SBC Disclosure

En katzer Description vun Sache as du grigscht un wie du gecovered bischt: Was daer Plaen covere dutt un was du bezaahlscht fer Services as du griege mechscht

Die Zeit vun Coverage: [See instructions]

: ^{Coverage fer: | Was fer Plaen:}

Daer katz Description vun Sache as du grigscht un wie du gecovered bischt ("Summary of Benefits and Coverage", SBC) helft dich choos-e en Insurance Plan. Der SBC weist dich wie du un der Insurance Plan die Koschte fer gecoverdi Services shar-e deetet. NOTE: Du zellscht Information griege weeich die Koscht vun daer Plan (was mer heest en Premium) separate. Des is yuscht en katzer Description. Fer meh Information griege

weeich dei Coverage, adder fer en Copy griege vun all die Details vun Coverage [insert contact information]. Fer Definitions vun commoni Wadde, so wie allowed amount, balance billing, coinsurance, copayment, deductible, provider odder annri Wadde as underlined sin, guck die Glossary. Du kannscht die Glossary an

[www.insert.com] odder 1-800-[insert] uffrufe fer froge fer en Copy.

Wichdichi Questions	Andwadde	Ferwas Des Wichdich Is:
Was is der gans Deductible?	$
Hot's Services as gecovered sin eb du hoscht bezaahlt dei Deductible?
Hot's annri Deductibles fer particulari Services?	$
Was is der Out-of-Pocket Limit fer daer Plan?	$
Was is net include in der Out-of- Pocket Limit?
Zellscht du wennicher bezaahle wann du en Network Provider yuuscht?
Brauchscht du en Referral fer en Specialist sehne?

Alli Copayment un Coinsurance Koschte in daer Chart sin nooch as du dei Deductible bezaahlt hoscht, wann en Deductible applye dutt.

En Commoner Medical Situation	Services As Du Brauche Mechscht	Was Du Bezaahle Musscht:		Restrictions un Annri Wichdichi Information
		Network Provider (Du bezaahlscht s'wennichscht)	Out-of-Network Provider (Du bezaahlscht s'menscht)
Wann du gehscht zu en Health Care Provider sei Office adder Clinic	En Visit fer Care griege wann du wehgeduh adder grank bischt
	Specialist Visit
	Preventive Care/ Screening/ Shots griege
Wann du en Test hoscht	Diagnostic Test (X-ray, Blut teste)
	Imaging (CT/PET Scans, MRIs)
Wann du Drugs brauchscht fer dich treate Meh Information wege Prescription Drug Coverage kann mer griege an [www.insert.com]	Generic Drugs
	Brand-Naame Drugs as preferred sin
	Brand-Naame Drugs as net preferred sin
	Specialty Drugs
Wann du Outpatient Surgery brauchscht	Der Fee fer der Blatz (so wie en Ambulatory Surgery Center)
	Die Fees fer en Dockter adder en Surgeon
Wann du Care griege brauchscht graadeweck	Emergency Schtubb Care
	Emergency Medical Transportation
	Urgent Care
Wann du im Hospital sei musscht	Der Fee fer der Blatz (so wie en Hospital Schtubb)
	Die Fees fer en Dockter adder en Surgeon
Wann du Mental Health, Behavioral Health, odder Substance Abuse Services brauchscht	Outpatient Services
	Inpatient Services
Wann du an ekschpeckte bischt	Office Visits
	Professional Services fer en Baby hawwe
	Blatz Services fer en Baby hawwe
Wann du Hilf brauchscht fer besser warre adder annri abbadichi Health Needs	Home Health Care
	Rehabilitation Services
	Habilitation Services
	Skilled Nursing Care
	Durable Medical Equipment
	Hospice Services
Wann dei Kind Zaah adder Aage Care braucht	Kinnner Eye Exam
	Brille fer Kinner
	Zaah Checkup fer Kinner

Services as Net Gecovered Sin un Annri Services:

Services As Dei Plan Gweenlich NET Covere Dutt (Guck dei Policy adder Plan Document fer meh Information un en List vun of ennichi annri Services as exclude sin.)
		

Annri Gecoverdi Services (Samm Limitations mechde applye do. Die List dutt net alles includ-e. Guck dei Plan Document.)
		

Dei Rechte fer Aahalde Coverage Griege: S'hot Bletz as dich helfe kenne wann du aahalde witt Coverage griege nochdem as er ausgloffe is. Du kannscht selli Bletz contact do: [insert State, HHS, DOL, and/or other applicable agency contact information]. Du mechscht aa annri Options hawwe so wie Private insurance kaafe deich der Health Insurance Marketplace. Fer meh Information wege der Marketplace, geh zu www.HealthCare.gov adder ruf 1-800-318- 2596 uff.

