INSURANCE

COMPANY

A Guide To Our Services

AultCare Insurance Company and AultCare Corporation

AultCare Health Plans Helpful Tips Things to have on hand when you call us:

• Your AultCare ID Card, which has your group information and member ID on it

• Your explanation of benefits (EOB) form, if

you are calling about a claim (You can access your EOBs by going to www.aultcare.com and logging into your account.) AultCare Service Center Contact Information

• 330-363-6360 (local) • 1-800-344-8858 (toll-free) • TTY Line for the Hearing Impaired: 330-363-2393 (local) or 1-866-633-4752 (toll-free) Special Communication Needs AultCare offers numerous services to meet the cultural and linguistic needs of our members. These services include access to translators of various foreign languages and a TTY line for the hearing impaired. 24-Hour Nurse Hotline Contact Information • 330-363-7620 (local) • 1-866-422-9603 (toll-free) AultCare Mailing Address: AultCare P.O. Box 6910 Canton, OH 44706 www.aultcare.com

1 About AultCare About AultCare AultCare 11 3 About Your Physician is Your Partner Disease in H ealth & Wellness and Case Management 33 Frequently Asked Questions Programs 5 Care Coordination 5 Disease CaseManagement) Management (Diseaseand & Case 7 AultCare Pharmacy Program Programs 6 24-Hour Nurse is Hotline Your Physician Your Partner 99 AultCare Pharmacy Program in Health and Wellness 7 Care Coordination 11 Your Physician is Your Partner (Utilization Management) 11 Utilization Management in Health and Wellness (UM) and Access to UM Services 9 Pharmacy Program 13 Utilization Management (UM) 15 and FilingAccess a Claim to UM Services 11 What’s Not Covered 17 Filing Enrollee Rights and 17 a Claim 13 Filing a Claim Responsibilities 19 What’s Not Covered 15 Grievance & Appeals 19 Glossary 21 Enrollee Rights and 17 Responsibilities Enrollee Rights & Responsibilities

19 Privacy Practices 23 Glossary 21 Frequently Asked Questions 23 Glossary



About AultCare Since 1985, we have been committed to offering high quality, affordable health insurance to people and businesses in our community. As the only locally owned and operated health insurance Company in Stark County, we are committed to leading our members and community to improved health. Our large network of providers, hospitals, programs and services are here to make sure our members get the care they need and empower them to live healthier lives.

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Where You Matter

Advocate

We believe your health care plan should be focused on your needs, in ways that matter to you. From the network you choose to how you receive communication from us, our plans and services are designed with you in mind so that you can take an active role in your health. When you are covered by AultCare, you are part of our local family!

We help our members live healthier lives by giving them the tools and support that will help them take control of their health. If you are diagnosed with a health condition, our experienced Care Coordination and Case and Disease Management teams can identify your health care needs and help you with programs and services you need.

Accessible

24-Hour Free Nurse Line

When you call us, we pick up the phone. You won’t get stuck in an automated answering system. When you have questions, we are here to help you. We make it easy for you to get information day or night. Meet with us in-person, call us to speak with a knowledgeable customer service representative, or visit our website at www.aultcare.com or our mobile app anytime you need answers.

We offer our members a way to get credible health information and support 24 hours a day, 7 days a week. AultCare members can talk with an experienced registered nurse and get answers to their health related questions, concerns by calling 330-363-7620 or toll free 1-866-422-9603. Calls are confidential and are free for our members.

Answers Answers Answers Understanding your health plan can be

AultCare offers you: • •Accurate AultCare offers you:

-Healthis fairs - Health fairs Accuracy at the heart of what we do. -Wellness programs - Wellness programs Our processes are tested and streamlined, -Counseling acase casemanager manager Counseling from so you can trustfrom thatawhat you receive from us -Diseasemanagement management - Disease is dependable and accurate. We value your trust and are committed to giving you Accolades Accolades consistent, excellent service. Don’t just take our word it. Over 90 percent Don’t just take our word forfor it. 97 percent of our

of ourrenew clientswith renew every year, proving clients us with everyusyear, proving that we do what we say we’ll do. wethat do what we say we’ll do. Recognition The National Committee for Quality Assurance AultCare has also earned the following AultCare has also earned the following (NCQA)recognitions: has awarded our Commercial PPO, industry recognitions: industry Commercial HMO, Medicare HMO, and • •Marketplace Health Utilization Management Health Utilization Management AccreditaPPO products with AccreditaNCQA Health tion from URAC, a Washington, D.C. based tion from URAC, a Washington, D.C. based Plan Accreditation. health plan accrediting organization that health plan accrediting organization that establishes quality standards forfor thethe establishes quality standards healthcare industry (2006) healthcare industry (2006)

• •Provider Credentialing Accreditation from Full Provider Credentialing Accreditation URAC (2005) from URAC (2005, 2008) & UM

Prefer to use the internet? The AultCare Understanding your health plan can be challenging. AultCare isis here here to toyour help.health website, www.aultcare.com, is challenging. AultCare help. and wellness hub and where you can We will will answer answer the the phone phone personally personally when when We manage your account. members call call for for help help with with claims claims or or coverage coverage members questions. So when you have questions about questions. when you have questions about Online, youSocan: your health health plan, plan, we’ll we’ll handle handle it. it. •your Create an online account to manage your Ask personal claim information, your Ask our current current members aboutview our service. service. our members about our They EOBs, download and more They continue to tell tellforms, us that that sets us apart apart continue to us itit sets us from other health plans. plans. •from Look for providers other health

•Prefer Findto current health related information use the Internet? internet? The AultCare web•site, Tellwww.aultcare.com, us what matters to you by taking website, www.aultcare.com, is aalso a source is also source of of information. satisfactionThere, surveys you can:

Look for providers Lookfor forproviders providers Review ofofcovered prescription drugs Reviewlists lists covered prescriptions drugs Research health conditions Research conditions Research health health Download formsconditions Download forms Download forms Access other health-related information Access health-related Accessother other health-related information Online access to personal information claim information

and EOBs

YourAdvocate Advocate Your

•

Best Customer Care for Ohio - “2006/07 Customer Care Award” from National Research Corporation (NRC)

Full PPO Accreditation • •Best Customer Care for Ohio- “2006/07 from NCQA, an independent, Customer Care Award” from National nonprofit organization Research Corporation (NRC) that assesses and reports on the quality of the nation’s managed care plans.

PPO Product

Receivingaaserious seriousdiagnosis diagnosiscan canbe be Receiving overwhelming. overwhelming. Each AultCare member who isEach diagnosed with a serious condition may be AultCare member who is diagnosed with partnered with a Case Manager case manager who provides: a serious condition may be partnered with a case managersupport who provides: Emotional Emotional support and emotional support Medical explanations Medical explanations Medical Ideas for explanations researching your condition Help researching your condition Ideas for to researching your condition Referrals Referrals to support supportagencies agencies Referrals to support agencies Financial recommendations and Community resources and references Financial recommendations and references references Participate in one or all of our many wellness Participate one or all of programs our many and wellness and disease in management learn and disease management programs and how to better manage your condition, get learn how better manage healthy andtolive to the fullest. your condition, get healthy and live to the fullest.

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Your Physician Physician is is Your Your Partner Partner Healthand & Wellness ininHealth Wellness YouYou should visit your forregular regularcheckups checkups should visit yourprimary-care primary care physician physician for toto maintain andwellness. wellness. maintainyour yourbest bestlevel level of of health and Choosing a Doctor Doctor

When you join AultCare, AultCare,you youcan cansee seeany anydoctor in the network. With AultCare PPO health doctor in the network. If you need specialty plansyour you do not have get a referral care, primary caretophysician (PCP)from can your primary care doctor for specialty care. identify network doctors who treat your If you need specialty your doctor condition. You can care, also go toprimary our website to can identify network doctors who treat your search for a doctor in our network. condition. You can also go to our website to searchyour for asearch doctorbyingoing our network. Begin to www.aultcare.com where you can identify and select network Begin your search by going to www.aultcare.com physicians theselect characteristics where you according can identifytoand network that are important to you,to including: physicians according the characteristics that important to you, including: •are Office location • Officespoken location • Language • Languages spoken • Gender • Age • Specialty • Gender • Hospital affiliations • Specialty • Acceptance ofaffiliations new patients • Hospital • Board certifications • Acceptance of new patients • Board certifications Customer service representatives are also available help you. They can help Customertoservice representatives areyou alsofind aavailable doctor who can meet your special or to help you. They can help you find a cultural needs. doctor who can meet your special or cultural needs. For additional information about a doctor, For additional information about doctor, the the Ohio License Center may be aable to help OhioatLicense Center may be ableThe to help you you https://license.ohio.gov. center at https://license.ohio.gov. Thephysicians center provides provides information about licensed information about physicians licensed in Ohio, in Ohio, such as their education and training, such as their education and training, specialty specialty and disciplinary history. and disciplinary history.

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Your physician may have more than one office. Alternate offices and locations of your physician may be considered outside the network. Please refer to your provider directory, the online Provider Directory at www.aultcare.com or contact the AultCare Service Center, 330-363-6360 or 1-800-344-8858. If you are ill and your physician cannot see you at the network office, please contact the Utilization Management Department at the above phone numbers for assistance. If your physician or believes specialist feels that it is necessary for you to be admitted to a hospital, he/she will make the necessary arrangements with AultCare for you. Sometimes it may be necessary for your provider to refer you out of your network for specialized health care. If that is the case, your provider will be required to submit a referral to AultCare as outlined above. before you receive treatment. Refer to your plan documents for your physical and wellness benefits and for specific information about access to providers. If you need mental health and/or substance abuse services and do not have a mental health provider, please contact your primary physician. If your need is an emergency, go to the nearest emergency facility for evaluation. There are behavioral health providers available to you within your network.

Some examples of emergency situations are: High fever Convulsions Difficulty breathing Uncontrolled vomiting and/or diarrhea Broken bones Possible miscarriage or pregnancy with vaginal bleeding Poisoning Severe bleeding Severe burns Severe pain in the stomach or chest Shock Unconsciousness

In Case of Emergency If you feel you that have you have a medical problem a medical problem away and that must be treated right away, and it isis is that must be treated right away, and itit after your physician’s normal office hours, after your physician’s normal office hours, call his/her his/her office office and and the the physician physician on on call call call will assist you. will assist you. If you have an emergency, call 911 or go Iftoyou an emergency, call 911 or go thehave nearest emergency care facility. You to care facility. You dothe notnearest have toemergency contact AultCare to obtain emergency do not haveservices. to contact AultCare to obtain emergency services. If you are out of town and need emergency care, please go to the nearest emergency If you are out of town and need emergency care facility. If you become ill, are out of care, to the nearestoremergency town,please and it go is not an urgent emergency care facility. ill and are out of situation tryIftoyou callbecome your physician, first. If that town and it is not an urgent or emergency is not possible, seek treatment at the nearest medical care or physician’s office.If situation, first,facility try to call your physician. Notify the AultCare Service Center next that is not possible, seek treatmentthe at the businessmedical day if you admitted to an nearest careare facility or physician’s out-of-town hospital. Schedule an office. Notify the AultCare Service Center appointment with your physician for all the next business if you are admitted follow-up care andday services. to an out-of-town hospital. Schedule an appointment with your physician for all follow-up care and services.

Remember, if you need emergency services: 1

Go to the nearest emergency care facility. Be sure to present your AultCare ID card.

2

If you are admitted to the hospital, please make sure AultCare is notified on the next business day.

3

Remember to contact your PCP as soon as possible after your visit.

4

Schedule an appointment with your PCP for all follow-up care and services.

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Care Coordination Disease and Case

(Disease & Case Management) Management Programs AultCare offers a Care Coordination program to advocate for you. Helping you make the right choices Whether you have a simple health-related question or you are living with a complex medical condition, we can help you get the care, services and information you need. Disease Management ManagementProgram Program Receiving a diagnosis of diabetes, high blood blood Disease Management Program Receiving a diagnosis of diabetes, high

pressure,or depression, or any other other chronic condition pressure any other or chronic condition pressure, depression, any chronic Receiving a diagnosis of diabetes, high condition changes your life. AultCare is blood here to changes your life. AultCare is here provide pressure, depression, chronic hearttoand failure, or any provide helpful health information reliable helpful health information and your reliable other chronic condition changes your life. resources to help you manage condition. AultCare istohere provide helpful resources helptoyou manage yourhealth condition. Our Disease and Management Programtoishelp free you information reliable resources and members are automatically enrolled. manage your condition. Program is free Our The Disease programManagement provides: and members are automatically enrolled. The programs are free andprofessionals members arewho •OurPhone calls with health program provides: specialize inenrolled. managing for health conditions . automatically Thecare programs a nurse who specializes Phone calls with health professionals whoin provide: •• specialize Informative mailings and handouts about managing for health conditions incare managing care for health conditions Phone calls with your condition . health professionals who specialize in managing care for health conditions.

•

• Informative mailings and handouts about your condition.

