Certificate of Coverage

1 2021 Certificate of C 1 BHNC0001-0520 Section 1 - Title Page (Cover Page) Individual Policy This document includes important information that describes Your Policy. Your Policy is a legal contract between the Subscriber and Bright Health Company of North Carolina, hereinafter referred to as Bright Health . It explains the Benefits for health care services. Benefits are for Covered Persons and are subject to plan terms, conditions, exclusions and limitations. This Policy is issued when We receive the application and in consideration of any and all required payment(s). This is a Network-Only Plan. This plan uses a network of Participating Providers to provide benefits to You. That means this Plan does not provide benefits for services You receive from Non-Network Providers except as described in Section 5 - How to Access Your Services and Obtain Approval of Benefits.

2 Entire Contract In addition to this Evidence of Coverage , this Policy includes Your: Schedule of Benefits Enrollment Application The documents above make up the entire legal contract between Bright Health and You, the Subscriber. Read Your Policy carefully. As of the effective date of the Contract, this Policy supersedes all other agreements between the Subscriber and Bright Health. Changes to the Policy must be given to You in writing. Changes to the Policy must be signed by the executive officer of Bright Health and approval must be endorsed on or attached to this Policy. No agent has authority to change this policy or to waive any of its provisions. How to Use this Document Read Your Policy and Amendments. We especially encourage You to review these sections: Schedule of Benefits What is Covered Limitations/Exclusions Make sure You understand how Your Policy works. Many sections refer to other sections.

3 You may not find all the information You need in one section. Keep the Policy in a safe place so you can find and read it as needed. Ten Day Right to Return Policy Read your policy carefully. If for any reason you are not satisfied with your policy, you may return it to Us within 10 days of the date you received it and the premium you paid will be promptly refunded. Your Policy will be considered null and void from the effective date. Important Cancellation Information Please read Section 11 -Termination/Nonrenewal/ Continuation found on page 90 of the policy. Information about Defined Terms The Definitions section of this Policy will help you understand the content. When you see a word or term that begins with a capital letter, you will find it in the Definitions section. Please read the Definition to find out what a word or term means. When You see the words "We," "Us," and "Our", We are referring to Bright Health.

4 When You see the words "You" and "Your," We are referring to Covered Persons. If the Covered Person is under age 18, You and Your refers to the Responsible Adult. 2 BHNC0001-0520 BRIGHT HEALTH Simeon Schindelman, Chief Executive Officer 3 BHNC0001-0520 Section 2 - Contact Us Please contact Us for more information. Questions About Your Benefits Customer Service: On Our Website at: (855) 827-4448 To Send Us Claims or Other Written Correspondence, Mail to: Claim Submissions and Correspondence Address: Bright Health Plan Box 16275 Reading, PA 19612 NONDISCRIMINATION NOTICE AND ASSISTANCE WITH COMMUNICATION Bright Health does not exclude, deny benefits to, or otherwise discriminate against any individual on the basis of sex, age, race, color, national origin, or disability.

5 Bright Health means Bright Health plans and their affiliates, which are listed below. Language assistance and alternate formats: Assistance is available at no cost to help You communicate with Us. The services include, but is not limited to: Interpreters for languages other than English; Written information in alternative formats such as large print; and Assistance with reading Bright Health websites. To ask for help with these services, please call Customer Service at the number listed above or on Your ID Card. If You think that We failed to provide language assistance or alternate formats, or You were discriminated against because of Your sex, age, race, color, national origin, or disability, You can send a complaint to: Bright Health Civil Rights Coordinator Bright Health Box 16275 Reading, PA 19612-6275 Phone: (844) 202-2154 Email: You can also file a complaint with the Dept. of Health and Human Services, the Office of Civil Rights: Online: Complaint forms are available at Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD) Mail: Dept.

6 Of Health and Human Services. 200 Independence Avenue, SW Room 509F, HHH Building Washington, 20201 If You need help with Your complaint, please call the Customer Services number on your member ID card. You must send the complaint within 60 days of discovering the issue. Language Assistance and Alternate Formats If You or someone you re helping has questions about Bright Health, You have the right to get help and information in Your language, at no cost. To ask for another format, please call Customer Service at the number listed above or on Your ID Card. 4 BHNC0001-0520 5 BHNC0001-0520 6 BHNC0001-0520 7 BHNC0001-0520 Section 3 - Table of Contents Section 1 - Title Page (Cover Page) .. 1 Entire Contract .. 1 How to Use this Document .. 1 Ten Day Right to Return Policy .. 1 Information about Defined Terms .. 1 Section 2 - Contact Us .. 3 Section 3 - Table of Contents.

