitals participating in our Networks are compensated using a variety of payment arrangements, including capitation, fee for service, per diem, discounted fees, and global reimbursement. You also may receive care from a Physician Assistant (PA) or Nurse Practitioner (see “Definitions” section). For a list of In-Network providers and facilities, please visit XxxxxxxXxxxx.xxx or call Customer Service at 1-800-811-4793. Preferred Provider Option Your health insurance plan is a comprehensive benefit plan called a “Preferred Provider Plan.” This means that you have a choice when you go to a Physician, Hospital or other health care provider. The Contract is divided into two sets of benefits: In-Network and Out-of-network. If you choose Out-of-Network benefits, you will pay more. Each time you visit a provider, you will have that choice to make. That’s why it’s called Preferred Provider. By visiting XxxxxxxXxxxx.xxx you can choose a provider or practitioner from our network. You also may contact Alliant Customer Service at 1-800-811-4793 and a representative will help you find an In-Network Provider. After selecting a provider, you may contact the provider’s office directly to schedule an appointment. Out-of-Service-Area Provider Coverage A member who needs a medical provider, physician or facility outside of our service area, can locate an In-Network Provider by contacting Alliant Customer Service at 1-800-811-4793. Copayment or Out-of-Pocket Whether you choose In-Network or Out-of-Network benefits, you will be charged a cost-share. Cost- sharing is a Copayment or an Out-of-Pocket amount for certain services, which may be a flat-dollar amount or a percentage of the total charge. Any cost-share amounts required are shown in the Summary of Benefits and Coverage’s. If applicable, any emergency room Copayment is waived when a Member is admitted to the Hospital through the emergency room. The Calendar Year Deductible Before this plan begins to pay benefits, other than for preventive care, you must meet any Deductible required. Deductible requirements are stated in the Summary of Benefits and Coverage’s. Carry Over Deductible When insured by this health plan, Covered Services during the last three months of a calendar year applied to that year’s Deductible can carry over and also apply toward the next year’s Deductible. If a change is made during the last 3-months of a calendar year, the deductible carry-over is restricted to the time period covered under the “newest” health plan with Alliant Health Plans. Coinsurance and Out-of-Pocket Limit

Xxxxxx Children. Xxxxxx children are children whose natural parental rights have been terminated by the state and who have been placed in an alternative living situation by the state. A child does not become a xxxxxx child when the parents voluntarily relinquish parental power to a third party. In order for a xxxxxx child to have coverage, a Member must provide confirmation of a valid xxxxxx parent relationship to Alliant. Such confirmation must be furnished at the Member’s expense. Xxxxxx children for whom a Member assumes legal responsibility Children are not covered automaticallyautomatically added to Your policy. For Coverage to begin, an application form to add the child as a Dependent and a payment of any applicable Premium must be received by Us within thirty-one (31) days from the date of legal assumption. The Premium shall include the first thirty-one (31) days of coverage. If you the application and Premium are not received by Us within thirty-one (31) days from the date of legal assumption, Coverage will terminate at the end of the thirty-one (31) day period. If the application and Premium are received by Us after the thirty-one (31) day period, but within sixty (60) days from the date of legal assumption, Coverage will be reinstated retroactively with no break in Coverage. If You purchased through the Health Insurance Marketplace, You must notify the Health Insurance Marketplace. If you purchased outside the Health Insurance Marketplace, you must notify Alliant in- writing by submitting an enrollment application If additional Premium is required to continue coverage beyond the 31-day period, the Member will be required to submit any additional Premium within the 31day period or the xxxxxx child will be treated as CHANGING YOUR COVERAGE (removing a Late Enrollee. Changing Your Coverage or Removing a Dependent dependent) When any of the following events occur: • Divorce; • Death of an enrolled family member (a different type of coverage may be necessary); • Dependent child reaches age 26 (see “When Your Coverage Terminates”); • Enrolled Dependent child becomes totally or permanently disabled. If you You purchased through the Health Insurance Marketplace, You must notify the Health Insurance Marketplace. If you You purchased outside the Health Insurance Marketplace: , notify Customer Service at 1(000) 000-800-811- 4793 0000 and ask for the appropriate forms to complete. How CHANGING YOUR COVERAGE (removing a dependent) When any of the following events occur: • Divorce; • Death of an enrolled family member (a different type of coverage may be necessary); • Dependent child reaches age 26 (see “When Your Benefits Work Coverage Terminates”); • Enrolled Dependent child becomes totally or permanently disabled. If You purchased through the Health Insurance Marketplace, You must notify the Health Insurance Marketplace. If You purchased outside the Health Insurance Marketplace, notify Customer Service at (000) 000-0000 and ask for the appropriate forms to complete. HOW YOUR BENEFITS WORK FOR YOU‌ Whether You Whether you purchased coverage through the Health Insurance Marketplace or not, there is no substantial difference in the benefits this contract Contract provides. Note: Te r m s s u c h as C o v e r e d S e r v i c e s , M e d i c a l N e c e s s i t y , In -Network Hospitals and Out-of-Pocket Limit are defined in with the Definitions section. Introduction All Covered Services must be Medically Necessary, and coverage or certification exception of services that are not Medically Necessary may be denied. A Member has direct access to primary and specialty care directly from any In-Network Physician. Physicians and Hospitals participating in our Networks are compensated using a variety of payment arrangements, including capitation, fee for service, per diem, discounted fees, and global reimbursement. You also may receive care from a Physician Assistant (PA) or Nurse Practitioner (see “Definitions” section). For a list of In-Network providers and facilities, please visit XxxxxxxXxxxx.xxx or call Customer Service at 1-800-811-4793. Preferred Provider Option Your health insurance plan is a comprehensive benefit plan called a “Preferred Provider Plan.” This means that you have a choice when you go to a Physician, Hospital or other health care providerthe Grace Period. The Contract is divided into two sets of benefits: In-Network Grace Period differs based on where You purchased Your policy and Out-of-network. If you choose Out-of-Network benefits, you will pay more. Each time you visit a provider, you will have that choice to make. That’s why it’s called Preferred Provider. By visiting XxxxxxxXxxxx.xxx you can choose a provider or practitioner from our network. whether You also may contact Alliant Customer Service at 1-800-811-4793 and a representative will help you find receive an In-Network Provider. After selecting a provider, you may contact the provider’s office directly to schedule an appointment. Out-of-Service-Area Provider Coverage A member who needs a medical provider, physician or facility outside of our service area, can locate an In-Network Provider by contacting Alliant Customer Service at 1-800-811-4793. Copayment or Out-of-Pocket Whether you choose In-Network or Out-of-Network benefits, you will be charged a cost-share. Cost- sharing is a Copayment or an Out-of-Pocket amount for certain services, which may be a flat-dollar amount or a percentage of the total charge. Any cost-share amounts required are shown in the Summary of Benefits and Coverage’s. If applicable, any emergency room Copayment is waived when a Member is admitted to the Hospital through the emergency room. The Calendar Year Deductible Before this plan begins to pay benefits, other than for preventive care, you must meet any Deductible required. Deductible requirements are stated in the Summary of Benefits and Coverage’s. Carry Over Deductible When insured by this health plan, Covered Services during the last three months of a calendar year applied to that year’s Deductible can carry over and also apply toward the next year’s Deductible. If a change is made during the last 3-months of a calendar year, the deductible carry-over is restricted to the time period covered under the “newest” health plan with Alliant Health Plans. Coinsurance and Out-of-Pocket LimitAdvance Premium Tax Credit (APTC).