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• Informative Equipment mailings such as the andCardiocom handouts about

Telescale® to help you manage your your condition condition from the convenience of • your Equipment such the CardioCom homestaff toas Dedicated guide you in the right Telescale® for heart failure or the GlucoCom® and help you work your • direction Dedicated staff to guide youwith in right Diabetic monitoring systems sothe you can doctors toand improve yourwork direction help you with yourcare take a more active role inhealth your health doctors improve your from thetoconvenience ofhealth your home. Reliable referrals to service agencies in the •• community Reliable referrals service agencies in Dedicated staff totoguide you in the right the community direction and help you work with your ourtoService Service Center to speak speak to to aa disease Contact doctors improve your to health. Contact our Center nurse,member 330-363-6360 management team management team to member 330-363-6360 or •disease Reliable referrals serviceat agencies in 1-800-344-8858. or 1-800-344-8858. 330-363-6360 or 1-800-344-8858. the community.

• •

Casereversal Management Case Program • Sterilization LiveManagement a healthy lifestyle. •Complex and someProgram infertility

you’re faced with serious When you’reand faced withaaservices. seriousconcern, health conprocesses related we are here for you. Our Case Management cern, trust AultCare. Our Case Management • Check your schedule of benefits. offers Manager who will Program offersadrugs aCase caseand manager who willhelp •Program Implantable certain injectable help you get theinformation care,know information and get the care, community •youinfertility Let your employer ifand there are drugs. community services you need. services you need. changes with you and your dependents. • Physical, mental or substance abuse The Case Management is free • examinations Get all required pre-approvals (predone forProgram or ordered by to AultCare members. Services include: certifications) and second opinions. third parties.

An Oncology program members Equipment such as the for Cardiocom Ask your employer or callorAultCare ••• Telescale® Immunizations for travel work. if you battling cancer that provides help to help you manage your

have questions about your coverage or with physician community referrals, condition from and the convenience of your responsibilities. medications • home Over-the-counter medical information and more. and supplies. You have a Right to: Oncology Program for members • An Our catastrophic care program for •• battling Marital counseling. Receive information about your cancer thatwith provides help with members dealing a major surgery coverage and services (see your physician and community referrals, such as an organ transplant. This • medical Services for the treatment ofassistance sexual plan documents). information and more program includes, telephone program includes telephone assistance dysfunction or inadequacies including from aacase casemanager manager andresourses resources from and forthat catastrophic care program for therapy, supplies or counseling. • Our A list of doctors, hospitals, and other promote self-care and holistic care. self-care. members dealing with a major surgery AultCare network providers. Visit our such as an organ transplant. This program Contact the AultCare Service Center to Contact our Service Center to speak Most plans exclude all forms of gastric website www.aultcare.com or call speak includes telephone assistance from to a or Disease Management teama a Case case manager to self referpurpose and restrictive procedures for the our Service Center. case manager and resources that toweight determine if you areifCheck eligible member toloss/control. determine you areyour eligible for of promote self-care and for this program at specific plan or contact the AultCare these programs at 330-363-6360 • Be treated with dignity and respect. holistic care 330-363-6360 or Center to determine if Customer Service or 1-800-344-8858. these procedures are with covered •1-800-344-8858. A frank discussion yourunder doctor Utilization Management Evaluation of Contact our your specific plan. about yourService medical condition, including New and Center to Existing speakand Technology appropriate medically necessary AultCare investigates all requests for coverto treatment a must case manager You consult yourregardless specific plan options, of cost age of new technology using a medical to or self referContact and to AultCare’s document. Service benefit coverage and to participate in technology assessment company as a determine if you are Center if you have additional questions. making decisions about your health guideline. additional information is eligible forIfthis care. Your doctors are independent. needed, AultCare utilizes sources including, program at not restricted They are or prohibited but not limitedorto Medicare and Medicaid 330-363-6360 from discussing treatment options with policies and Food and Drug Administration 1-800-344-8858. you, including those that are not releases of any current medical peer review covered. literature. This information is reviewed and evaluated by AultCare’s medical director and other physician advisors in order to determine if a new technology is appropriate for coverage under your AultCare plan. Members may request that a certain new technology be investigated for coverage by contacting the UM department.

• •

AultLine

Special Communication Needs

• Privacy of your healthHotline care and 24-Hour Nurse AultCare offers numerous services to claims information. Your personal meet the needs of all ofwill ourbemembers health information used to AultCare offers a health and andpay continue to fulfill our mission to claims, as permitted by HIPAA information to assist members AultCare nowline offers a health and “Lead Community to Improved andOur as described your Notice of with health related questions daywith information line to in assist members Health. ” These services include aaccess TTY to Privacy Practices. Personal Health or night. health related questions day Line 330-363-2393 toll-free ator night. translators of various foreign languages Information willor not be disclosed to & a others TTY Line for the hearing imparied. 1-866-633-4752 foryour the hearing without authorization. By callingand 330-363-7620, or toll free impaired access to translators of TTY Line: 330-363-2393 orbe directed 1-866-422-9603, you will • Ask questions, raise concerns, maketo various foreign languages. Toll-Free at 1-800-633-4752. whoisis an complaints, experienced registered that and appeal nurse denials, available 24 hours a day to answer your as explained in your plan documents. health-related questions and provide confidential be able to: confidential information.They willabout • To make information. recommendations AultCare’s Member Rights and Provide first-aid instructions and general Responsibilities Policy. health information Determine what level of care is most appropriate for your condition Answer your medication questions Offer suggestions for self care

New Technology Assessment AultCare investigates all requests for The 24-hour isofa information trusted AultLine is a nurse trustedhotline source coverage new using source of of information support for a and support for atechnology wideand range of health awide medical technology assessment range of health and topics, concerns and topics, concerns from family health company ashealth a guideline. If additional from family and medication and medication questions to illness and information isillness needed, utilizes questions injury first aid. injury first to aid. Calls and areAultCare confidential and resources such as Medicare, Medicaid and sources including Medicare and Calls arecharge. confidential and free of charge. free of the Food and Drug Administration for Medicaid policy. The Food and Drug guidance. This information reviewed Administration releases anyisiscurrent The 24-hour nurse hotline for health-and evaluated by AultCare’s medical director medical peer-reviewed literature. Thisto related questions only. Calls relating and other physician advisors in order information reviewedmust and evaluated benefits andiscoverage be madeto to determine if aService new technology is other by medical director and theAultCare’s AultCare Center. appropriate for coverage your physician advisors in orderunder to determine AultCare plan. if a new technology is appropriate for coverage under your AultCare plan.

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Utilization Management (UM) and Access to UM Services Care Coordination Utilization Management is theisevaluation and determination of the appropriate Utilization Management the evaluation and determination of the use of medical-care resources and the providing of any needed assistance to the appropriate use of medical-care resources and the providing of any needed member, physician or other provider. Thephysician UM process ensures appropriate use of assistance to the member, or other provider. The Utilization Management program ensures that you receive theauthorization assistance, resources through the health care system. This may include prior The UM process ensures appropriate use of resources through the healthof resources and services covered under your plan. This may include, prior authorization, a care product or service, concurrent you are an in or anyservice, health system. This may includereview prior while authorization ofinpatient a product inpatient reviewfor and discharge planning. Reviews and determinations care facility which benefits are covered, and discharge planning. concurrent review while you are an inpatient in any health care facility for are based on your plan and coverage. which benefits are covered, and discharge planning.

(Utilization Management)

AultCare is committed to providing Decisions arehealth madecare based whetherand or exceptional andonservices, not a service is medically necessary and our Utilization Management Program covered your and plan.ensure Refer to your will help under determine that theplan documents information about are what appropriate for health care resources services are covered under your plan. available to our members and providers. a service is medically necessary and

Pre-Certification Pre-Certification, also known as preauthorization or pre-approval, is the process of notifying your health plan prior Pre-Certification to an elective hospital stay or elective surgery procedure. This process helps to determine that all medical care possibilities have been explored and are within acceptable time limits. The pre-certification process has two parts: 1) Notification – AultCare receives a request for services from your provider. 2) Determination of coverage/ verification of eligibility – we review your plan document and clinical information as it relates to the request for services. Getting pre-certification for a procedure does not mean that the service will be covered and paid at the highest level of benefit, or at all. 13

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All claims are subject to review upon receipt Getting for a procedureand doesare of the pre-certification actual claim or documentation not mean that the service will be covered and subject to updates in eligibility upon receipt paid at the highest level of benefit, or at all. All of the actual claim. claims are subject to review upon receipt of theYou actual claim or to documentation and are should refer your plan documents, subject to updates in eligibility upon receiptorof access our website at www.aultcare.com thecontact actual the claim. AultCare Service Center to determine if your particular plan has additional You should refer torequirements your plan documents, pre-certification or to get a list access our website at www.aultcare.com of items requiring pre-certification. or contact the AultCare Service Center to determine if Utilization Management Evaluation of your particular New and Existing Technology plan has AultCare investigates all requests for coverage additional preof new technology using a medical technolcertification ogy assessment company as a guideline. If requirements or additional information is needed, AultCare to get a list of utilizes sources including, but not limited to items requiring Medicare and Medicaid policies and Food and pre-certification. Drug Administration releases of any current medical peer review literature. This information is reviewed and evaluated by AultCare’s medical director and other physician advisors in order to determine if a new technology is appropriate for coverage under your AultCare plan. Members may request that a certain new technology be investigated for coverage by contacting the UM department.

Denials are documented in the form of a letter to you and the requesting provider. The letter includes:

How to Submit a Request for Pre-Certification Requests should be submitted by phone, fax How To Submit a Request For Preor in writing to:

• •

The specific reason for denial .

•

Decision of additional information needed to analyze the request request. perfect the

•

Notification that you can obtain a copy of the actual benefit provision, guideline, protocol or criteria on which the denial was based (this is upon request and at no extra cost).

Certification

Requests should submitted by phone, fax, AultCare Carebe Coordination or P.O. in writing to: Box 6910 AultCare Management Canton, Utilization Ohio 44706 P.O. Box 330-363-6360 6910 Phone: or 1-800-344-8858 Canton, Ohio 44706 Fax: 330-454-9635 Phone: 330-363-6360 or 1-800-344-8858 Reponses are made according to the Fax: 330-454-9635 following time lines: Care: does not require UM• Emergency responses are made according to the preauthorization following time lines:

• Urgent care: not later than 72 hours of receipt of the request .

• Non-urgent, pre-service: within 15

calendar days of receipt of the request .

• Post-service: within 30 calendar days of receipt of the request.

• Requests to extend treatment of urgent care: within 24 hours of the request.

• Reduction or terminations of previously approved course treatment: Adequate notice is given to allow an appeal to be completed.

*Emergencycare caredoes doesnot notrequire requirepre-certification. pre-certification. Emergency

• •

Reference to the benefit provision, guideline, protocol or other similar criteria on which the denial decision is based.

Description of your appeal rights and appeal process, including your right to have an authorized representative act on your behalf. A description of the expedited appeal process if the denial is urgent pre-service or urgent concurrent review.

If the denial is based on medical necessity, a reviewer is available to discuss the decision with the physician or provider. * AultCare provides you with access to staff to discuss the UM process and any issue relating to the UM process. Professional staff members are available from 8 a.m. to 5 p.m. Monday-Friday by contacting the AultCare Service Center at 330-363-6360 or toll free at 1-800-344-8858. The TTY number for the hearing impaired is 330-363-2393 or toll-free at 1-866-633-4752. If you call after business hours, please leave a message and we will respond to your call the next business day.

