Information About You and Your Visits to the Website All information we collect on this Website is subject to our Privacy Policy. By using the Website, you consent to all actions taken by us with respect to your information in compliance with the Privacy Policy.
Your Grievance and Appeals Rights If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact your state insurance department at (000) 000-0000 or by email at XxxxxxXxxXxxxxxx@xxxx.xx.xxx, the U.S. Department of Labor, Employee Benefits Security Administration at 0-000-000-0000 or xxx.xxx.xxx/xxxx, or the U.S. Department of Health and Human Services at 0-000-000-0000 x00000 or xxx.xxxxx.xxx.xxx. Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: Para obtener asistencia en Español, llame al 0-000-000-0000. Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) ◼ Amount owed to providers: $7,540 ◼ Plan pays $7,490 ◼ Patient pays $50 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $0 Copays $20 Coinsurance $0 Limits or exclusions $30 Total $50 Managing type 2 diabetes (routine maintenance of a well-controlled condition) ◼ Amount owed to providers: $5,400 ◼ Plan pays $4,760 ◼ Patient pays $640 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $0 Copays $300 Coinsurance $300 Limits or exclusions $40 Total $640 These examples are based on coverage for an individual plan. Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? • Costs don’t include premiums. • Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan. • The patient’s condition was not an excluded or preexisting condition. • All services and treatments started and ended in the same coverage period. • There are no other medical expenses for any member covered under this plan. • Out-of-pocket expenses are based only on treating the condition in the example. • The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. Does the Coverage Example predict my own care needs?
HOW WE MAY USE YOUR PERSONAL INFORMATION 8.1 We will use the personal information You provide to Us to:
OUR SERVICE TO YOU We will act honestly, fairly and professionally in accordance with Your best interests. We will normally represent You, rather than acting on behalf of the insurer. If We do not represent You, We will inform you accordingly. We will normally give You advice and a personal recommendation about the insurance contract being proposed. If We do not give You advice and a personal recommendation, We will inform You accordingly. Where We propose or advise on an insurance contract, We will inform You whether We are: • Giving a personal recommendation on the basis of a fair and personal analysis of the market. This is Our normal service. • Under a contractual obligation to place business exclusively with one or more insurers (in which case We will provide You with the names of those insurers). Examples of this type of service would include ‘single insurer’ or ‘panel of insurers’ type arrangements. • Not under a contractual obligation to place exclusively with one or more insurers and We do not give a personal recommendation on the basis of a fair and personal analysis of the market (in which case We will provide You with the names of those insurers). An example of this type of service would be where We only approach Your existing insurers for renewal terms. We will identify Your demands and needs and ensure that the insurance contract being proposed is consistent with them. Where We give advice and a personal recommendation, We will explain why the insurance contract being proposed best meets Your demands and needs. If We do not give You advice and a personal recommendation, You are responsible for ensuring that the insurance contract being proposed is suitable for You. We will provide You with a letter/report setting out key aspects of the insurance cover being proposed; however, this is not intended to be a substitute for the insurer(s) policy wording, which will take precedence in setting out the terms of the cover. We will endeavor to place insurance cover on Your behalf, but We do not guarantee to be able to do this. We will provide You with details of the cover effected on Your behalf, including the insurer who is underwriting the risk. Where We offer to arrange a facility with a premium finance provider which allows You to pay Your insurance premium by regular instalments, We do not offer advice in relation to this facility; however, We may ask some questions to narrow down the selection of options available. You must make Your own choice on which option to accept. When arranging a facility with a premium finance provider on Your behalf, We only act as a credit broker; We do not act as a lender. Although We take care to ensure that the information contained on Our website is accurate and up to date, We give You no promises, representations or warranties about the accuracy, completeness, reliability or suitability of any information on Our website.
Customer Service Standards The Franchising Authority hereby adopts the customer service standards set forth in Part 76, §76.309 of the FCC’s rules and regulations, as amended. The Grantee shall comply in all respects with the customer service requirements established by the FCC.
Permitted Uses and Disclosures by Business Associate 1. Business Associate may only use or disclose protected health information as necessary to perform the services as outlined in the underlying agreement.
Collection and Use of Your Information You acknowledge that when you download, install, or use the Application, Company may use automatic means (including, for example, cookies and web beacons) to collect information about your Mobile Device and about your use of the Application. You also may be required to provide certain information about yourself as a condition to downloading, installing, or using the Application or certain of its features or functionality, and the Application may provide you with opportunities to share information about yourself with others. All information we collect through or in connection with this Application is subject to our Privacy Policy. By downloading, installing, using, and providing information to or through this Application, you consent to all actions taken by us with respect to your information in compliance with the Privacy Policy.
What To Do If You Find A Mistake On Your Statement If you think there is an error on your statement, write to us at the address(es) listed on your statement. In your letter, give us the following information:
Information About Your Right to Dispute Errors In case of errors or questions about your Card Account, call 0-000-000-0000 or write to Cardholder Services, X.X. Xxx 000000, Xxxxxxxxxxxx, XX, 00000. if you think an error has occurred on your Card Account or if you need more information about a transaction listed on your electronic or written history or receipt. We must allow you to report an error until sixty (60) days after the earlier of the date you electronically access your Card Account, if the error could be viewed in your electronic history, or the date we sent the FIRST written history on which the error appeared. You may request a written history of your transactions at any time by calling 0-000-000-0000 or writing to X.X. Xxx 000000, Xxxxxxxxxxxx, XX, 00000. You will need to tell us:
INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT Thank you for choosing Blue Cross & Blue Shield of Rhode Island (BCBSRI) for your healthcare coverage. We appreciate the trust you’ve placed in us and want to help you make the most of your health plan. In this Subscriber Agreement (agreement), you’ll find valuable information about your plan, including: • how your health coverage works; • how BCBSRI processes claims for the health services you receive; • your rights and responsibilities as a BCBSRI member; • BCBSRI’s rights and responsibilities; and • tools and programs to help you stay healthy and save money. We encourage you to read this agreement to learn about all the advantages of being a BCBSRI member. How to Use This Agreement Below are some helpful tips on how to find what you need in this agreement. • As a member, you are responsible for understanding the benefits to which you are entitled under this agreement and the rules you must follow to receive those benefits. • The Table of Contents will help you find the order of the sections as they appear in the agreement. • The Summary of Benefits, included in this agreement, shows the amount you pay out of your own pocket. • Important contact information, such as, telephone numbers, addresses, and websites are located at the end of this document. • Some words and phrases used in this agreement are in italics. This means that the words or phrases have a special meaning as they relate to your healthcare coverage. Please see Section 8 for definitions of these words. • When we use the words “we,” “us,” and “our,” we are referring to BCBSRI. When we use the words “you” and “your” we are referring to the enrolled subscriber and/or member. These words are also defined in the Glossary. • Many sections of this document are related to other sections. You may need to reference more than one section to find the information you need.