Xxxxxx Children. Xxxxxx children are children whose natural parental rights have been terminated by the state and who have been placed in an alternative living situation by the state. A child does not become a xxxxxx child when the parents voluntarily relinquish parental power to a third party. In order for a xxxxxx child to have coverage, a Member must provide confirmation of a valid xxxxxx parent relationship to Alliant. Such confirmation must be furnished at the Member’s expense. Xxxxxx children for whom a Member assumes legal responsibility Children are not covered automaticallyautomatically added to your policy. For Coverage to begin, an application form to add the child as a Dependent and a payment of any applicable Premium must be received by us within thirty-one (31) days from the date of legal assumption. The Premium shall include the first thirty-one (31) days of coverage. If the application and Premium are not received by us within thirty-one (31) days from the date of legal assumption, Coverage will terminate at the end of the thirty-one (31) day period. If the application and Premium are received by us after the thirty-one (31) day period, but within sixty (60) days from the date of legal assumption, Coverage will be reinstated retroactively with no break in Coverage. If you purchased through the Health Insurance Marketplace, You you must notify the Health Insurance Marketplace. If you purchased outside In the Health Insurance Marketplace, you must notify Alliant in- writing by submitting an enrollment application If additional Premium event there is required to continue coverage beyond the 31-day period, the Member will be required to submit any additional Premium within the 31day period or the xxxxxx child will be treated more than one insurance policy in force; there is no Coordination of Benefits for individual/family plans (such as this one). CHANGING YOUR COVERAGE (removing a Late Enrollee. Changing Your Coverage or Removing a Dependent dependent) When any of the following events occur: • Divorce; • Death of an enrolled family member (a different type of coverage may be necessary); • Dependent child reaches age 26 (see “When Your Coverage Terminates”); • Enrolled Dependent child becomes totally or permanently disabled. If you purchased through the Health Insurance Marketplace, You you must notify the Health Insurance Marketplace. If you purchased outside the Health Insurance Marketplace: , notify Customer Service customer service at 1(000) 000-800-811- 4793 0000 and ask for the appropriate forms to complete. How Your Benefits Work for You HOW YOUR BENEFITS WORK FOR YOU‌ Whether you purchased coverage through the Health Insurance Marketplace or not, there is no substantial difference in the benefits this contract Contract provides. Note: Te r m s s u c h as C o v e r e d S e r v i c e s , M e d i c a l N e c e s s i t y , In -Network Hospitals and Out-of-Pocket Limit are defined in with the Definitions section. Introduction All Covered Services must be Medically Necessary, and coverage or certification exception of services that are not Medically Necessary may be denied. A Member has direct access to primary and specialty care directly from any In-Network Physician. Physicians and Hospitals participating in our Networks are compensated using a variety of payment arrangements, including capitation, fee for service, per diem, discounted fees, and global reimbursement. You also may receive care from a Physician Assistant (PA) or Nurse Practitioner (see “Definitions” section). For a list of In-Network providers and facilities, please visit XxxxxxxXxxxx.xxx or call Customer Service at 1-800-811-4793. Preferred Provider Option Your health insurance plan is a comprehensive benefit plan called a “Preferred Provider Plan.” This means that you have a choice when you go to a Physician, Hospital or other health care providerthe Grace Period. The Contract is divided into two sets of benefits: In-Network Grace Period differs based on where you purchased your policy and Out-of-network. If whether you choose Out-of-Network benefits, you will pay more. Each time you visit a provider, you will have that choice to make. That’s why it’s called Preferred Provider. By visiting XxxxxxxXxxxx.xxx you can choose a provider or practitioner from our network. You also may contact Alliant Customer Service at 1-800-811-4793 and a representative will help you find receive an In-Network Provider. After selecting a provider, you may contact the provider’s office directly to schedule an appointment. Out-of-Service-Area Provider Coverage A member who needs a medical provider, physician or facility outside of our service area, can locate an In-Network Provider by contacting Alliant Customer Service at 1-800-811-4793. Copayment or Out-of-Pocket Whether you choose In-Network or Out-of-Network benefits, you will be charged a cost-share. Cost- sharing is a Copayment or an Out-of-Pocket amount for certain services, which may be a flat-dollar amount or a percentage of the total charge. Any cost-share amounts required are shown in the Summary of Benefits and Coverage’s. If applicable, any emergency room Copayment is waived when a Member is admitted to the Hospital through the emergency room. The Calendar Year Deductible Before this plan begins to pay benefits, other than for preventive care, you must meet any Deductible required. Deductible requirements are stated in the Summary of Benefits and Coverage’s. Carry Over Deductible When insured by this health plan, Covered Services during the last three months of a calendar year applied to that year’s Deductible can carry over and also apply toward the next year’s Deductible. If a change is made during the last 3-months of a calendar year, the deductible carry-over is restricted to the time period covered under the “newest” health plan with Alliant Health Plans. Coinsurance and Out-of-Pocket LimitAdvance Premium Tax Credit (APTC).