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AultCare Pharmacy Pharmacy Program Program Your employer may have chosen another pharmacy vendor. Ifthen AultCare is not your pharmacy If AultCare is not your pharmacy benefit administrator, this information If AultCare is not your pharmacy benefit administrator, then this information benefit administrator, then this information does not apply to you. Check your plan does not apply to you. Check your plan documents to see if AultCare is documents does not apply to you. Check your plan documents to see if AultCare is to see ifadministering AultCare is administering yourbenefits. pharmacy benefits. your pharmacy administering your pharmacy benefits. AultCare’s pharmacy program provides you with a variety of safe, effective and affordable prescription choices to meet your medication needs. Designed by a panel of physicians and pharmacists, AultCare runs on an open formulary design. AultCare’s Pharmacy Program“closed provides you These requirements that the drug the ability to select theensure medication that is right Unlike the more traditional with a variety of safe, effective and affordable prescribed is clinically appropriate for the for you while also keeping budget issues inplan formulary” plans, AultCare’s program allows prescription choices to meet your medication member and also helps us manage drug plan mind. Copies of the formulary can be accessed you to choose, for a higher co-payment, needs. Find out what medications are covered costs. A team of physicians and on the AultCare website www.aultcare.com or by medications are often excluded from under your planthat by accessing your plan’s formulary pharmacists developed these the AultCare Service Center. plans. This gives youcontacting and your doctor at other www.aultcare.com or by the AultCare calling requirements for our Service Center. The formulary is a list of medications plan to help us provide your plan covers based on evaluations of efficacy, quality coverage to our Generic medications,members. with the lowest co-payments, are affordsafety, and cost-effectiveness. For a current First Tier able alternatives that have met multiple listing of medicationsquality and safety Generic Drugs standards FDA.require prior If your pharmacy benefits are covered under aset by the that authorization, please co-pay structure, you will save money by asking your doctor if your prescription can be filled with check the website at Second Tier Drugs such as heart medications, anticonvulsants and diabetic a generic equivalent or by choosing drugs in the www.aultcare.com or Preferred Brand-Name medications necessary forservice members with serious lowest-cost tiers of your plan design. Talk to yourthat arecall customer Drugs (Life-Sustaining) conditions. doctor about which prescriptions will work best at 330-363-6360 or for you. Generic medications, with the lowest 1-800-344-8858. co-payments, are affordable alternatives that have Tierand safety standards These medications are considered to increase the quality of life met multipleThird quality set by Preferred Brand-Name but not sustain life – such as allergy and pain medications. the FDA. Drugs (Quality of Life) For certain prescription drugs, AultCare has additional requirements for coverage. Fourth Tier These drugs have the highest level of co-payment. Non-Preferred BrandName Drugs

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Mail Order Some AultCare plansmailBioScrip is AultCare’s include the option to order pharmacy. Your have your prescriptions mail-order option offers filleda by mail-order. you low-cost alternative to the retail pharmacy for If you havemedications. a mail-order long-term option, Walgreens is Mail-order service offers AultCare’s mail-order you the convenience of pharmacy. Your mailhome delivery and the order option offers you ability to refill orders online, by phone, fax an alternative to the retail pharmacy for or mail. medications. Mail-order service long-term offers you the convenience of home delivery To filled by mailandhave the your abilityprescription to refill orders online, by phone, order, simply ask your physician for a new fax or mail. prescription written for a 60-day supply. Mail it toyour BioScrip, or have filled your physician To have prescription by mail- fax simply directly. ask yourYou physician formoney a new itorder, to BioScrip will save prescription. your plan by paying theCheck appropriate fee documents for your 60to see how Please many days’ plan day supply. refer supply to youryour individual will cover.ofMail it to Walgreens, or have schedule benefits to determine youryour physician fax it to Walgreens directly. Please actual co-payment. Also, some plans may refer to your individual schedule of benefits allow up to a 90-day supply by mail-order. to determine your actual co-payment. Most plans allow up to a 60- or 90-day supply by mail-order. Prior Authorization To obtain information regarding the mail-order Certain medications require prior services, please call AultCare at 330-363-6360 authorization, meaning that your physician or visit the Pharmacy area on our website at must consult with AultCare before www.aultcare.com. prescribing a medication for you for the first If prior authorization is required, Priortime. Authorization your physician must submit letter of Certain medications require aprior medical necessity to theyour AultCare Utilization authorization, meaning physician must Management Department. The letter of a consult with AultCare before prescribing medical necessity be faxed to AultCare medication for youmay for the first time. Utilization Management at 330-454-9635 For a current listing of medications requiring prior or mailed to P.O. 6910, Canton, authorization, log inBox to the member areaOhio of our website, review your plan benefit documents, or call 44706. customer service at 330-363-6360 or 1-800-344-8858.

Medication Safety The medications you take are an important part of your health. AultCare has compiled some guidelines you can use to help your doctor and pharmacist provide you with quality health care. They are as follows: Keep an updated list of all the medications you take (including prescription, over-thecounter, herbal remedies and supplements). Make sure all of your doctors know all of the medications you are taking. Read prescription labels carefully and always follow the directions exactly. If you have questions about a prescription, such as side effects or interactions with other medications or food, ask your doctor or pharmacist. If a medication you’ve taken before looks different, notify your pharmacist immediately. When you get a new prescription ask your doctor if it replaces any of your current medications. Keep medications in their original container, unless you use a pill organizer. Throw away all expired medications. Discard all expired medications properly. Whenever possible, use only one pharmacy. This will ensure that you do not take conflicting medications. If you use both retail and mail order pharmacies, make sure that each pharmacy is aware of all your medications and allergies. 10 10

Enrollee Rights and What’s Not Covered Responsibilities

should to their documents to determine These Members medical plans dorefer not cover allplan health care expenses and include which health care services are covered and to what extent. exclusions and limitations. Members should refer to their plan documents to determine which health care services are covered and to what extent. Quality care benefits responsibilities you share with your The health following is aand partial list ofare services that are usually NOT covered. doctors and your plan. We want you to know your rights and responsibilities. However documents may contain exceptions to this based After you enroll inplan a plan, you will receive identification cards andlist your plan Please read your planmandates documents forplan a full description. If you have a on state or the design purchased. documents which explain exact coverage terms and conditions. question, concern, or a recommendation for how AultCare could improve The following is a partial list of services that are usually NOT covered. its policies for promoting enrollee responsibilities and rights, contact us However, your plan documents may contain exceptions to this list based through our website at www.aultcare.com or call our Service Center at on state mandates or the plan design purchased. 330-363-6360 or toll free at 1-800-344-8858. • All medical and hospital services • Radial keratotomy, lasik or related not specifically covered in, procedures. You or which are limited or excluded have a Responsibility to: (including medications) doctor is Allyour medical hospital services Radial keratotomy, lasik orthe related procedures. •• Cosmetic surgery, except as specifically • in planand documents, includingnot recommending. specifically covered in,card or which Take your AultCare ID when you stated in the benefit descriptions. • costs of services before coverage are limited or excluded in your plan • Hearing aids and hearing tests, except as go to the hospital, drug store, or begins anddoctor, after coverage ends. • Respite, Follow your doctor’s medical documents, including costs of services • custodial and residential careand specifically stated in the benefitadvice descriptions. health care provider. It contains instructions. Take medications as before coverage beginsHaving and after except as specifically stated in thedirected. • Care, services or supplies which are not important information. your card Let thedescriptions. doctor know if youashave a bad coverage ends. • benefit Cosmetic surgery, except specifically deemed may helpmedically save timenecessary. and prevent reaction. Let your doctor know if stated in the benefit descriptions.your mistakes. symptoms do not get better, or if they get • Treatment, services or procedures Care, services or supplies which arethat notare worse. Schedule • experimental, or investigative. deemed medically necessary. • Respite, custodialrecommended and residentialfollow-up care Tell the doctor or nurse about appointments. stated in the benefit descriptions. your condition. Tellchiropractic your doctorservices. what •• Non-rehabilitative Treatment, procedures that medicationsservices you areortaking. Answer any are experimental, investigative or are notin questions the doctor or nurse may • Dental care, except as specifically stated medically necessary. ask benefit you completely and truthfully. the descriptions. This information may help your doctor Non-rehabilitative chiropractic services. •• Eyeglasses, contact lenses, hearing aids form treatment goals and alternatives. and their fittings, hearing testsand Understand your and health problems Dental care, asstated specifically • except as specifically in thestated participate inexcept developing mutually in the benefit descriptions. benefit descriptions. agreed-upon goals.

••

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Eyeglasses, contact aids Ask questions if youlenses, do nothearing understand and their fittings, except as specifically something about your medical stated in the descriptions. condition andbenefit the treatment alternatives

•• • • • • • •• •

Live a healthy lifestyle. Sterilization reversal and some infertility processes and related services. Check your schedule of benefits. Implantable drugs and certain injectable Let your employer know if there are infertility drugs. changes with you and your dependents. Physical, mental or substance abuse Get all required pre-approvals (preexaminations done for or ordered by certifications) third parties. and second opinions. Ask your employer or callorAultCare Immunizations for travel work. if you have questions about your coverage or responsibilities. medications Over-the-counter and supplies.

You have a Right to:

••

Marital Receivecounseling. information about your coverage and services (see your • Services for the treatment of sexual plan documents). dysfunction or inadequacies including supplieshospitals, or counseling. • therapy, A list of doctors, and other AultCare network providers. Visit our Most plans www.aultcare.com exclude all forms oforgastric website call restrictive procedures our Service Center. for the purpose of weight loss/control. Check your specific plan or contact theand AultCare • Be treated with dignity respect. Customer Service Center to determine if these procedures are with covered • A frank discussion yourunder doctor your specific about yourplan. medical condition, including appropriate and medically necessary Youtreatment must consult yourregardless specific plan options, of cost document. AultCare’s Service or benefitContact coverage and to participate in Center if you have additional questions. making decisions about your health care. Your doctors are independent. They are not restricted or prohibited from discussing treatment options with you, including those that are not covered.

AultLine

• Privacy of your health care and 24-Hour Nurse Hotline We Want Your Feedback

claims information. Your personal information will be used to AultCare offers a health and As ahealth part of our AultCare family, pay claims, as permitted by HIPAA information to assist members AultCare nowline offers a health and your opinions are important to us. and as described in your Notice of with health related questions daywith information line to assist members Provide us your feedback, and we Privacy Practices. Personal Health or night. health related questions day or night. will Information listen. Whatwill our members tell us not be disclosed to helps us to evaluate our services and others without your authorization. By calling 330-363-7620, or toll free processes, and make improvements 1-866-422-9603, be directed when • Askneeded. questions, you raisewill concerns, maketo who an complaints, experiencedand registered nurse that appeal denials, isis available 24 hours a dayplan to answer your as explained in your documents. Surveys Our Members Receive: health-related questions and provide Survey confidential information. They willabout be able to: confidential information. • •To New makeEnrollee recommendations •AultCare’s Customer ServiceRights Survey Member and Provide first-aid instructions and general Responsibilities Policy. information Wayshealth you can complete a survey: The surveys can be taken two ways: online Determine level of returned care is most or printed and awhat paper copy by youronline: condition mail.appropriate To take the for survey log into your AultCare online member account. Answer your medication questions Register for a new account if you don’t yet have one. Once logged in, the survey link Offer suggestions for self care will appear in the bottom right hand corner of24-hour your dashboard. nurse hotlinesource is a trusted source of AultLine is a trusted of information information for a of wide range and supportand for asupport wide range health Ifof you do not have internet access but health concerns and topics, from family concerns and topics, from family health would still to participate, contact health andlike medication questions to the illness and medication questions to illness and AultCare Service Center toare request a and injury first aid. Calls confidential injury first aid. Calls are confidential and and paper free ofcopy. charge. As always, your answers areisconfidential, The 24-hour nurse hotline for healthanonymous, and in no way affectto related questions only. Callswill relating your coverage. benefits and coverage must be made to the AultCare Service Center.

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Filing Filing A Claim Physician Claims You do not need to send in claim forms when you use network providers. As longAsaslong youas use when you use network providers. network providers, your physician will submit you use network providers, your physician claims to AultCare forAultCare you. will submit claims to for you. You may, however, need to submit claim forms if If your doctor is not a network provider, call you Utilization go to a non-network provider. our Management department at 330-363-6360 or 1-800-344-8858. In some If yourwe doctor not a network call cases, mayiscontinue to pay provider, for covered services at the network provider rate for our Utilization Management departmentaat limited period or of 1-800-344-8858. time to let you complete 330-363-6360 In some a course of treatment. We also will help you find cases, we may continue to pay for covered an in-network provider or you may reference services at the network provider rate for a our provider directory at http://www. limited period of time to let you complete aultcare.com/myproviders. a course of treatment. We also will help you in-network provider or you Iffind youanhave an approved referral to amay non-network those services may reference our provider, provider directory. be covered at the same level as network providers. Charges that exceed Usual, Services from Non-Network Providers Customary and Reasonable (UCR) rates are If you choose a non-network provider, you not covered by your plan and are therefore may not receive thetosame level of your responsibility pay. Refer to benefits your plan’s from your of health planfor that you do with a schedule benefits details. network provider. Some plans limit coverage under the plan only to network providers for certain or all benefits. Refer to your plan documents for details. If you have an approved referral to a nonnetwork provider, those services may be

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Ifcovered your non-network does notproviders. send in at the sameprovider level as network your claim, you should: Charges that exceed Usual, Customary and Reasonable (UCR) rates are not covered by your 1. Filland out are thetherefore Application forresponsibility Benefits formto plan your pay. Refer to your of plan’s of benefits for 2. Include a copy the schedule bill from your details. non-network provider 3. Mail those two forms to AultCare at the If your non-network address below: provider does not send in your claim, you should: AultCare 1. Fill out the Application for Benefits form 2.P.O. Box 6910 Include a copy of the bill from your Canton, Ohio 44706 non-network provider 3. Mail those two forms to AultCare at the address below: AultCare P.O. Box 6910 Canton, Ohio 44706

Use a Current ID Card You will need to show your ID card when you go to a provider for services. Your provider will use the information on that card to verify coverage. If your coverage changes you might get a new ID card. Use changes, the most current cardcard as reflected by the Use the most current as reflected by effective datedate on the card.card. the effective on the

Application for Benefits

You can get a copy of an Application for You can get a copy of the Application for Benefits form form on from the AultCare website Benefits AultCare’s website at www.aultcare.com or by calling our www.aultcare.com or by calling our Service Service Center at at 330-363-6360 330-363-6360 or or 1-800-344-8858. 1-800-344-8858. Center A separate Application for Benefits form is needed for each bill. Be sure to complete all sections of the form that apply to your situation and sign it.

