2026 CODAC Benefit Summaries and Carrier Flyers

Provider means any person or company that provides a health care service including, without limitation, Physicians, Hospitals, Ambulatory Surgical Centers, pharmacies, skilled nursing facilities, and residential treatment centers.

Prudent Layperson means a person with average knowledge of health and medicine who is not formally educated or specialized in the field of medicine.

QMCSO means a Qualified Medical Child Support Order in accordance with applicable law.

Qualified means licensed, registered, and/or certified in accordance with applicable state law, and the particular service or treatment being provided is within the scope of the license, registration, and/or certification. Qualified Provider means a Provider duly licensed, registered, and/or certified by the state in which he or she is practicing, whose scope of practice includes the particular service or treatment being provided that is payable under this Plan. Recognized Amount means, in the Plan’s determination of the allowed amount payable for covered services subject to the Protection from Balance Bills, the amount on which Co-pays, Plan Participation, and applicable Deductibles are based for the below covered health services when provided by non Network Providers: • Non-Emergency covered health services received at certain Network facilities by non-Network Physicians, when such services are either Ancillary Services or non-Ancillary Services that have not satisfied the notice and consent criteria of section 2799B-2(d) of the Public Service Act. For the purpose of this provision, the term "certain Network facility" is limited to a Hospital (as defined in section 1861(e) of the Social Security Act), a Hospital Outpatient department, a critical access Hospital (as defined in section 1861(mm)(1) of the Social Security Act), an Ambulatory Surgical Center (as described in section 1833(i)(1)(A) of the Social Security Act), and any other facility specified by the Secretary of Health and Human Services. • Non-Network Emergency health services.

The amount is based on either:

an All Payer Model Agreement if adopted,

• •

state law, or

• the lesser of the qualifying payment amount as determined under applicable law or the amount billed by the Provider or facility.

The Recognized Amount for air ambulance services provided by a non-Network Provider will be calculated based on the lesser of the qualifying payment amount as determined under applicable law or the amount billed by the air ambulance service Provider. Note: Covered health services that use the Recognized Amount to determine Your cost-sharing may be higher or lower than if cost-sharing for these covered health services was determined based upon a Covered Expense. Reconstructive Surgery means surgical procedures performed on abnormal structures of the body caused by congenital Illness or anomaly, Accident, or Illness. The fact that physical appearance may change or improve as a result of Reconstructive Surgery does not classify surgery as Cosmetic Treatment when a physical impairment exists and the surgery restores or improves function.

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