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, e pei 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?	$	O le tulaga masani ai, e ao ona e totogia le tau mai foma’i/falema’i e o’o atu i le aofaiga o tupe toesea a’o le’i o’o ina amata ona totogi e lenei peleni. [For family coverage, see instructions for additional applicable language.]
Pe iai ni auaunaga e kavaina a’o le’i o’o ina e ausia au tupe toesea?	Ioe. [Insert: major categories]	O lenei peleni na te kavaina nisi mea ma auaunaga e tusa lava pe e te le’i ausia le aofaiga o tupe toesea. Peita’i atonu o le totogi e oe (copayment) po’o le totogi e le inisiua (coinsurance) e ono fa’aaogā iai. [For non- grandfathered plans, insert: “Mo se faata’ita’iga, o lenei peleni e kava ai nisi oauaunaga taupuipuiga e aunoa ma se totogi e faasoa ma a’o le’i ausia lau tupe toesea. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.”]
Pe e iai nisi tupe toesea mo auaunaga faapitoa?	Ioe. $	E tatau ona e totogia tau uma mo nei auaunaga e o’o atu i le aofaiga ua faama’oti mai e le tupe toesea a’o le’i amata e lenei peleni ona totogi nei auaunaga.
O le ā le tapulaa o tupe e totogi e oe lava ia mo lenei peleni?	$	O le tapulaa e totogi e oe lava ia o le aofaiga pito tele lea e te totogia i le tausaga mo auaunaga e kavaina. [For family coverage, see instructions for additional applicable language.]
O le ā e aofia ai i le tapulaa o tupe e totogi e oe lava ia?	[Insert: major exceptions]	E ui e te totogia nei tupe fa’aalu, e lē faitaulia faasaga i le tapulaa o tupe e totogi e oe lava ia.
Pe o le a itiiti le tau e te totogia pe a e fa’aaogina se li’o o so’otaga o foma’i?	Ioe. Taga’i i le [www.insert.com] pe telefoni le 1-800- [insert] mo se lisi o le li’o o so’otaga o foma’i/falema’i.	O lenei peleni na te fa’aaogaina se foma’i/falema’i e iai i le li’o o so’otaga. E itiiti le tupe e te totogia pe afai e te fa’aaogaina se foma’i/falema’i e i le peleni i le so’otaga. E tele atu le tupe e te totogia pe afai e te fa’aaogaina se foma’i/falema’i e lē o iai i le li’o o so’otaga, ma atonu o le a e mauaina se pili mai se foma’i/falema’i mo le eseesega i le va o le pili a le foma’i/falema’i ma le mea e totogi e lau peleni (faapaleniina o le pili). Ia mataalia, e ono fa’aaogā e lau foma’i/falema’i o i le li’o o so’otaga se foma’i/falema’i e lē o iai i le so’otaga mo nisi auaunaga (e pei o auaunga i falesu’etoto). Siaki i lau foma’i/falema’i a’o le’i e mauaina le auaunaga.
Pe e te manaomia se faasinoga (referral) e vaai ai se foma’i faapitoa?	Ioe	O lenei peleni o le ia totogia nisi o tau po’o le tau atoa e vaai ai se foma’i faapitoa mo auaunaga e kavaina ae se’i vaganā e maua se faasinoga a’o le’i vaaia le foma’i faapitoa.

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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