Hospital Claims When you receive services at a hospital, show your AultCare ID card. The hospital will send the claim information to AultCare.

Other Coverage Each year AultCare will request an update about other coverage that you and your dependents may have. The information about other coverage is needed so we know whether to pay as primary or secondary on claims for your family members. You may not be able to collect benefits from both plans.

Keep Your Records Up to Date We need current information about you and your dependents so we can accurately pay claims. Outdated or incorrect information can cause mistakes, delays in payment or denial of coverage. Updating Your Records Tell your your employer employer (groups) within 31orcalendar Tell AultCaredays if there are changes in your (individuals) within 31 calendar days if there are- Name changes in your: - Address - Name - Phone number - Address - Marital status - Phone number - Family status – including information - Marital status about your dependents, new depen - Family status _ including information dents, changes in family status or who about your dependents, new is to be covered by the health plan dependents, changes in family status or who is to be covered by the health plan Each year we will ask you to update your family’s information and other coverage Remember: employer of Check your plan information Notify for us. your For most plans, changes, additions, orchildren to end coverage documents details. coverage willforend for who are as soon as possible. age 19 or older unless that child is a fulltime student or disabled. your plan Tell your employer as soonCheck as possible to documents for details. update, change, add or end coverage for yourself or a dependent. Tell your employer as soon as possible to update, change, add or end coverage for yourself or a dependent.

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specific benefit, you have the right to appeal AultCare’s decision and request a review of that determination. This is known as the Appeals Process. You may contact the AultCare Service Center or refer to your plan documents for further instruction on how to file an appeal. Please contact the AultCare Service Center you would like aadditional copy of the appeal that willif provide us with information procedure that isappeal. specific your group relating to your Wetowill take intoplan, account youreconsideration at no cost. and one will beprovided providedintoour all information of the original decision. A full and fair review will AultCare offerson youalland/or your provider, be conducted appeals. Clinical appeals, or that will relating provide usdecisions with additional information or authorized representative to act on appeals to based onyour medical relating to your appeal. We will take into account behalf, 180are calendar days by after you receive our necessity, conducted health professionals all information provided in our reconsideration determination to initiate the appeal process. who are: of the original decision. full and fair review This allows youspecialty to submit written comments, 1. The same asA the physician or will be conducted on all appeals. Clinical appeals, or documents, andthe other information provider records who made initial request appeals basedinformation on medical that will relating provide to us decisions with additional necessity, are conducted by health professionals relating to your appeal. We will take into account 2. Board-certified, if applicable who are: all information provided in our reconsideration 1. the The same specialty as the physician or will of original decision. A full review 3. In the same profession andand in afair similar 15 be conducted provider who made the initial request allwho appeals. Clinical appeals, specialty ason one typically manages theor appeals relating to decisions based on medical service requested 2. Board-certified, if applicable necessity, are conducted by health professionals who are: 3. The In the same profession andphysician in a similar 1. same specialty as the or specialty as one who typically manages 1. The same specialty as the the initial physician the provider who made request requested orservice provider who made the initial request.

Grievance and Appeals

How To Let AultCare Know If You Are Unhappy Or Disagree With A Decision About Your Benefit Coverage

If you are unhappy with anything about Ault-

How Toyour Let network AultCareproviders, Know Ifyou Youshould Are Care or How To Let AultCare Know If You Are Unhappy Or Disagree With A Decision contact us as soon as possible. This process Unhappy Or Disagree With A Decision About Your Benefit Coverage is known as the Grievance Process. You may About Your Benefit Coverage contact AultCare Service Center to voice If you arethe unhappy with anything about

If youconcern. areor unhappy with about your Younetwork will beanything forwarded to AultAultCare your providers, you Care or contact your network providers, should should us as soon as possible. This someone who can assist you andyou instruct contact us as soon as possible. This process How To Let AultCare Know If You Are is known as the Grievance Process. You you in the necessary steps to help reach a is known asYou the Grievance Process. You may may contact the AultCare Service Center to in Unhappy Or Disagree With A Decision resolution. may also put your grievance contact the AultCare Service Center to voice voice your concern. You will be forwarded About Your Benefit Coverage writing to the attention of: your concern. Youcan will beanything forwarded to Aultsomeone who assist you and instruct Ifto you are unhappy with about someone who can assist you and instruct you inorthe necessary to help a Care your network providers, youreach should Grievance and Appealsteps Coordinator resolution. You may also put your grievance you in the necessary steps to help reach a in contact us as soon as possible. This process P.O. Box 6029 writing to the attention of: resolution. You may also put your grievance is knownOhio as the Grievance Process. You may in Canton, 44706 writing to attention of: Center to voice contact thethe AultCare Service Grievance andYou Appeal Coordinator your will be forwarded to If youconcern. disagree with a determination about a Grievance and Appeal Coordinator P.O. Box 6029 someone who can specific benefit, youassist haveyou the and rightinstruct to appeal P.O. Box 6029 Canton, Ohio 44706 you in the necessary steps to help reach aof AultCare’s decision and request a review Canton, Ohio 44706 resolution. You may This also isput your grievance that determination. known as the Ap-in writing to the attention of: peals Process. You may contact the AultCare If you disagree with a determination about a Service Center or refer to your plan docuspecific benefit, you have the right to appeal Grievance and Appeal Coordinator ments for further instruction on how to file an AultCare’s decision andthe request a review of P.O. Box Please 6029 appeal. contact AultCare Service that determination. This is known as the ApCanton, 44706 like a copy of the appeal Center ifOhio you would peals Process. may contact AultCare procedure thatYou is specific to yourthe group plan, Service Center or refer to your plan docuIfand youone disagree with a determination about will be provided to you at no cost. a ments for furtheryou instruction how file an specific benefit, have theon right to to appeal appeal. Please contact the AultCare Service AultCare’s decision request review of AultCare offers you and and/or your aprovider, Center if you would like a copy of thethe appeal that determination. This is known Apor authorized representative to actason your procedure that is specific to your group plan, peals Process. You may contact the AultCare behalf, 180 calendar days after you receive our at no cost. and oneCenter will beto to you Service orprovided refer to the your plan docudetermination initiate appeal process. ments for further on how to file an This allows you toinstruction submit written comments, AultCare offers you and/or your provider, appeal. Please contact the AultCare Service documents, records and other information or authorized representative to of actthe onappeal your Center if you would like a copy behalf, 180 calendar days after you receive our procedure that is specific to your group plan, determination initiate the appeal process. at no cost. and one will betoprovided to you This allows you to submit written comments, 15 15 AultCare documents, records and other offers you and/or yourinformation provider, or authorized representative to act on your behalf, 180 calendar days after you receive our determination to initiate the appeal process.

2. Board-certified, Board-certified,if ifapplicable. applicable 2. 3. 3. InInthe thesame sameprofession professionand andinina a similar similar specialty as one who typically specialty as one who typically manages the manages the service requested. service requested 4. 4. Are Are not not reviewed reviewed by the individual by the who made the original decision nor are individual they a subordinate of that person who made the original AultCare will send you notification in decision nor writing regarding the determination are they a your appeal based upon the type of of subordinate frames are as follows: appeal. of thatTime person. Pre-service appeals will be answered within 15 calendar days of receipt by AultCare

• • •

Post-service appeals will be answered within 30 calendar days of receipt by AultCare Urgent care appeals will be answered

4. Are not reviewed by the individual who made the original decision nor are they a subordinate of that person AultCare will send you notification in writing regarding the determination of your appeal based upon the type of appeal. Time frames are as follows: Pre-service appeals will be answered • within Pre-service appealsdays will be answered 15 calendar of receipt by AultCare within 15 calendar days of receipt by AultCare.

Health Maintenance Programs Promoting health and wellness for all

The AultCare website (www.aultcare.com) has the following health links:

•

Access to a Health Illustrated Encyclopedia that you can use for reference.

•

Interactive health-assesment tools that allow you to learn healthy-lifestyle strategies.

• •

•

Post-service appeals will be answered within 30 30 calendar calendar days days of of receipt receipt by within by AultCare. AultCare Urgent/concurrent care appeals will be answered asappeals soon aswill possible but not Urgent care be answered greater than 72 hours of receipt as soon as possible but not greater by AultCare. than 72 hours of receipt by AultCare

Preventive Care Alerts that send reminders to you for wellness checkups and screenings.

and/ Please refer to your plan documents and/or letter of denial forfor additional levels of of or letter of denial additional levels appeal appeal that that are are available available to to you. you. Utilization Management decisions are Utilization Management decisions are based based only on appropriateness of care and only on appropriateness of care and service service and the existence of coverage. There andno thefinancial existence of coverage. AultCare does are incentives for utilization not specifically reward practitioners of carein management decision makers that result or other individuals for issuing denials of under utilization. coverage or service care.

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Enrollee Rights and Enrollee Rights &Responsibilities Responsibilities Quality health care and benefits are responsibilities you share with your doctors and your plan. We want you to know your rights and responsibilities. Please read your plan documents for a full description. If you have a question, concern, or a recommendation for how AultCare could improve its policies for promoting enrollee responsibilities and rights, contact us through our website at www.aultcare.com or call our Service Center at 330-363-6360 or toll free at 1-800-344-8858.

You have a Responsibility to:

•

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Take your AultCare ID card when you go to the doctor, hospital, drug store, or health care provider. It contains important information. Having your card may help save time and prevent mistakes.

•

Tell the doctor or nurse about your condition. Tell your doctor what medications you are taking. Answer any questions the doctor or nurse may ask you completely and truthfully. This information may help your doctor form treatment goals and alternatives. Understand your health problems and participate in developing mutually agreed-upon goals.

•

Ask questions if you do not understand something about your medical condition and the treatment alternatives

(including medications) the doctor is recommending.

•

Follow your doctor’s medical advice and instructions. Take medications as directed. Let the doctor know if you have a bad reaction. Let your doctor know if your symptoms do not get better, or if they get worse. Schedule recommended follow-up appointments.

lifestyle. Live a healthy • •AultCare offers you: Health fairs •• -- Wellness Check your schedule of benefits. Check your schedule of benefits. programs from a case manager • - Counseling Let your employer (groups) or AultCare Let yourmanagement employer there are with •- Disease (individuals) know know if thereif are changes changes you and your with dependents. you and your dependents.

Accolades • Get all required pre-approvals

• Get required pre-approvals (pre- of our Don’t justalltake our word for it.second 97 percent (pre-certifications) and opinions. certifications) second opinions. clients renew with and us every year, proving that yourwe employer we• doAsk what say we’llor do.call AultCare if you haveemployer questionsorabout your coverage • Ask your call AultCare if you AultCare has also earned the following have or responsibilities. questions about your coverage or industry recognitions: responsibilities. •

Health Utilization Management AccreditahaveURAC, Right to: Youfrom have aaRight to: tion a Washington, D.C. based health plan accrediting organization that •• Receive information about your Receive information about the organization, establishes quality standards theproviders, and (seefor your plan coverage its services, its services practitioners and healthcare industry (2006) documents). and member rights and responsibilities.

• Provider Credentialing Accreditation from •• AReceive information aboutand yourother coverage list of doctors, hospitals,

•

URAC AultCare and(2005) services (see your certificate benefits plan documents). newtwork providers. Visitorour booklet). www.aultcare.com or call our • website A list of doctors, hospitals, and other AultCare networkhospitals, providers. Visit our • Service A list of Center. doctors, and other website at www.aultcare.com or our call AultCare network providers. Visit • Be dignity and respect. ourtreated Service Center. website at with www.aultcare.com or call our • Service Center. treated with dignity and respect. • ABefrank discussion with your doctor •• about Be treated with dignity and A frank discussion with yourrespect. doctor about your medical condition, including • appropriate your medical condition, including and medically necessary A frank discussion with your doctor about appropriate and medically necessary options, regardless of cost treatment your medical condition, including treatment options, regardless of cost or benefit coverage and to necessary participate or appropriate and medically in benefit coverage and to participate making decisions about your treatment options, regardless ofhealth costinor Customer Care for Ohio“2006/07 Best making decisions about your health care. Your doctorsand are independent. benefit coverage to participate incare. Customer Care Award” from National Your are doctors are independent. They are not restricted prohibited They making decisions aboutoryour health care. Research Corporation (NRC) not restricted ortreatment prohibited from discussing discussing options with from Your doctors are independent. They are you, treatment options with you, including those includingor those that arefrom not discussing not restricted prohibited that are notoptions covered. covered. treatment with you, including those that are not covered.

