Family Access Medical

1. Purpose of Coverage

Urgent & Emergency Coverage is designed to provide insurance-style coverage for unexpected medical emergencies and urgent situations that occur outside of Family Access Medical's clinic and normal operating hours.

This Coverage is intended to supplement, not replace, Essential Care.

2. Eligibility & Enrollment

• Urgent & Emergency Coverage is optional
• Coverage must be selected at enrollment or during annual renewal
• Coverage applies on a 12-month calendar-year basis
• Coverage cannot be added, removed, or modified mid-year except through an approved formal upgrade process

Coverage becomes active on the effective date confirmed at enrollment.

3. Covered Services

Subject to the terms below, Urgent & Emergency Coverage may include coverage for:

3.1 Emergency Services

• Emergency room visits
• Emergency hospital admissions
• Ambulance transportation (ground or air when medically necessary)
• Emergency diagnostic testing performed in an emergency setting
• Emergency procedures required to stabilize a medical condition

3.2 Urgent Care Services

• Urgent care center visits
• After-hours urgent medical treatment
• Acute illness or injury requiring immediate attention

3.3 Hospital-Based Emergency Services

• Emergency inpatient stays
• Hospital-administered medications related to emergency treatment
• Emergency surgical or procedural interventions required for stabilization

4. Cost-Sharing Structure

Urgent & Emergency Coverage operates under a traditional insurance-style cost-sharing model, which may include:

• Deductibles
• Co-insurance
• Out-of-pocket maximums

All applicable cost-sharing amounts are disclosed at enrollment and may vary based on the specific plan selected.

5. Non-Covered Services

Urgent & Emergency Coverage does not cover routine, preventive, or planned medical services, including but not limited to:

• Routine primary care visits
• Preventive care or wellness exams
• Imaging or diagnostics ordered through Family Access Medical
• Elective or planned surgeries
• Non-emergency specialty care
• Physical therapy, chiropractic care, or behavioral health services
• Ongoing prescription management or refills outside emergency treatment
• Follow-up care after an emergency event

Post-emergency follow-up care should be managed through Essential Care or other applicable coverage.

6. Medical Necessity & Appropriate Use

Coverage applies only when services are medically necessary and provided in response to an urgent or emergency condition.

Non-emergent use of emergency services may result in reduced or denied coverage.

Family Access Medical does not determine emergency medical necessity; determinations may be made by the applicable coverage administrator or provider.

7. Network & Provider Considerations

Coverage may be subject to:

• Network provider requirements
• Out-of-network limitations
• Facility-specific billing practices

Members are responsible for understanding any applicable network rules disclosed at enrollment.

8. Emergency Situations

Urgent & Emergency Coverage is not a substitute for emergency response.

In the event of a medical emergency:

• Call 911 immediately
• Go to the nearest emergency department

Members should always prioritize personal safety over coverage considerations.

9. Claims, Billing & Administration

• Claims for covered services are processed according to the terms disclosed at enrollment
• Members may be responsible for amounts not covered due to deductibles, co-insurance, exclusions, or non-covered services
• Billing disputes must be raised within the timeframe specified by the coverage administrator

Family Access Medical is not responsible for third-party billing decisions.

10. Misuse & Abuse of Coverage

Improper or repeated non-emergency use of emergency services may result in:

• Denial of coverage for certain services
• Increased cost-sharing
• Non-renewal of coverage

11. Termination & Non-Renewal

Urgent & Emergency Coverage may be terminated or not renewed for:

• Non-payment
• Misrepresentation of eligibility
• Abuse of coverage
• Violation of applicable terms

Termination does not eliminate responsibility for incurred charges.

12. Limitation of Liability

Family Access Medical is not responsible for:

• Care provided by emergency or hospital providers
• Outcomes of emergency treatment
• Third-party billing or coverage determinations

13. Governing Law

These Emergency Coverage Terms are governed by the laws of the State of Ohio.

14. Acceptance & Pending Status

Enrollment in Urgent & Emergency Coverage constitutes acceptance of these Terms. These Terms are pending final legal review and subject to change.