Common use of Representation Regarding Waiting Periods Clause in Contracts

Representation Regarding Waiting Periods. By entering into this Agreement, the Group hereby represents that the Group does not impose a waiting period exceeding ninety (90) days on its employees who meet the Group’s substantive eligibility requirements. For purposes of this requirement, a "waiting period" is the period that must pass before coverage for an individual who is otherwise eligible to enroll under the terms of a group health plan can become effective, in accordance with the waiting period requirements in the Patient Protection and Affordable Care Act and regulations. In addition, the Group represents that eligibility data provided by the Group to the Health Plan will include coverage effective dates for the Group’s employees that correctly account for eligibility in compliance with the waiting period requirements in the Patient Protection and Affordable Care Act and regulations. XXXXXX FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC. BY: Xxxx Xxxxxxx Vice President, Marketing, Sales & Business Development XXXXX X XXXXXXX LEVINDALE HEBREW GERIATRIC HOSP(MN) 0000 X XXXXXXXXX XXX BALTIMORE, MD 21215 guide to YOUR 2020 BENEFITS AND SERVICES xxxxxxxxxxxxxxxx.xxx KAISER FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC. GROUP EVIDENCE OF COVERAGE MARYLAND This plan has Excellent accreditation from the NCQA See 2020 NCQA Guide for more information on Accreditation Xxxxxx Foundation Health Plan of the Mid-Atlantic States, Inc. 0000 Xxxx Xxxxxxxxx Xxxxxx Xxxxxxxxx, Xxxxxxxx 00000 KFHP-EOC COVER (01/14)MD HMO NONDISCRIMINATION NOTICE Xxxxxx Foundation Health Plan of the Mid-Atlantic States, Inc. (Kaiser Health Plan) complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We also: • Provide no cost aids and services to people with disabilities to communicate effectively with us, such as: • Qualified sign language interpreters • Written information in other formats, such as large print, audio, and accessible electronic formats • Provide no cost language services to people whose primary language is not English, such as: • Qualified interpreters • Information written in other languages If you need these services, call 0-000-000-0000 (TTY: 711) If you believe that Kaiser Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by mail or phone at: Xxxxxx Permanente, Appeals and Correspondence Department, Attn: Kaiser Civil Rights Coordinator, 0000 Xxxx Xxxxxxxxx Xx., Xxxxxxxxx, XX 00000, telephone number: 0-000-000-0000. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at xxxxx://xxxxxxxxx.xxx.xxx/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 000 Xxxxxxxxxxxx Xxxxxx XX., Xxxx 000X, XXX Xxxxxxxx, Xxxxxxxxxx, XX 00000, 0-000-000-0000, 0-000-000-0000 (TDD). Complaint forms are available at xxxx://xxx.xxx.xxx/ocr/office/file/index.html. HELP IN YOUR LANGUAGE ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 0-000-000-0000 (TTY: 711). አማርኛ (Amharic) ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 0-000-000-0000 (TTY: 711). .ناجملاب كل رفاوتت ةيوغللا ةدعاسملا تامدخ نإف ،ةيبرعلا ثدحتت تنك اذإ :ةظوحلم (Arabic) ةيبرعلا .)711 :TTY( 0-000-000-0000 مقرب لصتا Ɓǎsɔ́ ɔ̀ Wùɖù (Bassa) Dè ɖɛ nìà kɛ dyéɖé gbo: Ɔ jǔ ké m̀ Ɓàsɔ́ ɔ̀ -wùɖù-po-nyɔ̀ jǔ ní, nìí, à wuɖu xx xx ɖò po-poɔ̀ ɓɛ́ìn m̀ gbo kpáa. Ɖá 0-000-000-0000 (TTY: 711) বাºলা (Bengali) লBয কªনঃ যদি আপদি বাºলা, কথা বলতে পাতেি, োহতল দি%খেচায় ভাষা সহায়ো পদেতষবা উপলB আতে। ফ াি কªি 0-000-000-0000 (TTY: 711)। ACA-CATLAR (2018) 中文 (Chinese) 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 0-000-000-0000（TTY：711）。 یارب ناگيار تروصب ینابز ت”يهست ،دينک یم وگتفگ یسراف نابز هب رگا :هجوت (Farsi) یسراف .ديريگب سامت (711 :TTY) 0-000-000-0000 اب .دشاب یم مهارف امش Français (French) ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 0-000-000-0000 (TTY: 711). Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, xxxxxx Xxxxx kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 0-000-000-0000 (TTY: 711). ગજુ રાતી (Gujarati) સચ ના: જો તમે ગજ રાતી બોલતા હો, તો નિ:શCુ ક ભાષા સહાય સેવાઓ તમારા માટે ઉપલ‘ધ છે. ફોિ કરો 0-000-000-0000 (TTY: 711). Kreyòl Ayisyen (Haitian Creole) ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis xx xxx xxxx ki disponib gratis pou ou. Rele 0-000-000-0000 (TTY: 711). हिoदी (Hindi) eयान द”: यदि आप द िी बोलते तो आपके ललए मुPत म” भाषा स ायता सेवाए˙ उपलoध । 0-000-000-0000 (TTY: 711) पर कॉल कर”। Igbo (Igbo) NRỤBAMA: Ọ bụrụ na ị na asụ Igbo, ọrụ enyemaka asụsụ, n’efu, dịịrị gị. Kpọọ 0-000-000-0000 (TTY: 711). Italiano (Italian) ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 0-000-000-0000 (TTY: 711). 日本語 (Japanese) 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。0-000-000-0000（TTY: 711）まで、お電話にてご連絡ください。 한국어 (Korean) 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 0-000-000-0000 (TTY: 711) 번으로 전화해 주십시오. Naabeehó (Navajo) D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh, 47 n1 h0l=, koj8’ h0d77lnih 0-000-000-0000 (TTY: 711.) Português (Portuguese) ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 0-000-000-0000 (TTY: 711). Pусский (Russian) ВНИМАНИЕ: eсли вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 0-000-000-0000 (TTY: 711). Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 0-000-000-0000 (TTY: 711). Tagalog (Tagalog) PAUNAWA: Kung nagsasalita xx xx Tagalog, maaari kang gumamit ng mga serbisyo ng tulong xx xxxx nang walang bayad. Tumawag sa 0-000-000-0000 (TTY: 711). ไทย (Thai) เรยน: ถา้ คณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟรี โทร 0-000-000-0000 (TTY: 711). ںيم تفم تامدخ یک ددم یک نابز وک پآ وت ،ںيہ ےتلوب ودرا پآ رگا :رادربخ (Urdu) ودرُا .(711 :TTY) 0-000-000-0000 ںيرک لاک ۔ ںيہ بايتسد Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch xx xx trợ xxxx xxx miễn phí xxxx xxx bạn. Gọi số 0-000-000-0000 (TTY: 711). ACA-CATLAR (2018) Yorùbá (Yoruba) AKIYESI: Ti o ba nso ede Yoruba ofe ni iranlowo xxxx xxx wa fun yin o. E pe ero ibanisoro yi 0-000-000-0000 (TTY: 711). TABLE OF CONTENTS SECTION 1 – INTRODUCTION TO YOUR XXXXXX PERMANENTE HEALTH PLAN 1.1 Welcome to Xxxxxx Permanente 1.1 Our Commitment to Diversity and Nondiscrimination 1.1 About This Group Agreement 1.1 How Your Health Plan Works 1.2 Xxxxxx Permanente SignatureSM 1.3 Eligibility for This Plan 1.3 Disabled Dependent Certification 1.4 Rights and Responsibilities of Members: Our Commitment to Each Other 1.5 Payment of Premium 1.7 Payment of Copayments, Coinsurance and Deductibles 1.7 Open Enrollment 1.8 Enrollment Period and Effective Date of Coverage 1.8 Special Enrollment Due to Reemployment After Military Service 1.11 Genetic Testing 1.11

Representation Regarding Waiting Periods. By entering into this Agreement, the Group hereby represents that the Group does not impose a waiting period exceeding ninety (90) days on its employees who meet the Group’s substantive eligibility requirements. For purposes of this requirement, a "waiting period" is the period that must pass before coverage for an individual who is otherwise eligible to enroll under the terms of a group health plan can become effective, in accordance with the waiting period requirements in the Patient Protection and Affordable Care Act and regulations. In addition, the Group represents that eligibility data provided by the Group to the Health Plan will include coverage effective dates for the Group’s employees that correctly account for eligibility in compliance with the waiting period requirements in the Patient Protection and Affordable Care Act and regulations. XXXXXX FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC. BYBy: Xxxx Xxxxxxx Xxxxxxxx Vice President, Marketing, Sales & Business Development XXXXXXX XXXXX X XXXXXXX LEVINDALE HEBREW GERIATRIC HOSP(MN) 0000 X XXXXXXXXX XXX BALTIMORECALPERS PO BOX 942714 SACRAMENTO, MD 21215 CA 94229 guide to YOUR 2020 2021 BENEFITS AND SERVICES xxxxxxxxxxxxxxxx.xxx KAISER FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC. GROUP EVIDENCE OF COVERAGE MARYLAND DISTRICT OF COLUMBIA SELECT CARE DELIVERY SYSTEM This plan has Excellent accreditation from the NCQA See 2020 2021 NCQA Guide