Answers

Privacyofofyour your health care andclaims claims •Understanding • Privacy health your healthcare planand can be

AultCare ispersonal here to help. information. YourProtected health challenging. information. Your Health information will be used to payclaims, claims,as Information will be used to pay We will answer the phone personally when permitted by HIPAA andand as described in as permitted by HIPAA as described members call for help with claims or coverage your Notice of Privacy Practices. Protected in your Notice of Privacy Practices. So when you have questions about questions. Health Information will not bewill disclosed Personal Health Information not be to your health plan, we’ll handle it. others without your without authorization, disclosed to others your except Ask asauthorization. permitted by HIPAA and state law. our current members about our service.

to tell us concerns, that it sets us apart •They Askcontinue raise make • Askquestions, questions, raise concerns, make

other health plans. from make complaints, and appeal denials, complaints, and appeal denials, complaints, and appeal denials, as as explained in your certificate or explained in Internet? your planThe documents. Prefer to use the AultCare web benefits booklet. site, www.aultcare.com, is also a source of

To make recommendations about Tomake makerecommendations recommendations about ••information. • To about There, you can:

•

AultCare’s Member Rights and AultCare’sMember MemberRights Rightsand and AultCare’s Look for providers Responsibilities Policy. ResponsibilitiesPolicy. Policy. Responsibilities

Review lists of covered prescription drugs

To requesthealth accommodation Research conditions if you have limited knowledge of the English language. Download forms Access other health-related information

Your Advocate Receiving a serious diagnosis can be overwhelming. Each AultCare member who is diagnosed with a serious condition may be partnered with a case manager who provides: Emotional support Medical explanations Ideas for researching your condition Referrals to support agencies Financial recommendations and references Participate in one or all of our many wellness and disease management programs and learn how to better manage your condition, get healthy and live to the fullest.

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Privacy Practices Notice of Privacy Practices Notice of Privacy Practices

McKinleyInsurance Life AultCare, on behalf of AultCare AultCare, on behalf of McKinley Life Insurance Insurance Co. (MLIC), amaintains Notice of Company, maintains Notice ofaPrivacy Co. (MLIC), maintains a Notice of Privacy Privacy Practices that provides information Practices that provides information on the use Practices that provides information on the Use on the Use andofDisclosure ofHealth Personal and disclosure Protected Information and Disclosure of Personal Health Information HealthThis Information (PHI). Thison noticewebsite is (PHI). notice is available (PHI). This notice is available on ourour website available on our website www.aultcare.com. www.aultcare.com. If you also would like a copy www.aultcare.com. AultCare distributes AultCare also distributes the Notice of AultCare’s Notice of Privacy Practices, the Notice of Privacy Practices annuallyofto each Privacy Practices annually each of please contact Service at our of our members. Ifour you wouldtoCenter like a copy of members. If you would like a copy of 330-363-6360 or toll free at 1-800-344-8858. AultCare’s Notice of Privacy Practices, please AultCare’s NoticeCenter of Privacy Practices, contact our Service at 330-363-6360 please contact our Service Center AultCare prides itself on ensuring or toll free at 1-800-344-8858. If yourour plan is at 330-363-6360 toll freebyat member’s protected health information (PHI) self-funded, you areor covered your employer 1-800-344-8858. Your plan may be is maintained with appropriate privacy and group plan’s Notice of Privacy Practices (NPP) covered yourAll employer’s Notice of confidentiality. employees are held to as well. Forby a copy of your self-funded plan’s Privacy Practices as well. If that is the internal of protecting NPP, pleasestandards contact your employer.written, case, our electronic Service Center will direct oral, and PHI through theyou to contact your employer to Statement obtain a copy. Corporate Confidentiality and AultCare prides itself on ensuring our Agreement. Use and Disclosure of PHI to members’ personal health information (PHI) AultCare prides itself on ensuring our plan sponsors handled withprivacy security and is maintained withis appropriate and members’ personal information certification that thehealth plan sponsor confidentiality. All employees are heldagrees to (PHI) is with appropriate privacyoral, and tomaintained AultCare’s policies on PHI. written, internal standards of protecting confidentiality. All employees are held to and electronic PHI through the Corporate internal ofa protecting written, AultCarestandards maintains Notice of Privacy Confidentiality Statement and Agreement. electronic PHI important through the Practices that provides Useoral, andand Disclosure of PHI to plan sponsors is Corporate Confidentiality Statement and information on the Use Disclosure of handled with security and and certification that Use and Disclosure of PHI Protected Health Information (PHI) andtoyour theAgreement. plan sponsor agrees to AultCare’s policies is handled securityfrom and rights regarding your PHI.with Highlights onplan PHI. sponsors certification that the plan agrees the notice are outlined onsponsor the right. to AultCare’s policies on PHI. AultCare maintains a Notice of Privacy Practices that provides important information maintains a Notice of Privacy onAultCare the Use and Disclosure of Personal Health Practices that Information (PHI)provides and yourimportant rights regarding information on thefrom Use the andnotice Disclosure your PHI. Highlights are of Personal Health Information (PHI) and your outlined below. rights regarding your PHI. Highlights from Uses Disclosures. We on arethe permitted theand notice are outlined right. or 19 required by law to make certain uses and disclosures of your personal health information without your authorization. For a detailed list

Uses of theand usesDisclosures and disclosures that do not require We are permitted orplease required by law makeof your authorization, review theto Notice protected certain and disclosures of your personal Privacy uses Practices. health information without your authorization. For a detailed of thelisted uses below and disclosures Except for the list reasons or as that do not require your authorization, required/permitted by law, we will not please use or review the Notice of Privacy Practices. disclose your personal health information for any purpose unless you have signed a form Except for the below or have as the authorizing thereasons use or listed disclosure. You required/permitted by law, we willinnot use or right to revoke that authorization writing disclose your personal health information foron disclose your protected health information for unless we have taken any action in reliance any purpose unless you have signed a form the authorization. authorizing the use or disclosure. You have • Treatment the right to revoke that authorization in writing • Payment unless we have taken any action in reliance • Health-Related Products or Services on• the authorization. Research •• Business Associates Treatment •• Health Care Payment Operations •• Family and Friends Involved Your Care Health-related products or In services • Research • Business Associates • Health care operations • Family and friends involved in your care

Accounting for Disclosures of Your Personal Information Protected Health Health Information You have the right to receive an accounting of certain disclosures made by us of your protected personal health health information after April 14, 2003. Requests should be made in writing and signed by you or your representative.

Access HealthInformation Information Access to to Your Your Protected Personal Health You have the right to copy and/or inspect much of the protected healthinformation information personal health that we retain on your behalf. All requests for access must be made in writing and signed by you or your representative. Restrictions on Use and Disclosure of Your Your Protected Information Personal HealthHealth Information You have the right to request restrictions on certain uses and disclosures of your protected personal health information for treatment, payment, or health care operations by notifying us of your request for a restriction in writing.

Please review the Notice of Privacy Practices for more detailed information on our Use and Disclosure of Personal Protected Health Information. The Notice of Privacy Practices and the necessary request forms are available on our website www.aultcare.com. If you would like a copy of the notice or the request forms, please contact our Service Center at 330-363-6360 or toll free at 1-800-344-8858.

Amendments Protected AmendmentstotoYour Your Personal Health Health Information Information You have the right to request in writing an amendment or correction to the protected personal health information that we maintain about you. We are not obligated to make all requested amendments, but we will give each request careful consideration. All amendment requests should be in writing, signed by you or your representative, and must state the reasons for the amendment/ correction request.

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Frequently Asked Questions Q. A.

Do I need a Primary Care Physician (PCP)?

We recommend you have a PCP to help guide you in your health care needs.

Q.

How can I find a doctor? How do I find a doctor in my network?

A.

You may search for network doctors in various ways: • Via the AultCare website www.aultcare.com. Select the appropriate drop-down for your plan when you search • By calling the AultCare Service Center

When making an appointment with your doctor, be sure to confirm that the doctor or provider is still a network provider.

Q.

What if my PCP cannot provide the care I need?

A.

Your doctor may refer you to a specialist. If the recommended specialist is in your network, no additional actions are necessary.

Q.

What if my doctor refers me to an non-network doctor?

A.

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If the specialist is not in the network, your network doctor will need to provide detailed information to the Utilization Management Department and request an approval before you seek treatment.

Q.

My PCP or network doctor has sent a request for my treatment with a non-network doctor. How will I know if my treatment was approved?

A.

You will receive a letter from our Utilization Management Department. The letter will tell you if your treatment has been approved at the network level of benefits, or if it has been denied (for PPO plans, services can be partially approved, which means the services have been approved at the non-network level of benefits).



If you receive care from a non-network provider you may have to pay a different deductible and/or co-insurance. You will be responsible for paying any difference between what the provider charges for the service and what the plan allows.

Q.

The letter approving my care at the network level of benefits mentioned UCR. What does this mean?

A.

This means that the non-network treatment requested by your network doctor has been approved at the network level of benefits, and payable based on Usual, Customary, and Reasonable (UCR) schedule of charges.



Q. What If youThe receive care from achosen non-network does UCR mean? Formularypanel of drugs by the provider you Care pay aOrganization deductible and cohospital, Managed or other UCR is a schedule of average fees A. maypatients. also be responsible healthinsurance. plan usedYou to treat that most providers in the area charge for paying any difference between what for a given procedure. It affects theAny provider charges for the service and Genericlegend drug dispersed as a less insurance reimbursement and out-ofwhatsubstitute the plan allows. expensive for the prescription drug. pocket charges you might have to pay. your provider charges more than the Q. IfThe letter approving my care at the GrievanceAny written or verbal complaint UCR you will be responsible for paying network level of benefits expressing dissatisfaction from amentioned member/ the difference between what the UCR. representative What does thatregarding mean? the authorized provider has changed and the UCR delivery of service from the organization that A. This means non-network amount thatthat willthe be used to pay cannot be resolved during the initial contact or treatment requested by your network your benefits. supervisor involvement. doctor has been approved at the network of benefits, andUCR? payable Will I owelevel the amounts over Q. Home Health- Items and services provided as based on the Usual, Customary and needed in The a patient’s home a health agency A. Yes. amounts overby UCR are not Reasonable (UCR) schedule of charges. or by under arrangements made by a others covered by your plan. You are Home Health Agency. responsible for those amounts. Q. We What does UCR suggest thatmean? you discuss payment HospiceA healthcare facility that provides options with your provider. Reasonable (UCR) A. Usual, Customary and supportive care for the terminally ill. is a schedule of average fees that most received a letter that the Q. Iproviders in the area charge for a given InquiryCustomer contacts AultCare to recommended treatment was not procedure. It’s important to understand request information or to provide AultCare with approved. What does this mean? this term because it affects insurance information. reimbursement and out-of-pocket the treatment may be A. Although charges you might have to pay.itIfmay recommended by your doctor, Insured Product- A pre-designed benefit plan yourbe provider moreplan. thanIfUCR not coveredcharges under your for smaller companies whichyour is purchased you might beapproved, responsible for paying referral is not there is no orthe through premiums. The insurance company difference between what the provider reduced for the assumes the riskcoverage rather than the treatment employer. has charged and Always the UCRrefer amount that under your plan. to your will be used to pay your benefits. plan document for specific limitations Medically Necessary- Services or supplies thatby apply. Also refer to page for your provided a hospital, physician or 15 other appeal rights. Q. WilltoI owe theor amounts UCR? provider identify treat anover illness or injury on a cost effective basis, when those services A. Yes. The amounts over UCR are not or supplies are determined to be: 1. Consistent covered by your plan. You are with the symptom or diagnosis and treatment responsible for those amounts. of the condition, disease, ailment or injury.

Q. What if I need help my We suggest that youunderstanding discuss payment 2. Appropriate with regard to the standards

approval/denial letter options withpractice. your provider. of good medical 3.content? Not primarily for the convenience of the patient, the physician A. Contact the Utilization Management or other provider. 4. The most appropriate Q. I received a letter that the recommended Department at 330-363-6360 or supplies or services that can be provided safely treatment was not approved. What does 1-800-577-8858. Refer to your plan to the patient. For inpatients, it means that the this mean? for specific limitations that apply. document services or supplies cannot be provided safely Also refer to page 15 for your appeal rights. thebasis. treatment may be A. on anAlthough outpatient recommended by your doctor, some What if I need after hours care in or out of Q. referrals not be approved. Please MemberThemay enrollee or dependent listed read the area? theplan letter from our Utilization Management on the is considered a “member” of the Department very carefully for a detailed health program. A. If you need care after hours, contact your reason. Please contact physician’s office. If youthe feelUtilization your needs Management Department ifisyou have Non-certificationdecision made byemergency, are urgent or A your situation an questions or need help understanding the Utilization Management Department, proceed to the nearest emergency room, the letter’s content. You reach including ancare AultCare physician, that an that urgent center, or callmay 911. department at 330-363-6360 or health admission, extension of stay, or other 1-800-577-8858. Always refer tobased youronline? plan care been reviewed and on service How dohas I view my medical benefits Q. document for specificdoes limitations thatthe apply. the information provided, not meet Go torefer www.aultcare.com A. Also to pagefor15medical for yournecessity, appeal rights. clinical requirements - Log-in to your account appropriateness, level of care, or effectiveness under the auspices of the applicable health - Click on Eligibility Q. If I have an emergency and cannot get to a benefit plan. - Select Member theI do? network provider, what from should drop-down box You should go“Active” to the nearest Out-of-PocketThe total amount aemergency claimant A. - Select from the Status carebefore facility. UCR willbox apply.paying (refer to may pay benefits begin at page 100%12) drop-down or percent defined by the plan. This does not - Click “Search” include amounts above the usual, customary - Select to seeamounts, benefits or reasonable and fee,plan ineligible OR exceeding the benefit limitations. amounts Call Customer Service @ 330-363-6360 Outpatient ServicesMedical and/or other or toll free at 1-800-344-8858 services by a hospital, or other (TTYprovided Line: 330-363-2393 or 1-866-633-4752) qualified facility or supplier, such as mental health clinic, mobile x-ray unit or freestanding dialysis unit. Such services include outpatient physical therapy, diagnostic x-rays and laboratory tests.

