Part 2 – Explanation of Terms (continued) WORDS IN ITALICS ARE EXPLAINED IN PART 2. Page 20 Mental Health Providers This health plan provides coverage for treatment of a mental condition when these covered services are furnished by a covered provider who is a mental health provider. These covered providers include any one or more of the following kinds of health care providers: alcohol and drug treatment facilities; clinical specialists in psychiatric and mental health nursing; community health centers (that are a part of a general hospital); day care centers; detoxification facilities; general hospitals; licensed alcohol and drug counselor I providers; licensed independent clinical social workers; licensed marriage and family therapists; licensed mental health counselors; mental health centers; mental hospitals; opioid treatment program providers; physicians; psychiatric nurse practitioners; psychologists; and other mental health providers that are designated for you by Blue Cross Blue Shield HMO Blue. Out-of-Pocket Maximum (Out-of-Pocket Limit) Under this health plan, there is a maximum cost share amount that you will have to pay for certain covered services. This is referred to as an “out-of-pocket maximum.” Your ID card will show the amount of your out-of-pocket maximum. The Schedule of Benefits for your plan option will show the amount of your out-of-pocket maximum and the time frame for which it applies—such as each calendar year or each plan year. It will also describe the cost share amounts you pay that will count toward the out-of-pocket maximum. (Also refer to riders—if there are any—that apply to your coverage in this health plan.) Once the cost share amounts you have paid that count toward the out-of-pocket maximum add up to the out-of-pocket maximum amount, you will receive full benefits based on the Blue Cross Blue Shield HMO Blue allowed charge for more of these covered services during the rest of the time frame in which the out-of-pocket maximum provision applies. There are some costs that you pay that do not count toward the out-of-pocket maximum. These costs that do not count toward the out-of-pocket maximum are:  The premium you pay for your health plan.  The costs you pay when your coverage is reduced or denied because you did not follow the requirements of the Blue Cross Blue Shield HMO Blue utilization review program. (See Part 4.)  The costs you pay that are more than the Blue Cross Blue Shield HMO Blue allowed charge.  The costs you pay because your health plan has provided all of the benefits it allows for that covered service. Note: As required by federal law for “surprise billing,” any cost share amounts paid for certain covered services furnished by non-preferred providers will contribute toward satisfying your in-network out-of-pocket maximum amount. (See Part 2, “Allowed Charge” for an explanation of these services.) See the Schedule of Benefits for your plan option for other costs that you may have to pay that do not count toward your out-of-pocket maximum. The out-of-pocket maximum is indexed to the average national premium growth and the amount may be increased annually. This means that your out-of-pocket maximum amount may increase from time to time, as determined by Blue Cross Blue Shield HMO Blue. Blue Cross Blue Shield HMO Blue will notify you if this happens. However, the amount of your out-of-pocket maximum will never be more than the maximum out-of-pocket maximum amount allowed under applicable law. Outpatient The term “outpatient” refers to your status as a patient. Your status is important because it affects how much you will pay for covered services. You are an outpatient if you are getting emergency room services, observation services, outpatient day surgery, or other hospital services such as lab tests or x-rays and the doctor has not written an order to admit you to the hospital or health care facility as an inpatient.