SBC Disclosure

Weeimwoscheel Benefisio me Bwalbwal: Mili kka Plano e Bwalúw me Óbwóssul Setbisio		Tempool Bwalabwal Yeey: [See Instructions]
___________________:_________________________	Bwalabwalul: ________ | Iital Plano: ______

W eeimwoscheel Benefisio me Bwalabwal (SBC) dokumento yéél ebwe alisi yóómw affil mil ghatsch plano. SBC ebwe abwaari ngelugh meeta yeel me plano aubwe schuu reel óbwóssul mili kka e bwalabwal na setbisio. WERI: Infotmasion reel góóstol plano (iital nge premium) ikka eppwaal isisiwow. Milleel nge weeimwoscheel schagh. Ngare u mweschel mas infotmasion reel mili kka e bwalabwal, ngare copial alongal bwalabwal, [insert contact information]. Seletil kkapas kka allowed amount, balance billing, coinsurance, copayment, deductible, provider, me akkááw kkapas, amwéri réél Glossary. Emmwel ubwe weri Glossary reel [www.insert.com] ngare faingi 1-800-[insert] bwe ubwe tingór yóómw copy.

Mil Impotante na Aiyegh	Appalúwal	Búlúúl Lifilifil Yeey
Meeta yóómw deductible?	$0	Pipiiy Common Medical Events chart imu faal reel fitoow óbwóssul setbisio reel plano.
Eyoor mas setbisio ilummwal yóómw deductible?	Ehe	Ubwe óbwóssuw mo deductible ngare plano ebwe mmwel le óbwóss inaamwo meet na setbisio.
Eyoor mas deductible reel akkááw setbisio?	Ehe	Inaamwo use meet li deductibles bwe ubwe yááyá setbisio.
Meeta kka out-of-pocket limit reel plano yeel?	Ese fil	Esóór out-of-pocket limit reel plano yeel.
Meeta kka ese bwalabwal lóll out-of-pocket limit?	Ese fil	Esóór out-of-pocket limit reel plano yeel reel yóómw gusto.
Emmwel ubwe amééw ngare e tetiiw óbwóssul network provider?	Ese fil	Esóór network provider lóll plano yeel. Emmwel ubwe resibii mil bwalubwal na setbisio me reer akkááscheey provider.
U nisisitai referral ngare ubwe weri specialist?	Ehe	Emmwel ubwe weri specialist iye u tipáli sin referral.

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.

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