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Glossary Glossary • This glossary defines many commonly used terms, but isn’t a full list. These glossary terms and Accessdefinitions are intended educational and may bechiropractors, different frompodiatrists, the terms and andadefinitions nurses. inoryour patient’s abilityto tobe obtain otherwise be have performed by physician, AAhealth patient’s ability to obtain Accessplan or insurance policy. Some of these terms also might not exactly the same meaning The term is sometimes used synonymously medical care, care, taking taking into into consideration consideration the health workers who do(See notyour usually engage medical when used in your policy or plan, and in any case, the policy or plan governs. Summary of with paramedicalpractice. personnel, all health workers the availability of medical services, the independent of medical services, the accept availability Benefits and Coverage for information on how to get aincopy of your policy or plan document.) ability to the patient, the location of the who perform tasks that must otherwise be acceptability to the patient, the location care services, the availability of con•health Underlined text indicates a term defined in this Glossary. performed a physician, or health workers of the health care services, the availability Ambulatoryby CareHealth services venient transportation, the hours ofhours opera-of delivered onusually an outpatient If the who do not engagebasis. in independent ofSee convenient transportation, the •tion, page 6 for an example showing how deductibles, coinsurance and out-of-pocket limits work the cost of the care and other factors. patient makes a trip to the doctor’s office together a real practice. operation, in the costlife of situation. the care and other or surgical care center without an overfactors. night stay, it is considered ambulatory care. Accreditation- A formal recognition by an Ambulatory Health on Coinsurance-CareYour share ofservices the costsdelivered of a Allowed AmountThis isthat the evaluates maximumand agency or organization an outpatient basis. If the patient makes a trip covered health care service, calculated as a AccreditationA formal recognition by payment the plan will pay for a covered recognizes an institution as meeting cerAncillary ServiceSpecialized such percentage (for office example, 20%)support of care the allowed health careor service. May also beevaluates called to the doctor’s or surgical center an agency organization that tain predetermined standards. as durable medical equipment, radiology, amount for the service.stay, You generally pay “eligible expense”, without an and overnight it isnursing. considered and recognizes an“payment institutionallowance”, as meeting laboratory, health coinsurance plushome any deductibles you owe. or “negotiated rate”. ambulatory certain predetermined AdjudicationProcessing standards. a claim through a (For example,care. if the health insurance or plan’s series of edits to determine proper payment. allowed amount for an office visit is $100 and AppealA formal request in writing Appeal- A request that your health insurer Ancillary ServiceSpecialized support such AdjudicationProcessing a claim through you’ve met your deductible, your coinsur(unless expedited) by a covered member/ or plan review a decision that denies a ance payment of 20% would be $20. The authorized representative or a member’s AdmissionThe entry of a covered person as durable medical equipment, radiology, a series of edits to determine proper benefit or payment (either in whole or health insurance or plan pays the rest of the provider, forand review of health an initial decision, as an inpatient to a hospital or other health laboratory, home nursing. payment. in part). allowed amount.) determination for such as utilization care facility. medical necessity, coverage of service or AppealA formal request in writing (unless AdmissionTheWhen entryaofprovider a covered Balance Billingbillsperson you benefit payment issues. Complications PregnancyConditions Admitting DiagnosisThe statement ofhealth for theinpatient balance remaining on the bill that expedited) by aofcovered member/authorized as an to a hospital or other due to pregnancy, labor, and delivery that medical condition, cause, or disease your doesn’t cover. This amount is the representative orcare a member’s provider, for care plan facility. require medical to prevent serious ApplicantAn individual who is applying observed when the patient is initially difference between the actual billed amount review an health initial such as harm toofthe of the mother orutilization or reapplying to bedecision, a network healthcare admitted to a health careFor facility. and the allowed amount. example, if the determination for medical necessity, coverage of Admitting DiagnosisThe statement the fetus. Morning sickness and a provider. provider’s charge is $200 and the allowed non-emergency caesarean section service or benefit payment issues. of medical condition, cause, or disease amount is $110, the provider may bill you for Admitting PhysicianThe physician generally complications of pregnancy. observed when the patient is of initially the remaining This happens most often Behavioralaren’t Health Care- Evaluation and responsible for$90. the admission a patient when you to seeaoran out-of-network treatment of and substanceor to a hospital other health careprovider facility. ApplicantAnpsychological individual who is applying admitted health care facility. Copaymentfixed amounthealthcare (for example, (non-preferred provider). A network provider abuse disorders. reapplying toAbe a network provider. $15) you pay for a covered health care (preferred provider) may not bill you for Allied Health PersonnelTrained and Admitting Physician- The physician service, usually you receive the for covered services. Benefit- The limitwhen or degree of payment licensed health workers other of than Behavioral Health CareEvaluation and treatment responsible for the admission a patient service. The amount can vary by the type coverage of services assubstance identified abuse in a policy physicians, of psychological and disorders. to a hospitaldentists, or otheroptometrists, health care facility. service. ClaimA request for a benefit (including andcovered payablehealth undercare the terms of the policy. chiropractors, podiatrists and nurses. reimbursement of a health expense) The term is sometimes usedcare synonymously BenefitThe limit degree of payment for Alliedparamedical Health Trained and Cost Yourorshare of costs forprocess made by you Personnelor your health care provider with personnel, all health Case SharingManagementA collaborative coverage of services as identified in a policy and licensed health workers other than services that a plan covers that you must to your health insurer or plan for items or workers who perform tasks that must which identifies, coordinates, directs, pay out of your own pocket (sometimes services youdentist, think are covered. payable under the terms of the policy.2 physicians, optometrists, monitors, and evaluates options and services called “out-of-pocket costs”). (cont.)

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to Some meet an examples individual’s ofAcost health sharing needs are through Case Managementcollaborative process communication copayments, deductibles, and available and resources coinsurance. to which identifies, coordinates, directs, monitors, promote Family cost quality sharing cost-effective is the share outcomes. of cost and evaluates options and services to for deductibles and out-of-pocket costs you meet individual’s health child(ren) needs through andan your spouse and/or must Certificate of CoverageThe document that communication and available to pay outthe of your own pocket.resources Other costs, identifies terms, conditions and limitapromote quality cost-effective outcomes. including your premiums, penalties you tions of benefits provided by AultCare, and may have to pay, or the cost care a plan that each individual enrolled forofcoverage doesn’t cover usually aren’t considered Certificate of CoverageThe document with AultCare receives upon enrollment.that cost sharing. identifies the terms, conditions and limitations of benefits provided by made AultCare, and that each CertificationA decision by the Cost-sharing ReductionsDiscounts thatan Utilization Management Department that individual enrolled for coverage with AultCare reduce the amount you pay for certain admission, extension of stay, or other health receives upon enrollment. services byreviewed an individual you care servicecovered has been and,plan based buy through the Marketplace. You may on the information provided, meets the get Certificationdecision bynecessity, thea certain a discount ifA your income is below clinical requirements for made medical level, and you choose a Silver level health Utilization Management that an appropriateness, level of Department care or effectiveness. plan or if you’re a member of a federallyadmission, extension of stay, or other health recognized tribe, which includes being care service been reviewed based Chronic Care-has Ongoing care for aand, patient with a shareholder in an Alaska Native Claims on the information provided, meets the a long-term illness. Settlement Act corporation. clinical requirements for medical necessity, appropriateness, of care orcould effectiveness. ClaimA requestAn tolevel an insurer for payment Deductibleamount you oweof benefits under an insurance contract. during a coverage period (usually one year) for covered health care services before with your Chronic Care- Ongoing care for a patient plan begins to pay. An overall deductible A lawillness. that requires employers to aCOBRAlong-term applies to all or almost all covered items offer continued health insurance coverage and services. A plan with an overall to employees or dependents who had theirof ClaimA request an insurer for payment deductible maytoalso havecoverage separate insurance terminated. This can benefits under antoinsurance contract. that apply services bedeductibles extended up 18, 29 to or specific 36 months, or groupson of the services. A plan may also have depending circumstances only separate deductibles. (For example, COBRAA law that requires employers to if surrounding termination of employment. your deductible is $1000, your plan won’t offer continued health insurance coverage pay anything you’ve met your $1000 to employees oruntil dependents who had theirs Co-Insurancepercentage of the provider’ deductibleThe for covered health care services Usual, Customary and Reasonable Charge insurance terminated. This coverage can subject to the deductible.) for extended which theup claimant is responsible after be to 18, 29 or 36 months, meeting the plan deductible. depending onTestthe Tests circumstances surrounding Diagnostic to figure out what termination of employment. your health problem is. For example, an Complaint(verbal) expression x-ray canAn beinformal a diagnostic test to see if of dissatisfaction from a member/authorized you have a broken bone. Co-InsuranceThe percentage of theofprovider’s representative regarding the delivery service; Usual, Customary and Reasonable Charge for an expression of an expectation that was not met.

Durable Medical Equipment (DME)Coordination of Benefits(COB) A method which the claimant is responsible after of Equipment and supplies ordered by acare health preventing duplicate payments for meeting the plan deductible. care provider everyday or extended use. provided to afor covered person having more DMEone mayhealth include:care oxygen equipment, than policy. Complaintinformal (verbal) expression wheelchairs,An and crutches. of dissatisfaction from a member/authorized Continuity of Care- A process of assuring that representative regarding the delivery of Emergency Medical ConditionAn illness, care is delivered seamlessly across a multitude service; an expression of an expectation thatof injury, symptom (including severe of delivery sites and throughout thepain), course was not met.process. or condition severe enough to risk serious the disease danger to your health if you didn’t get medical attention right away. you didn’tvisits, Coordination Benefits(COB)Iffor A method Co-paymentAofset fee charged office get immediate medical attention you could emergency visits or other services as of preventing duplicate payments fordetercare reasonably expect one of the following: mined byto thea covered plan. person having more provided 1) Your health would be put in serious danger; than or 2) one You health would care havepolicy. serious problems with CredentialingThe process which AultCare your bodily functions; or by 3) You would have reviews and evaluates qualifications of serious damage to any part or organ of Continuity of Care- A process of assuring that licensed independent practitioners to provide yourisbody. care delivered seamlessly across ais multitude services to our enrollees. Eligibility of delivery sites and throughout the course determined by defined requirements for of Emergency Medical Transportationthe diseaselicensure, process. professional standing, education, Ambulance services foraccessibility, an emergency service availability and as well as medical condition. Types of emergency conformity to AAultCare’s utilization and quality Co-paymentset fee charged for office medical transportation may include management requirements. visits, emergency or other services as transportation byvisits air, land, or sea. Your plan may not cover determined by all thetypes plan.of emergency DeductibleThe amount or of may eligible medical transportation, payexpenses less for which must be paid by you for an accidental certain types. Credentialingprocess byeach which AultCare bodily injury orThe illness during benefit reviewsbefore and evaluates period benefits qualifications are payable. of Emergency Room Carepractitioners / EmergencytoServiceslicensed independent Services to check for an emergency medical provide services to you our enrollees. DependentThe card holder’s or condition and treat to keepspouse anEligibility emergency ismedical determined by defined requirements for unmarried children, stepchildren, legally condition from getting worse. These adopted children, anyprofessional children forstanding, whom the s education, licensure, services may be provided in a licensed hospital’ parent is the legal guardian, or any children emergency room orand other place that as provides service availability accessibility, well as who by emergency court mustutilization beconditions. provided care for medical conformity to order AultCare’s andhealth quality care coverage by the card holder or card management requirements. holder’s spouse. Excluded Services- Health care services that your plan doesn’t pay forof oreligible cover. expenses Deductibleamount DiagnosisTheThe statement of medical condition, which or must be paid by you for an accidental cause disease. Formularyof drugs youreach planbenefit covers. A bodily injuryAorlistillness during formulary may include how much your share period before benefits are payable. of the cost is for each drug. Your plan may put drugs in different cost sharing levels or tiers. (cont.)