7 7 Section 4 - Eligibility .. 11 Who is Eligible for Coverage .. 11 Eligible Subscribers .. 11 Eligible Dependents .. 11 When Coverage Begins .. 11 Open Enrollment Period .. 11 Special Enrollment Period .. 11 Enrolling Eligible Dependents .. 12 Change in Status Notice Required .. 14 Section 5 - How to Access Your Services and Obtain Approval of Benefits .. 15 Covered Health Services .. 15 THIS IS A NETWORK-ONLY PLAN .. 15 Choose Your Physician .. 15 Choose Your Physician from Our Network of Participating Providers .. 16 Transition of Care .. 16 Continuity of Care .. 17 Access Plan .. 18 Designated Facilities and Other Providers .. 18 Receiving Non-Emergent Care From Non-Network Providers .. 18 Receiving Emergency Care From Network Providers or Network Facilities .. 19 Receiving Emergency Care From Non-Network Providers or Non-Network Facilities .. 19 Pre-Authorized Care From Non-Network Providers .. 19 Payment for Charges to Non-Network Providers .. 19 Our Reimbursement Policies.

8 19 Limitations on Selection of Providers .. 20 Service Area .. 20 Medical Necessity .. 20 Pre-authorization .. 21 Coverage Determinations .. 22 Care Management .. 22 Decide What Services You Should Receive .. 22 Show Your ID Card .. 22 Member Cost Sharing Requirements .. 22 Section 6 - Benefits/ Coverage (What is Covered) .. 24 Benefit Determinations .. 24 Explanation of Covered Health 24 Listing of Covered Health Services .. 24 Accident Related Dental Services .. 24 Ambulance Services .. 25 Autism Spectrum Disorders (ASD) .. 25 Bariatric Surgery .. 25 Bone Mass Measurement for Diagnosis and Evaluation of Osteoporosis or Low Bone Mass26 Chemotherapy Services - Outpatient .. 26 Circumcision of Newborn Males .. 26 Cleft Lip and Cleft Palate Treatment .. 26 Clinical Trials .. 26 Congenital Defect and Birth Abnormalities .. 28 Dental Anesthesia .. 28 Diabetes Services .. 28 8 BHNC0001-0520 Dialysis Services - Outpatient.

9 29 Durable Medical Equipment .. 29 Emergency Medical Conditions .. 30 Family Planning Services .. 31 Genetic Testing .. 31 Hearing Services & Hearing Aids .. 31 High Tech Diagnostic Imaging, Nuclear Medicine, and Major Diagnostic Services Outpatient .. 32 Home Health Care .. 32 Hospice Care .. 32 Hospital and Free-Standing Facility Services .. 32 Immunizations .. 33 Infertility Services .. 33 Infusion Therapy Services - Outpatient .. 33 Inpatient Rehabilitative and Habilitative Service .. 34 Lab, X-Ray, and Diagnostic Services - Outpatient .. 34 Medical Supplies and Disposable Items .. 35 Mental Health and Substance Abuse Services Inpatient, Intermediate and Residential Treatment .. 35 Mental Health and Substance Abuse Services Outpatient .. 35 Nutritional Evaluation, Counseling, and Self-Management Training .. 36 Ostomy Supplies .. 36 Oxygen and the Oxygen Delivery System .. 36 Pediatric Dental Care .. 36 Pediatric Vision 38 Pharmaceutical Products Outpatient.

10 39 Physician Fees for Surgical and Medical Services .. 39 Physician's Services for Sickness and Injury .. 39 Positional Plagiocephaly .. 40 Pregnancy Maternity Services .. 40 Prescription Drugs .. 40 Preventive and Wellness Services .. 46 Private Duty Nursing .. 50 Prosthetic Devices .. 50 Radiation Services - Outpatient .. 50 Reconstructive Procedures .. 51 Rehabilitative and Habilitative Services Outpatient Therapy .. 51 Scopic Procedures Outpatient Diagnostic and Therapeutic .. 52 Second Opinions .. 52 Sexual Dysfunction .. 52 Skilled Nursing Facility .. 52 Sleep Studies .. 53 Surgery Outpatient .. 53 Temporomandibular Joint Disorder (TMJ) .. 53 Transplantation 53 Travel Expenses .. 54 Urgent Care Center Services .. 54 Section 7 - Limitations/Exclusions (What is Not Covered) .. 56 How We Use Headings in this 56 Benefit Limitations .. 56 Benefit Exclusions .. 56 Alternative Health Care Treatments .. 56 Chiropractic Care .. 56 Custodial or Domiciliary Care.