SBC Disclosure

Weeimwoscheel Benefisio me Bwalabwal: Mili kka Plano e Bwalúw me óbwóssul Setbisio Bwalabwal Yeey: [See Instructions]

: Bwalabwalul: | Iital Plano:

Weeimwoscheel Benefisio me Bwalabwal (WBB) dokumento yeel ebwe alisi yóómw affil mil ghatsch na plano. WBB ebwe abwaari yóómw plano me góósto reel alongal setbisio kka e bwalubwal. WERI: Infotmasion reel góóstol plano yeel (iital nge premium) imu epwaal isisiwow. Milleel nge weeimwoscheel schagh. Ngare u mweschel mas infotmasion reel mili kka e bwalabwal, me ngare copial alongal bwalabwal, [insert contact information]. Seletil kkepas kka allowed amount, balance billing, coinsurance, copayment, deductible, provider, me akkááw kkapas, amweri reel Glossary. Emmwel ubwe amweri Glossary reel [www.insert.com] ngare ffaingi 1-800-[insert] ngare ubwe tingór yóómw copy.

Mil Impotante Aiyegh	Appalúwal	Búlúúl Lifilifil Yeey
Meeta mas na deductible?	$
Eyoor mas setbisio kka e bwalabwal ilummwal yóómw deductible?
Eyoor mas deductible reel akkááw setbisio?	$
Meeta mas óbwóssul out-of-pocket limit reel plano yeel?	$
Meeta kka ese bwalabwal lóll out-of-pocket limit?
Emmwel ubwe amééw ngare e tetiiw óbwóssul network provider?
U nisisitai referral ngare ubwe weri specialist?

Alongal góóstol copayment me coinsurance kka lóll chart yeey nge mweril yóómw deductible, ngare eyoor deductible.

Buluul Yóómw Fáárágh	Setbisio Kka U Nisisitai	Meeta Ubwe Óbwóssuw		Órorosol, Mil Se Bwung, me Akkááw Impotante na Infotmasion
		Network Provider (Ebwe ghitighit óbwóss)	Out-of Network Provider (Ebwe tumógh óbwóss)
Ngare u bisitai health care provider’s ofis me ngare clinic	Ghommwal sáfeyal wós me sumwaay.
	Ngare u bisital Specialist
	Pilipiliil sumwaay/screening/ immunization
Ngare eyoor yóómw test	Diagnostic test (x-ray, blood work)
	Imaging (CT/PET scans, MRIs)
Ngare u nisisitai sáfeyal sumwaay. Eyoor mas arongorong reel prescription drug coverage me reel [www.insert.com]	Generic drugs
	Sáfey kka u tipeli
	Sáfey kka use tipeli
	Specialty drugs
Ngare u opera nge u outpatient	Óbwóssul fasilitad (e.g., leliyeel ambulatory na opera)
	Óbwóssul dokto me doktol opera
Ngare ughi nisisitai mutekkaay atension	Kuattol emergency na setbisio
	Emergency na waawa
	Ammwel kaay
Ngare u looló spitóód	Óbwóssul fasilitad (e.g., kuatto)
	Óbwóssul dokto me doktol opera
Ngare u nisisitai setbisiol mental health, behavioral health, me substance abuse	Setbisiol outpatient
	Setbisiol inpatient
Ngare u bwoobwo	Bisital ofis
	Layúlaay/amakkúúl professionat na setbisio
	Layúlaay/leliyeel amakkúúw
Ngare u nisisitai ubwe serragh me mil spesiat na alilis	Home health care
	Setbisiol Rehabilitation
	Setbisiol Habilitation
	Skilled nursing care
	Mil lléégh peiráághil sáfey
	Setbisiol amaamaa
Ngare loomw e nisisitai setbisiol ngii me maas	Tesil maasal ologhet
	Yaar antiyos ologhet
	Ngiil ologhet check-up

Mil se Bwalabwal me akkááw mil Bwalabwal na Setbisio:

Setbisio kka Yóómw Plano ese Bwalúw: (Amweri yóómw ppwol ngare tilighil plano reel mas infotmasion ngare listal mil ese bwalabwal na setbisio.)

Akkááw mil Bwalabwal na Setbisio (Eyoor órorosol mili kka na setbisio. Saabw alongal elo wóól lista yeel. Amweri dokumentol yóómw plano.

Diretchom Bwe Ubwe Kke Yáyáá Schagh Bwalabwal Kkei: Eyoor bwulasio kka rebwe scheelugh ubwe sóbweey bwalabwal kkei ngare a meeló. Emmwel ubwe faingi bwulasio kkei reel [insert State, HHS, DOL, and/or other applicable agency contact information]. Ebwal emmwel ubwe akkame yóómw insurance me reel Health Insurance Marketplace. Reel mas infotmasion lóll Marketplace, bisitai www.HealthCare.gov ngare ffaingi 1-800-318-2596.

Yóómw Grievance me Appeals Rights: Eyoor bwulasio kka emmwel rebwe scheelugh ngare reel complaint bwe yóómw plano e asefali claim. iital complaint yeel nge grievance me appeal. Ngare u nisisitai mas infotmasion reel diretchom, amweri kkapasal benefisio kka ubwe resibiiy faal yóómw medical claim. Dokumentol yóómw plano ebwal abwáári efaisul ubwe atolongow yóómw claim, appeal, me grievance inamwo met faal yóómw plano. Ngare mas infotmasion reel diretchom, arongorong me alilis yeel, faingi [insert applicable contact information from instructions].