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Dependentcard holder’s spouse For Dischargeexample, Release aThe formulary or dismissal may include from a or health generic care drug facility. and brand name drug tiers unmarried children, stepchildren, legally and different cost sharing amounts will adopted children, any children for whom apply to each tier. Disease Managementthat the parent is the legalServices guardian, or assist any members to adhere to their physicians’ children who by court order must be treatment Grievanceplans, A complaint monitor that member youby clinical provided health care coverage the card status and adherence communicate to your health to treatment insurer or recomplan. holder or card holder’s spouse. mendations, and monitor provider adherence to evidence-based practice guideHabilitation ServicesDiagnosisThe statement of medical lines. Disease management is typically Health care cause services help a person condition, or that disease. targeted to or members keep, learn improvewith skillsspecific and chronic diseases which often have complex functioning for daily living. Examplestreatment regimens that require the isn’t sustained DischargeRelease dismissal from a include therapy for aor child who efforts of patients and physicians. health care facility.at the expected age. walking or talking These services may include physical and Durable occupational therapy, Equipment speech-language (DME)DurableMedical Medical Equipment (DME)Equipment, pathology, such other asasaaservices wheelchair, for people which Equipment,and such wheelchair, whichisis used disabilities with primarily toinserve a variety a medical of inpatient purpose, used primarily tothe serve a medical purpose, and and/or not outpatient useful in settings. absence of illness and not useful in the absence of illness or or injury. injury. Health Insurance- A contract that requires aEmergencyhealth insurer anyto medical pay some condition or all ofthat youris Emergencyany medical condition severe health care enough costs toin cause exchange a prudent for a laythat person premium. with an A average healthtoinsurance knowledge contract of health may is severe enough cause a prudent and also medicine be called a to “policy” believe or that “plan”. absence of lay person with an average knowledge immediate medical attention couldthat result of health and medicine to believe in any of the following: Home Health Care- Health care attention services absence of immediate medical • Placing thein health of the individual, or and supplies you getofin your home could result any the following: withyour respect to pregnant women, the under doctor’s orders. Services • health Placing of the individual, ofthe thehealth woman or her unborn or may be provided by nurses, therapists, with respect to pregnant woman, the child, in serious jeopardy social workers, or other licensed health health of the woman or her unborn • Serious impairment to bodily care providers. Home health carefunctions usuallychild, • Serious dysfunction of any bodily organ doesn’t include help with non-medical in serious jeopardy or part tasks, such as cooking, cleaning, or driving. • Serious impairment to bodily functions • Serious dysfunction of any bodily organ EnroleeThe employee or person who is Hospice ServicesServices to provide or part the carrier of support the plan.for persons in the comfort and last stages of a terminal illness and their Enrollee- The employee or person who is families. the carrier of the plan. Exceeds Benefit Limitations- When services

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go beyond a specific dollar amount or number HospitalizationCare in a hospital Exceeds Benefit LimitationsWhen that services requires asdollar an the inpatient go a specific amount or ofbeyond visitsadmission determined by groupand plan. usually overnight by stay. numberrequires of visitsan determined theSome plans may consider an overnight stay for group plan. Expedited Appeal- Utilization review observation as outpatient care instead of conducted expeditiously when the patient’s inpatient care. Expedited Appeal- Utilization review con-answer. medical condition necessitates a quick ducted expeditiously when the patient’s The time frame fornecessitates the decision process is that Hospital Outpatient CareCareainquick a medical condition which The isthat warranted by for thethe patient’s medical hospital usually doesn’t require an answer. time frame decision condition. overnight stay. which is warranted by the process is that patient’s medical condition. Experimental/InvestigationalAny service, Individual Responsibility RequirementSometimes the “individual mandate”, Experimental/InvestigationalAny service, supply, carecalled or treatment which does not the dutycare youaccepted havemedical towhich be enrolled inand/or supply, ormay treatment does not constitute practice health coverage that provides minimum constitute accepted medical practice and/ is inconsistent with relevant clinical guidelines essential coverage. If you don’t clinical have or is inconsistent with relevant and/or Government oversight agency minimum essential coverage, you may guidelines and/or Government oversight guidelines and regulations at the have to guidelines pay a penalty you filetime agency andwhen regulations atyour thethe services were rendered. federal taxwere return unless you time theincome services rendered. qualify for a health coverage exemption. Explanation Benefits (EOB)a written Explanation ofof Benefits (EOB)a written In-network CoinsuranceYour share (for action statement showing statementto toa acovered coveredperson person showing example, 20%) of the allowed amount for action taken on a claim. taken on a claim. covered healthcare services. Your share is usually lower for in-network Extended Care FacilityA nursing home Extended Care FacilityA nursing home-type covered services. type setting that offers skilled, intermediate setting that offers skilled, intermediate or or custodial care. custodial care. In-network Copayment- A fixed amount (for example, $15) or you pay health for covered Facility- A hospital other care health care services to providers who FacilityA hospital or other health care establishment used to provide health contract with your health insurance or establishment used provide health services. Coverage forto care provided by services. a plan. In-network copayments usually are is Coverage for care by a facility facility is limited by provided contract definitions less than out-of-network oflimited covered and copayments. specificofbenefit byproviders contract definitions covered provisions. providers and specific benefit provisions. Marketplace- A marketplace for health insurance where individuals, families and Fee AA comprehensive listing ofof FeeScheduleSchedulecomprehensive listing small businesses can learn about their fees used by either a healthcare plan orplan the fees used by either a healthcare or the options; compare plans based on plan costs, government to reimburse physicians and/ benefits and other important features; to reimburse physicians and/or orgovernment other healthcare providers on a fee-forapply and receive financial with otherfor healthcare providers onhelp a fee-for-service service basis. premiums and cost sharing based on basis. income; and choose a plan and enroll in coverage. (cont.)

Also known an “Exchange”. The by the FormularyTheas panel of drugs chosen Marketplace is run byOrganization the state in some hospital, Managed Care or other states and by the federal government in health plan used to treat patients. others. In some states, the Marketplace also helps eligible consumers enroll in other GenericAny including legend drug dispersed a less programs, Medicaid andasthe expensive substitute for the prescription drug. Children’s Health Insurance Program (CHIP). Available online, by phone, and in-person. Grievance- Any written or verbal complaint Maximum Out-of-pocket LimitYearly expressing dissatisfaction from a member/ amount the federal government authorized representative regardingsets the as the most each individual or family canthat be delivery of service from the organization required to pay in cost sharing during the cannot during the initialservices. contact or plan be yearresolved for covered, in-network supervisor involvement. Applies to most types of health plans and insurance. This amount may be higher than the out-ofpocket stated for your plan. Home Health- Items limits and services provided as needed in a patient’s home by a health agency Medically NecessaryHealth care services or by others under arrangements made by a or supplies needed to prevent, diagnose, Home Health Agency. or treat an illness, injury, condition, disease, or its symptoms, including habilitation, and HospiceA healthcare thatofprovides that meet accepted facility standards medicine. supportive care for the terminally ill. Minimum Essential Coverage- Health InquiryCustomer contacts AultCare to coverage that will meet the individual request information or to provide AultCare with responsibility requirement. Minimum essential coverage generally includes information. plans, health insurance available through the Marketplace or other individual market Insured Product- A pre-designed benefit plan policies, Medicare, Medicaid, CHIP, TRICARE, forand smaller companies which is purchased certain other coverage. through premiums. The insurance company assumes the Value risk rather than the employer. Minimum StandardA basic standard to measure the percent of permitted costs the planNecessarycovers. If you’re offered an Medically Services or supplies employer plan that pays for at least 60% of provided by a hospital, physician or other the total allowed costs of benefits, the plan provider to identify or treat an illness or injury offers minimum value and you may not onqualify a cost effective basis,tax when those for premium credits andservices cost or supplies are determined 1. from Consistent sharing reductions to buytoabe: plan the with the symptom or diagnosis and treatment Marketplace. of the condition, disease, ailment or injury.

2.NetworkAppropriate regard to the standards Thewith facilities, providers and suppliers health insurer or plan has contracted ofyour good medical practice. 3. Not primarily forwith to convenience provide healthofcare services.the physician the the patient, or other provider. 4. The most appropriate NetworkorProvider Provider)supplies services(Preferred that can be provided safely A provider who has a contract with your to the patient. For inpatients, it means thathealth the insurer or plan who has agreed to provide services or supplies cannot be provided safely services to members of a plan. You will pay less on an outpatient basis.in the network. Also called if you see a provider “preferred provider” or “participating provider.” Member- The enrollee or dependent listed on the planand is considered a “member” of theand Orthotics ProstheticsLeg, arm, back neck braces, artificial legs, arms, and eyes, and health program. external breast prostheses after a mastectomy. These services include: adjustment, Non-certificationA decision made byrepairs, and replacements required because of breakage, the Utilization Department, wear, loss, or aManagement change in the patient’s including an AultCare physician, that an physical condition. admission, extension of stay, or other health care service has been reviewedYour and based Out-of-network Coinsuranceshare on the provided, not amount meet the (forinformation example, 40%) of thedoes allowed for covered health care services necessity, to providers clinical requirements for medical who don’t contract yourorhealth insurance appropriateness, levelwith of care, effectiveness or plan. Out-of-network coinsurance usually under of the applicable health costs the youauspices more than in-network coinsurance. benefit plan. Out-of-network Copayment- A fixed amount Out-of-PocketThe total amount a claimant (for example, $30) you pay for covered health may beforefrom benefits beginwho paying at 100% carepay services providers do not yourby health insurance or plan. orcontract percentwith defined the plan. This does not Out-of-network copayments usually are more include amounts above the usual, customary than in-network copayments. and reasonable fee, ineligible amounts, or amounts exceeding the benefit limitations. Out-of-network Provider (Non-Preferred Provider)- ServicesA providerMedical who doesn’t a Outpatient and/orhave other contract with your plan to provide services. services provided byout-of-network a hospital, or other If your plan covers services, qualified facility or supplier, such mental you’ll usually pay more to see anasout-of-network health clinic, mobile x-ray unit or freestanding provider than a preferred provider. Your policy will explain what those costs mayoutpatient be. May also dialysis unit. Such services include be called “non-preferred” “non-particiapting” physical therapy, diagnosticorx-rays and instead of “out-of-network provider”. laboratory tests.

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Out-of-pocket LimitThe most you could Panel or Preferred ProviderA provider that pay duringas a coverage periodmember (usually of one is enrolled a participating a year) for your share of the costs of specific panel or network. A Panel provider covered services. After you meet this limit agrees write off amounts above the the plantowill usually pay 100% of the usual, customary and reasonable fee. allowed amount. This limit helps you Theyfor exchange discounted services for plan health care costs. This limit never includes premium, balance-billed increasedyour volume. Benefits are usually charges healthlevel careand/or your plan paid at aor higher havedoesn’t a lower cover. Some plans don’t count all of deductible and out-of-pocket limit. your copayments, deductibles, coinsurance payments, out-of-network payments, or Pre-certificationThe process of notification other expenses toward this limit. prior to an elective hospital stay, or within the time prescribed for an care emergency Physician Services- Health services a hospital admission, to aid inincluding determining licensed medical physician, an M.D. (Medical Doctor) or D.O. (Doctor that all medical care possibilities haveof Osteopathic Medicine), provides been explored and are within acceptable or coordinates. time elements. PlanHealthConditioncoverage issued to you Pre-Existing An illness or injury directly (individual plan) or through an that a claimant may have been receiving employer, union or other group sponsor treatment for priorplan) to enrolling with a (employer group that provides health plan. coverage for certain health care costs. Also called “health insurance plan”, “policy”, insurance or Preferred“health Providers(PPO) policy” Physicians, “health insurance”. hospitals and other health care providers who contract to provide health services to Preauthorization- A decision by your persons covered by a particular health plan. health insurer or plan that a health care They exchange discounted services drug service, treatment plan, prescription fordurable increased volume. or medical equipment (DME) is medically necessary. Sometimes called prior authorization, priorcare approval or Preventive Care- Health emphasizing precertification. Your health insurance priorities for prevention, early detection, or plan may require preauthorization for and early treatment of conditions, certain services before you receivegenerally them, including routine physical examination, except in an emergency. Preauthorization immunization, and well-person care. or isn’t a promise your health insurance plan will cover the cost. Recredentialing- A process of periodic review to assess and update the qualifications

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and credentials of participating PremiumThe amount that musthealthcare be paid for your health insurance or plan. You and/or your practitioners for ongoing network participation. employer usually pay it monthly, quarterly, or yearly. Retrospective Review- Utilization review conducted after services have been provided to Premium Tax Credits- Financial help that lowers the patient. your taxes to help you and your family pay for private health insurance. You can get this help Nursing (SNF)A facility, ifSkilled you get healthFacility insurance through theor distinct part of anyour institution, is licensed Marketplace and incomethat is below a certain level. Advance payments of the tax credit can to provide inpatient care for persons requiring be used right away to lower your monthly skilled nursing services for a chronic disease or premium costs. convalescent stage of an injury or illness over a prolonged period, in a separately identified Prescription Drug Coverage- Coverage under a unit. plan that helps pay for prescription drugs. If the plan’s formulary uses “tiers” (levels), prescription Urgentare Care Center-together A medical drugs grouped by facility type orwhere cost. The amount you’llpatients pay in cost will be ambulatory cansharing be treated ondifferent a walkfor each without “tier” of covered prescription in basis, an appointment anddrugs. receive immediate, non-emergency care. Prescription Drugs- Drugs and medications that by lawCustomary require a prescription. Usual, and Reasonable Amount- For a service rendered or supply furnished means Preventive Carethe (Preventive Service)Routine the lesser of: usual charge for such service health care, including screenings, check-ups, or supply; and the prevailing charge for a and patient counseling, to prevent or discover comparable service or supply illness, disease, or other healthrendered problems.by any provider in that area with training, experience, and professional standing similar toincluding that of the Primary Care PhysicianA physician, provider who renders the service or furnishes an M.D. (Medical Doctor) or D.O. (Doctor of Osteopathic the supply. Medicine), who provides or coordinates a range of health care services for you. Review- The process of reviewing Utilization health care services for medical necessity, Primary Care Providerincluding an appropriateness, levelAofphysician, care, effectiveness, M.D. (Medical Doctor) or D.O. (Doctor of and/or quality of care. Utilization Review Osteopathic Medicine), nurse practitioner, may be performed before (prospectively), clinical nurse specialist, or physician assistant, at the sameunder time (concurrently) or after as allowed state law and the terms of the plan, who provides, or helps you (retrospectively) thecoordinates, services are rendered. access a range of health care services.

