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", SBC) 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?	$	Gweenlich musscht du alli Koschte bezaahle vun Providers nuff zu der Deductible Amount eb daer Plan schtaert bezaahle. [For family coverage, see instructions for additional applicable language.]
Sin's Services as gecovered sin eb du dei Deductible gedroffe hoscht?	Ya. [Insert: major categories]	Daer Plan covert deel Dinger un Services even wann du der Deductible Amount noch net gedroffe hoscht. Awwer en Copayment adder Coinsurance mecht applye. [For non-grandfathered plans, insert: “Fer en Example, daer Plan covert certaini Preventive Services unni Cost Sharing un eb du dei Deductible dreffscht. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.”]
Sin noch annri Deductibles fer specifici Services?	Ya. $	Du musscht alli Koschte bezaahle fer die Services nuff zu der specific Deductible Amount eb daer Plan schtaert bezaahle fer die Services.
Was is der Out-of-pocket Limit fer daer Plan?	$	Der Out-of-pocket Limit is der menscht as du bezaahle kenntscht fer gecoveredi Services in en Yaahr. [For family coverage, see instructions for additional applicable language.]
Was is net include in der Out-of-pocket Limit?	[Insert: major exceptions]	Although du bezaahlscht die Koschte, zaehle sie net geeich der Out-of-pocket Limit
Zellscht du wennicher bezaahle wann du en Network Provider yuuscht?	Ya. Guck [www.insert.com] adder ruf 1-800-[insert] uff fer en List vun Network Providers.	Daer Plan yuust en Provider Network. Du zellscht wennicher bezaahle wann du en Provider yuuscht as in der Plan Network is. Du zellscht's menscht bezaahle wann du en Out-of-network Provider yuuscht, un du mechscht en Bill griege vun en Provider fer der Difference gschwischich der Provider sei Charge un was dei Plan bezaahlt (Balance Billing). Geb acht, dei Network Provider mecht en Out-of-network Provider yuuse fer deel Services (so wie Lab Work). Check nei mit dei Provider eb du Services grigscht.
Brauchscht du en Referral fer en specialist sehne?	Ya.	Daer Plan zeelt deel adder all die Koschte bezaahle fer en Specialist sehne fer gecoveredi Services awwer yuscht wann du en Referral hoscht eb du der Specialist sehnscht.

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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