Xxxxxx Children. Xxxxxx children are children whose natural parental rights have been terminated by the state and who have been placed in an alternative living situation by the state. A child does not become a xxxxxx child when the parents voluntarily relinquish parental power to a third party. In order for a xxxxxx child to have coverage, a Member must provide confirmation of a valid xxxxxx parent relationship to Alliant. Such confirmation must be furnished at the Member’s expense. Xxxxxx children for whom a Member assumes legal responsibility Children are not covered automaticallyautomatically added to your policy. For Coverage to begin, an application form to add the child as a Dependent and a payment of any applicable Premium must be received by us within thirty-one (31) days from the date of legal assumption. The Premium shall include the first thirty-one (31) days of coverage. If the application and Premium are not received by us within thirty-one (31) days from the date of legal assumption, Coverage will terminate at the end of the thirty-one (31) day period. If the application and Premium are received by us after the thirty-one (31) day period, but within sixty (60) days from the date of legal assumption, Coverage will be reinstated retroactively with no break in Coverage. If you purchased through the Health Insurance Marketplace, You you must notify the Health Insurance Marketplace. If you purchased outside In the Health Insurance Marketplace, you must notify Alliant in- writing by submitting an enrollment application If additional Premium event there is required to continue coverage beyond the 31-day period, the Member will be required to submit any additional Premium within the 31day period or the xxxxxx child will be treated more than one insurance policy in force; there is no Coordination of Benefits for individual/family plans (such as this one). CHANGING YOUR COVERAGE (removing a Late Enrollee. Changing Your Coverage or Removing a Dependent dependent) When any of the following events occur: • Divorce; • Death of an enrolled family member (a different type of coverage may be necessary); • Dependent child reaches age 26 (see “When Your Coverage Terminates”); • Enrolled Dependent child becomes totally or permanently disabled. If you purchased through the Health Insurance Marketplace, You you must notify the Health Insurance Marketplace. If you purchased outside the Health Insurance Marketplace: , notify Customer Service at 1(000) 000-800-811- 4793 0000 and ask for the appropriate forms to complete. How Your Benefits Work for You HOW YOUR BENEFITS WORK FOR YOU‌ Whether you purchased coverage through the Health Insurance Marketplace or not, there is no substantial difference in the benefits this contract Contract provides. Note: Te r m s s u c h as C o v e r e d S e r v i c e s , M e d i c a l N e c e s s i t y , In -Network Hospitals and Out-of-Pocket Limit are defined in with the Definitions section. Introduction All Covered Services must be Medically Necessary, and coverage or certification exception of services that are not Medically Necessary may be denied. A Member has direct access to primary and specialty care directly from any In-Network Physician. Physicians and Hospitals participating in our Networks are compensated using a variety of payment arrangements, including capitation, fee for service, per diem, discounted fees, and global reimbursement. You also may receive care from a Physician Assistant (PA) or Nurse Practitioner (see “Definitions” section). For a list of In-Network providers and facilities, please visit XxxxxxxXxxxx.xxx or call Customer Service at 1-800-811-4793. Preferred Provider Option Your health insurance plan is a comprehensive benefit plan called a “Preferred Provider Plan.” This means that you have a choice when you go to a Physician, Hospital or other health care providerthe grace period. The Contract is divided into two sets of benefits: In-Network grace period differs based on where you purchased your policy and Out-of-network. If whether you choose Out-of-Network benefits, you will pay more. Each time you visit a provider, you will have that choice to make. That’s why it’s called Preferred Provider. By visiting XxxxxxxXxxxx.xxx you can choose a provider or practitioner from our network. You also may contact Alliant Customer Service at 1-800-811-4793 and a representative will help you find receive an In-Network Provider. After selecting a provider, you may contact the provider’s office directly to schedule an appointment. Out-of-Service-Area Provider Coverage A member who needs a medical provider, physician or facility outside of our service area, can locate an In-Network Provider by contacting Alliant Customer Service at 1-800-811-4793. Copayment or Out-of-Pocket Whether you choose In-Network or Out-of-Network benefits, you will be charged a cost-share. Cost- sharing is a Copayment or an Out-of-Pocket amount for certain services, which may be a flat-dollar amount or a percentage of the total charge. Any cost-share amounts required are shown in the Summary of Benefits and Coverage’s. If applicable, any emergency room Copayment is waived when a Member is admitted to the Hospital through the emergency room. The Calendar Year Deductible Before this plan begins to pay benefits, other than for preventive care, you must meet any Deductible required. Deductible requirements are stated in the Summary of Benefits and Coverage’s. Carry Over Deductible When insured by this health plan, Covered Services during the last three months of a calendar year applied to that year’s Deductible can carry over and also apply toward the next year’s Deductible. If a change is made during the last 3-months of a calendar year, the deductible carry-over is restricted to the time period covered under the “newest” health plan with Alliant Health Plans. Coinsurance and Out-of-Pocket LimitAdvance Premium Tax Credit (APTC).