Provider-The An panel individual or facility that Formularyof drugs chosen by the provides health care Someor other hospital, Managed Care services. Organization examples of a provider include a doctor, health plan used to treat patients. nurse, chiropractor, physician assistant, hospital, surgical center, skilled nursing Genericdrug dispersed as aplan less facility,Any andlegend rehabilitation center. The expensive substitute for the to prescription drug. may require the provider be licensed, certified, or accredited as required by state law.Any written or verbal complaint Grievanceexpressing dissatisfaction from a member/ Reconstructive Surgery-regarding Surgery and authorized representative the follow-up treatment needed to correctthat delivery of service from the organization or improve a part of the body because of cannot resolved during the initialorcontact or birthbe defects, accidents, injuries, supervisor involvement. medical conditions. Home HealthItems and services provided as ReferralA written order from your needed in acare patient’s home health primary provider for by youa to see aagency specialist get certain health care or by others or under arrangements made by a services. In Agency. many health maintenance Home Health organizations (HMOs), you need to get a referral before you can get health care HospiceA from healthcare facility that provides services anyone except your primary supportive care for the terminally ill. care provider. If you don’t get a referral first, the plan may not pay for the services. Inquiry- Customer contacts AultCare to Rehabilitation ServicesHealthAultCare care with request information or to provide services that help a person keep, get information. back, or improve skills and functioning for daily living that have been lost or Insured ProductA pre-designed plan impaired because a person wasbenefit sick, hurt, for or smaller companies which is purchased disabled. through premiums. The insurance company assumes the risk rather than the employer. Medically Necessary- Services or supplies provided by a hospital, physician or other Mail Claims Directly To: provider to identify or treat an illness or injury AultCare onP.O. a cost effective basis, when those services Box 6910 or supplies are 44706 determined to be: 1. Consistent Canton, OH with the symptom or diagnosis and treatment of the condition, disease, ailment or injury.

2.These Appropriate to physical the standards serviceswith mayregard include and speech-language ofoccupational good medicaltherapy, practice. 3. Not primarily for pathology, and psychiatric rehabilitation the convenience of the patient, the physician services in a variety of inpatient and/or oroutpatient other provider. 4. The most appropriate settings. supplies or services that can be provided safely to the patient. For inpatients, it means that the Screening- A type of preventive care that services ortests supplies cannot provided safely includes or exams tobe detect the presence onofan outpatient basis. something, usually performed when you have no symptoms, signs, or prevailing medical history of a disease MemberThe enrolleeororcondition. dependent listed on the plan is considered a “member” of the Skilledprogram. Nursing Care- Services performed or health supervised by licensed nurses in your home or in a nursing home. Skilled nursing care is not Non-certificationA decision made which by the same as “skilled care services”, are the Utilization Management Department, services performed by therapists or technicians including an AultCare (rather than licensedphysician, nurses) in that youran home or in a nursing extension home. of stay, or other health admission, care service has been reviewed and based on SpecialistA provider focusing on ameet specific the information provided, does not the area of medicine or a group of patients to diagnose, clinical requirements for medical necessity, manage, prevent, or treat certain types of appropriateness, level of care, or effectiveness symptoms and conditions. under the auspices of the applicable health benefit plan. Specialty Drug- A type of prescription drug that, in general, requires special handling or ongoing Out-of-PocketTheassessment total amount claimant monitoring and by aa health care may pay beforeorbenefits begin payingtoatdispense. 100% professional, is relatively difficult specialty are the orGenerally, percent defined bydrugs the plan. Thismost does not expensive drugsabove on a formulary. include amounts the usual, customary and reasonable fee, ineligible amounts, or UCR (Usual, Customary Reasonable)amounts exceeding theand benefit limitations. The amount paid for a medical service in a geographic area based on what providers in the Outpatient Servicesand/or area usually charge Medical for the same or other similar services by aUCR hospital, or other medicalprovided service. The amount sometimes is qualified or supplier, such as mental used tofacility determine the allowed amount. health clinic, mobile x-ray unit or freestanding dialysis Such include outpatient Urgentunit. CareCareservices for an illness, injury, or condition serious enough that a reasonable physical therapy, diagnostic x-rays and person would laboratory tests. seek care right away, but not so severe as to require emergency room care.

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AultCare/Aultra General Tag Lines for the State of Ohio English If you, or someone you are helping, have questions about AultCare/Aultra you have the right to get help and information in your language at no cost. To speak with an interpreter, call Local: 330.363.6360 Outside Stark County: 1.800.344.8858 TTY Local: 330.363.2393 Outside Stark County: 1.866.633.4752 Spanish Español Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca AultCare/Aultra tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al Local : 330.363.6360 Fuera del condado de Stark : 1.800.344.8858 TTY Local : 330.363.2393 Fuera del condado de Stark : 1.866.633.4752 Chinese 中文 如果您，或是您正在協助的對象，有關於 AultCare/Aultra 保险公司 方面的問題，您有權利免費以您的母語得到幫助和訊息。 洽詢一位翻譯員，請撥電話 本地： 330.363.6360 斯塔克縣外： 1.800.344.8858 TTY 線 本地： 330.363.2393 斯塔克縣外： 1.866.633.4752。 German Deutsche Falls Sie oder jemand, dem Sie helfen, Fragen zum AultCare/Aultra haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer Local: 330.363.6360 Außerhalb von Stark County : 1.800.344.8858 TTY –Linie Local: 330.363.2393 Außerhalb von Stark County : 1.866.633.4752 an. Arabic

‫ال عرب ية‬

‫ للتحدث مع مترجم اتصل ب‬.‫ لديك الحق في الحصول على المساعدة والمعلومات الضرورية بلغتك من دون اية تكلفة‬،‫العربية‬ ‫ إن كان لديك أو لدى شخص تساعده أسئلة بخصوص شركة التأمين‬AultCare/Aultra 1.800.344.8858 : ‫ خارج مقاطعة ستارك‬TTY ‫ الخط‬330.363.2393 :‫ المحلي‬1.866.633.4752 . ‫خارج مقاطعة ستارك‬

Pennsylvania Dutch Deitsch Wann du hoscht en Froog, odder ebber, wu du helfscht, hot en Froog baut AultCare/Aultra hoscht du es Recht fer Hilf un Information in deinre eegne Schprooch griege, un die Hilf koschtet nix. Wann du mit me Interpreter schwetze witt, kannscht du Local: 330.363.6360 Außerhalb von Stark County: 1.800.344.8858 TTY –Linie Local: 330.363.2393 Außerhalb von Stark County : 1.866.633.4752 uffrufe. Russian русский Если у вас или лица, которому вы помогаете, имеются вопросы по поводу Страховая компания AultCare/Aultra, то вы имеете право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните по телефону Местный: 330.363.6360 Вне Старка County : 1.800.344.8858 TTY линия Местный: 330.363.2393 Вне Старка County : 1.866.633.4752. French Français Si vous, ou quelqu'un que vous êtes en train d’aider, a des questions à propos de Compagnie d'Assurance AultCare/Aultra, vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, Appelez Locale 330.363.6360 En dehors du comté de Stark : 1.800.344.8858 ligne ATS Local : 330.363.2393 En dehors du comté de Stark : 1.866.633.4752. Vietnamese Việt Nam Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Công ty Bảo hiểm AultCare/Aultra quý vị sẽ có quyền được giúp và có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi Địa phương: 330.363.6360 Bên ngoài của Stark County : 1.800.344.8858 TTY đường dây Địa phương: 330.363.2393 Bên ngoài của Stark County : 1.866.633.4752. Cushite-Oromo Isin yookan namni biraa isin deeggartan AultCare/Aultra, irratti gaaffii yo qabaattan, kaffaltii irraa bilisa haala ta’een afaan keessaniin odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabdu. Nama isiniif ibsu argachuuf, lakkoofsa bilbilaa Local: 330.363.6360 Outside of Stark County: 1.800.344.8858 TTY Line Local: 330.363.2393 Outside of Stark County: 1.866.633.4752 tiin bilbilaa. AultCare/Aultra General Tag Lines

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Korean 한국어 만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 AultCare/Aultra 보험 회사 에 관해서 질문이 있다면 귀하는 그러한 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는 지역 : 330.363.6360 스타크 카운티 의 외부 : 1.800.344.8858 TTY 라인 지역 : 330.363.2393 스타크 카운티 의 외부 : 1.866.633.4752 로 전화하십시오. Italian Italiano Se tu o qualcuno che stai aiutando avete domande su AultCare/Aultra, hai il diritto di ottenere aiuto e informazioni nella tua lingua gratuitamente. Per parlare con un interprete, puoi chiamare Locale: 330.363.6360 Al di fuori di Stark County : 1.800.344.8858 TTY linea Locale: 330.363.2393 Al di fuori di Stark County : 1.866.633.4752. Japanese 日本語 ご本人様、またはお客様の身の回りの方でも AultCare/Aultra 保険会社についてご質問がございましたら、ご希望の言語でサ ポートを受けたり、情報を入手したりすることができます。料金はかかりません。通訳とお話される場合、 ローカル： 330.363.6360 スターク郡の外： 1.800.344.8858 TTY ライン ローカル： 330.363.2393 スターク郡の外： 1.866.633.4752 までお電話ください。 Dutch Nederlands Als u, of iemand die u helpt, vragen heeft over AultCare/Aultra, heeft u het recht om hulp en informatie te krijgen in uw taal zonder kosten. Om te praten met een tolk, bel Local : 330.363.6360 Buiten Stark County : 1.800.344.8858 TTY Line Local : 330.363.2393 Buiten Stark County : 1.866.633.4752. Ukrainian український Якщо у Вас чи у когось, хто отримує Вашу допомогу, виникають питання про Страхова компанія AultCare/Aultra, у Вас є право отримати безкоштовну допомогу та інформацію на Вашій рідній мові. Щоб зв’язатись з перекладачем, задзвоніть на Місцевий : 330.363.6360 Поза Старка County : 1.800.344.8858 TTY лінія Місцевий : 330.363.2393 Поза Старка County : 1.866.633.4752. Romanian Română Dacă dumneavoastră sau persoana pe care o asistați aveți întrebări privind Compania de Asigurari AultCare/Aultra, aveți dreptul de a obține gratuit ajutor și informații în limba dumneavoastră. Pentru a vorbi cu un interpret, sunați la Locale : 330.363.6360 In afara Stark Judet : 1.800.344.8858 TTY linie Locale : 330.363.2393 In afara Stark Judet : 1.866.633.4752. Non-Discrimination Notice: AultCare/Aultra complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. AultCare/Aultra does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. AultCare/Aultra provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters and written information in other formats (large print, audio, accessible electronic formats, other formats). AultCare/Aultra provides free language services to people whose primary language is not English, such as: Qualified interpreters and information written in other languages. If you need these services, or if you believe that AultCare/Aultra has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can contact or file a grievance with the: AultCare/Aultra Civil Rights Coordinator, 2600 6th St. S.W. Canton, OH 44710, 330-363-7456, [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, our Civil Rights staff is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

AultCare/Aultra General Tag Lines

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P.O. Box 6910 Canton, Ohio 44706

Rev. 616/16 10/08