SBC Disclosure

Otootoga o Faamanuiaga ma le Kavaina: Mea e Kava e lenei Peleni & Mea e te Totogia mo Auaunaga e Kavaina

_______________________________: ___________________

Vaitaimi o le Kavaina:[See Instructions]

Kava mo: __________ | Ituaiga Peleni: ______

O le pepa o faamatalga o le Otootoga o Faamanuiaga ma le Kavaina (Summary of Benefits and Coverage, SBC) o le a fesoasoani iā oe e filifili ai se peleni tausoifua maloloina. Ua fa’aalia mai e le SBC iā oe le auala o le a faasoa ai ma le peleni le tau mo auaunaga tausoifua maloloina. MATAU: O faamatalaga e faatatau i le tau o lenei peleni (ta’ua o le premium (totogi faatulagaina)) o le a ese lona tuuina atu. O lenei mea ua na ose otootoga. Mo nisi faamatalaga e faatatau i le kavaina, po’o le mauaina o se kopi o le feagaiga atoa o le kavaina, [insert contact information]. M Mo le faauigaina o faaupuga masani ai, epei o le, aofaiga faatagaina, paleni o le piliina, totogi e le inisiua, tupe e te totogia, tupe toesea, foma’i/falema’i, po’o isi faaupuga faapisinisi, taga’i i le Lisi o Faaupuga (Glossary). E mafai ona e taga’i i le Lisi o Faaupuga i le [www.insert.com] pe telefoni le 1-800-[insert] e talosaga ai se kopi.

Fesili Tāua	Tali	Aiseā e Afaina ai Lenei Tulaga:
O le ā le fua atoa o le tupe toesea?	$0	Taga’i i le siata o i lalo o Mea Masani Ona Fai e Foma’i mo tau e te totogia o auaunaga e kava e lenei peleni.
Pe iai ni auaunaga e kavaina a’o le’i o’o ina e ausia au tupe toesea?	Leai.	E ao ona e ausia tupe toesea a’o le’i totogia e le peleni so’o se auaunaga.
Pe e iai nisi tupe toesea mo auaunaga faapitoa?	Leai.	E lē tatau ona e ausia tupe toesea mo auaunaga faapitoa.
O le ā le tapulaa o tupe e totogi e oe lava ia mo lenei peleni?	E lē fa’aaogaina.	O lenei peleni e leai se tapulaa o tupe e totogi e oe lava ia.
O le ā e aofia ai i le tapulaa o tupe e totogi e oe lava ia?	E lē fa’aaogaina.	O lenei peleni e leai se tapulaa o tupe e totogi e oe lava ia i au tupetotogi.
Pe o le a itiiti le tau e te totogia pe a e fa’aaogina se li’o o so’otaga o foma’i?	E lē fa’aaogaina.	O lenei peleni e lē fa’aaogaina se li’o o so’otaga o foma’i/falema’i. E mafai ona e mauaina auaunaga e kavaina mai so’o se foma’i/falema’i.
Pe e te manaomia se referral (faasinoga) e vaai ai se foma’i faapitoa?	Leai.	E mafai ona e vaaia le foma’i faapitoa e te filifilia e aunoa ma se faasinoga.

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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