Plano yeel e ayoora Minimum Essential Coverage: (Aawer/Ehe)

Minimum Essential Coverage nge alongal plano me health insurance kka eyoor lóll Marketplace me akkááw ppwol, Medicare, Medicaid, CHIP, TRICARE, me bwal akkááw. Ngare emmwel ubwe yááyá Minimum Essential Coverage, meli nge u saabw mwel ubwe yááyá premium tax credit.

Plano Yeel e Schuupagh me Minimum Value Standards? (Aawer/Ehe/Ehe Ese Fil)

Ngare yóómw plano ese schuupagh me Minimum Value Standards, emmwel ubwe yááyá reel premium tax credit bwe ebwe scheelugh reel óbwóssul plano me lóll Marketplace.

Language Access Services:

Spanish (Español): Para obtener asistencia en Español, llame al [insert telephone number].

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa [insert telephone number].

Chinese (中文): 如果需要中文的帮助, 请拨打这个号码[insert telephone number].

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' [insert telephone number].

Pennsylvania Dutch (Deitsch): Fer Hilf griege in Deitsch, ruf [insert telephone number] uff.

Samoan (Gagana Samoa): Mo se fesoasoani i le Gagana Samoa, vala’au mai i le numera telefoni [insert telephone number].

Carolinian (Kapasal Falawasch): ngere aukke ghut alillis reel kapasal Falawasch au fafaingi tilifon ye [insert telephone number].

Chamorro (Chamoru): Para un ma ayuda gi finu Chamoru, å’gang [insert telephone number].

Ngare ubwe weri e faisul plano yeel ebwe óbwóssuw góóstol meeta na medical situation, pipiiy mweril section yeel.

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1146. The time required to complete this information collection is estimated to average 0.02 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Example Bwalabwal Kkei

Milleel Nge Saabw Estimator. Sáfey kkei nge examples schagh reel meeta kka e bwalabwal faal plano yeel. Yóómw óbwóss nge ebwe dependi reel meeta na setbisio u resibiiy, óbwóssul yóómw providers, me bwal akkááw. Suul ghatch ngali cost-sharing kkei (deductibles, copayments, me coinsurance) bawl bwalabwal na setbisio faal plano. Yááyá infotmasion kkei bwe ubwe awewei óbwóssul plano kka eyoor. Alongal bwalabwal kkei nge e fil reel self-only coverage.

Peg Ebwe Layulaay

(9 méraam reel pre-natal me spitóód)

Alongal planun deductible	$
Specialist [cost sharing]	$
Hospital (fasilidat) [cost sharing]	%
Other [cost sharing]	%

Milleel Na EXAMPLE Nge Elo Setbisio Kkei:

Specialist office visits (prenatal care)

Childbirth/Delivery Professional Services

Childbirth/Delivery Facility Services

Diagnostic tests (ultrasounds and blood work)

Specialist visit (anesthesia)

Ammwelil Joe’s Type 2 Diabetes

(Yeew ráágh reel sáfey me ammwel)

Total Example Cost	$12,700
Lóll example iyeel, Peg ebwe óbwóss:
Cost Sharing
Deductibles	$
Copayments	$
Coinsurance	$
Mili kka ese bwalubwal
Limits or exclusions	$
Alongal Yaal Peg Óbwóss	$

Alongal planun deductible	$
Specialist [cost sharing]	$
Hospital (fasilidat) [cost sharing]	%
Other [cost sharing]	%

Milleel Na EXAMPLE Nge Elo Setbisio Kkei:

Primary care physician office visits (including disease education)

Diagnostic tests (blood work)

Prescription drugs

Mil lléégh peiráághil sáfey (glucose meter)

Total Example Cost	$5,600
Lóll example iyeel, Joe ebwe óbwóss:
Cost Sharing
Deductibles	$
Copayments	$
Coinsurance	$
Mili kka ese bwalubwal
Limits or exclusions	$
Alongal Yaal Joe Óbwóss	$

Mia’s Mwétetteril Bwull

(Spitóód me Ammwel)

Alongal planun deductible	$
Specialist [cost sharing]	$
Hospital (fasilidat) [cost sharing]	%
Other [cost sharing]	%

Milleel Na EXAMPLE Nge Elo Setbisio Kkei:

Kuattol emergency na setbisio (including medical supplies)

Diagnostic test (x-ray)

Mil lléégh peiráághil sáfey (crutches)

Setbisiol Rehabilitation (physical therapy)

Total Example Cost	$2,800
Lóll example iyeel, Mia ebwe óbwóss:
Cost Sharing
Deductibles	$
Copayments	$
Coinsurance	$
Mili kka ese bwalubwal
Limits or exclusions	$
Alongal Yaal Mia Óbwóss	$

Plano yeel nge e lemeli akkááw góósto reel EXAMPLE kka e bwalabwal na

(OMB control number: 0938-1146/Expiration date: 05/31/2026)

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