Dei Grievance un Appeal Rechte: Es sin Bletz as helfe kenne wann du en Complaint geeich dei Plan hoscht fer nunnergedreht warre wege en Claim. So en Complaint heest mer en Grievance adder en Appeal. Fer meh Information wege dei Rechte, lees die Explanation vun Benefits as du grigscht fer seller medical Claim. Dei Plan Documents lege aus alles was mer duh muss fer submitte en Claim, Appeal, adder en Grievance fer ennicher Reason wege dei Plan. Fer meh Information wege dei Rechte, daer Notice, adder Hilf, geh zu: [insert applicable contact information from instructions].

Dutt daer Plan Minimum Essential Coverage gewwe? [Ya/Nee]

Minimum Essential Coverage dutt gweenlich includ-e Plans, Health Insurance as mer griege kann deich der Marketplace adder annri private Insurance Policies, Medicare, Medicaid, CHIP, TRICARE, un certaini annri Forms vun Coverage. Wann du qualifye duscht fer certaini Types vun Minimum Essential Coverage, mechscht du velleicht net eligible sei fer der Premium Tax Credit.

Is daer Plan gut genung fer die Minimum Value Standards? [Ya/Nee/Dutt Net Applye]

Wann dei Plan net gut genung is fer die Minimum Value Standards, mechscht du velleicht eligible sei fer en Premium Tax Credit fer dich helfe bezaahle fer en Plan deich der Marketplace.

Services fer Helfe Mit Schprooche:

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].

Fer Examples sehne wie daer Plan die Koschte fer en Sample Medical Situation covere mecht, geh zu die negscht Section.

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.

Wege die Coverage Examples:

Des is net en Cost Estimator. Die Treatments as gwisse warre do sin yuscht Examples vun wie daer Plan Medical Care covere mecht. Was du actually getschaertscht wattscht dependt uff die Care as du grigscht, die Prices as dei Providers tschaertsche, un en latt annri Dinger. Guck an die cost-sharing Amounts (Deductibles, Copayments un Coinsurance) un Services as exclude sin unich der Plan. Duh die Information yuuse fer compar-e mit was du bezaahle misscht unnich annri Health Plans. Die Coverage Examples duhn yuscht applye zu Leit as alles selwert bezaahle misse.

Die Peg Is an Eckscpeckte

(9 Muunet vun in-Network Care eb's Baby kummt un Delivery in en Hospital)

• Der Plan sei overall Deductible. $

• Specialist [Cost Sharing] $

• Hospital (Blatz) [Cost Sharing] %

• Other [Cost Sharing] %

Daer EXAMPLE Event dutt Services includ-e wie:

Office Visits bei Specialists (Care wann mer an eckschpeckte is)

Professional Services Fer En Baby Hawwe Bletz Services Fer En Baby Hawwe

Tests fer ausfiggere was letz is (Ultrasounds un Blut Tests)

Visit bei en Specialist (Anesthesia)

Der Joe sei Type 2 Diabetes Manag-e

(en Yaahr vun basic In-Network Care vun en Condition as gut controlled watt)

Total Example Koscht		$12,700
In daer Example deet die Peg bezaahle:
Cost Sharing
Deductibles	$
Copayments	$
Coinsurance	$
Was net gecovered is
Limits adder Exclusions	$
Alles was die Peg bezaahle misst	$

• Der Plan sei overall Deductible. $

• Specialist [Cost Sharing] $

• Hospital (Blatz) [Cost Sharing] %

• Other [Cost Sharing] %

Daer EXAMPLE Event dutt Services includ-e wie:

Family Dockter Office Visits (sell include aa lanne wege Diseases)

Tests fer ausfiggere was letz is (Blut Tests)

Prescription Drugs

Durable Medical Equipment (Glucose Meter)

En simpeler Fracture fer die Mia

(Visit zu en in-Network Emergency Schtubb un Follow-Up Care)

Total Example Koscht		$5,600
In daer Example deet der Joe bezaahle:
	Cost Sharing
	Deductibles		$
	Copayments		$
	Coinsurance		$
	Was net gecovered is
	Limits adder Exclusions		$
	Alles was der Joe bezaahle misst		$

• Der Plan sei overall Deductible. $

• Specialist [Cost Sharing] $

• Hospital (Blatz) [Cost Sharing] %

• Other [Cost Sharing] %

Daer EXAMPLE Event dutt Services includ-e wie:

Care in die Emergency Schtubb (sell include aa Medical Supplies)

Test fer ausfiggere was letz is (X-ray)

Durable Medical Equipment (Gricke)

Rehabilitation Services (Physical Therapy)

Total Example Koscht	$2,800
In daer Example deet die Mia bezaahle:
Cost Sharing
Deductibles		$
Copayments		$
Coinsurance		$
Was net gecovered is
Limits adder Exclusions		$
Alles was die Mia bezaahle misst		$

The Plan misst bezaahle fer die annri Koschte vun die EXAMPLE gecoveredi Services.

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

Page 0 vun 5