SBC Disclosure

Kadada' na Sinangan I Benefisiu Siha yan Kinobre Siha: Hafa esti na Planu ha Kokobre siha & Hafa Un Apasi para Ma Kobre na Setbisiu siha Tiempon Kinobre: [See Instructions]

: Kinobre para: | Klasin Planu:

Impottante na Kuestion Siha	Ineppe Siha	Hafa Na Gai Sustansia Esti:
Hafa i kinabales deductible?	$	Gi enerat, debi na un apasi todu i gasto siha ginen man pribeniniyi siha hulo esta deductible kinantida antes di esti planu ha tutuhon man apasi. [For family coverage, see instructions for additional applicable language.]
Kao guaha siha setbisiu man ma kobre antes di un fakcha'i iyo-mu deductible?	Hunggan. [Insert: major categories]	Esti planu ha kokobre palu kosas siha yan setbisiu siha achokha' ti un fakchacha'i i deductible kinantida. Lao i copayment osino coinsurance sina aplikao. [For non-grandfathered plans, insert: "Pot ehemplo, esti planu ha kokobre palu setbisiun tinagam siha sin pinatten gasto yan antes di un fakcha'i iyo-mu deductible. Atan i listan kinobre setbisiun tinagam siha gi https://www.healthcare.gov/coverage/preventive-care-benefits/."]
Kao guaha siha otro deductibles para spesifiku na sebisiu siha?	Hunggan. $	Debi na un apasi todu i gasto para esti siha na setbisiu esta hulo i spesifikat deductible kinantida antes di esti planu ha tutuhon man apasi.
Hafa ayu i san hiyong-i- boksa limite para esti planu?	$	I limiten sin hiyong-i-boksa sa i mas para un apasi gi halom un sakkan para man ma kobre na setbisiu siha. [For family coverage, see instructions for additional applicable language.]
Hafa ti ma inkluso gi halom i limiten san hiyong-i-boksa?	[Insert: major exceptions]	Achokha' un apapasi esti siha na gasto, ti man ma tufong halom gi limiten san hiyon-i-boksa.
Kao para un apasi ti megai yanggen un usa i man pribeniniyi network?	Hunggan. Atan [www.insert.com] osino a'gang 1-800-[insert] para i listan i man pribeniniyi network siha.	Esti planu ha u'usa i man pribeniniyi network. Siempre ti megai para un apasi yanggen un usa i man pribeniniyi gi halom i iyon planu network. Siempre un apasi mas yanggen un usa i man pribeniniyi san hiyong-i-network, yan sina kasi man risibi hao kubransa ginen i man pribeniniyi para i difrensia gi entalo i iyon man pribeniniy itinigon yan hafa iyo-mu planu ha apapasi (balansia na tinigon). Ke'tungo, iyo-mu man pribeniniyi network sina ha usa man pribeniniyi san hiyon-i-network para palu setbisiu siha (tat kumo che'cho' lab). Ke'sotda yan iyo-mu man pribeniniyi antes di un fanuli setbisiu siha.
Kao un nisisita i riniferi para un li'e i specialist?	Hunggan.	Esti planu siempre ha apasi palu osino todu i gasto siha para un li'e i specialist para man ma kobre na setbisiu siha lao solo yanggen guaha hao riniferi antes di un li'e i specialist.

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