SBC Disclosure

En katzer Description vun Sache as du grigscht un wie du gecovered bischt: Was Daer Plan Covere Dutt Un Was Du Bezaahlscht Fer Gecoveredi Services

:

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"), helft dich en Health Plan choos-e. Der SBC weist dich wie du un der Plan die Koscht fer gecoveredi Health Care 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?	$0	Guck der Common Medical Events Chart unne fer dei Koschte fer Services as daer Plan covere dutt.
Sin's Services as gecovered sin eb du nuff zu dei Deductible kummscht?	Nee.	Du zeelscht misse der Deductible meete eb der Plan fer ennichi Services bezaahlt.
Hot's annri Deductibles fer specifici Services?	Nee.	Du brauchscht net Deductibles meete fer specifici Services.
Was is der Out-of-pocket Limit fer daer Plan?	Sell dutt net applye.	Daer Plan hot ken Out-of-Pocket Limit.
Was is net include in der Out- of-pocket Limit?	Sell dutt net applye.	Daer Plan hot ken Out-of-Pocket Limit uff dei Expenses.
Zellscht du wennicher bezaahle wann du en Network Provider yuuse duscht?	Sell dutt net applye.	Daer Plan hot ken Provider Network. Du darfscht net gecoveredi Services griege vun ennicher Provider.
Brauchscht du en Referral fer en Specialist sehne?	Nee.	Du darfscht der Specialist sehne as du choos-e duscht unni en 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.

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

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