for more information on Accreditation Xxxxxx Foundation Health Plan of the Mid-Atlantic States, Inc. 0000 Xxxx Xxxxxxxxx Xxxxxx Xxxxxxxxx, Xxxxxxxx 00000 KFHP-EOC COVER (01/14)MD COVER(01-21)DC HMO NONDISCRIMINATION NOTICE Xxxxxx Foundation Health Plan of the Mid-Atlantic States, Inc. (Kaiser Health Plan) complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We also: • Provide no cost aids and services to people with disabilities to communicate effectively with us, such as: • Qualified sign language interpreters • Written information in other formats, such as large print, audio, and accessible electronic formats • Provide no cost language services to people whose primary language is not English, such as: • Qualified interpreters • Information written in other languages If you need these services, call 0-000-000-0000 (TTY: 711) If you believe that Kaiser Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by mail or phone at: Xxxxxx Permanente, Appeals and Correspondence Department, Attn: Kaiser Civil Rights Coordinator, 0000 Xxxx Xxxxxxxxx Xx., Xxxxxxxxx, XX 00000, telephone number: 0-000-000-0000. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at xxxxx://xxxxxxxxx.xxx.xxx/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 000 Xxxxxxxxxxxx Xxxxxx XX., Xxxx 000X, XXX Xxxxxxxx, Xxxxxxxxxx, XX 00000, 0-000-000-0000, 0-000-000-0000 (TDD). Complaint forms are available at xxxx://xxx.xxx.xxx/ocr/office/file/index.html. HELP IN YOUR LANGUAGE ATTENTION: If you speak EnglishIn the event of dispute, language assistance services, free the provisions of charge, are available to you. Call 0-000-000-0000 (TTY: 711). አማርኛ (Amharic) ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 0-000-000-0000 (TTY: 711). .ناجملاب كل رفاوتت ةيوغللا ةدعاسملا تامدخ نإف ،ةيبرعلا ثدحتت تنك اذإ :ةظوحلم (Arabic) ةيبرعلا .)711 :TTY( 0-000-000-0000 مقرب لصتا Ɓǎsɔ́ ɔ̀ Wùɖù (Bassa) Dè ɖɛ nìà kɛ dyéɖé gbo: Ɔ jǔ ké m̀ Ɓàsɔ́ ɔ̀ -wùɖù-po-nyɔ̀ jǔ ní, nìí, à wuɖu xx xx ɖò po-poɔ̀ ɓɛ́ìn m̀ gbo kpáa. Ɖá 0-000-000-0000 (TTY: 711) বাºলা (Bengali) লBয কªনঃ যদি আপদি বাºলা, কথা বলতে পাতেি, োহতল দি%খেচায় ভাষা সহায়ো পদেতষবা উপলB আতে। ফ াি কªি 0-000-000-0000 (TTY: 711)। ACA-CATLAR (2018) 中文 (Chinese) 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 0-000-000-0000（TTY：711）。 یارب ناگيار تروصب ینابز ت”يهست ،دينک یم وگتفگ یسراف نابز هب رگا :هجوت (Farsi) یسراف .ديريگب سامت (711 :TTY) 0-000-000-0000 اب .دشاب یم مهارف امش Français (French) ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 0-000-000-0000 (TTY: 711). Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, xxxxxx Xxxxx kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 0-000-000-0000 (TTY: 711). ગજુ રાતી (Gujarati) સચ ના: જો તમે ગજ રાતી બોલતા હો, તો નિ:શCુ ક ભાષા સહાય સેવાઓ તમારા માટે ઉપલ‘ધ છે. ફોિ કરો 0-000-000-0000 (TTY: 711). Kreyòl Ayisyen (Haitian Creole) ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis xx xxx xxxx ki disponib gratis pou ou. Rele 0-000-000-0000 (TTY: 711). हिoदी (Hindi) eयान द”: यदि आप द िी बोलते तो आपके ललए मुPत म” भाषा स ायता सेवाए˙ उपलoध । 0-000-000-0000 (TTY: 711) पर कॉल कर”। Igbo (Igbo) NRỤBAMA: Ọ bụrụ na ị na asụ Igbo, ọrụ enyemaka asụsụ, n’efu, dịịrị gị. Kpọọ 0-000-000-0000 (TTY: 711). Italiano (Italian) ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 0-000-000-0000 (TTY: 711). 日本語 (Japanese) 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。0-000-000-0000（TTY: 711）まで、お電話にてご連絡ください。 한국어 (Korean) 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 0-000-000-0000 (TTY: 711) 번으로 전화해 주십시오. Naabeehó (Navajo) D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh, 47 n1 h0l=, koj8’ h0d77lnih 0-000-000-0000 (TTY: 711the approved English version of the form will control.) Português (Portuguese) ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 0-000-000-0000 (TTY: 711). Pусский (Russian) ВНИМАНИЕ: eсли вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 0-000-000-0000 (TTY: 711). Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 0-000-000-0000 (TTY: 711). Tagalog (Tagalog) PAUNAWA: Kung nagsasalita xx xx Tagalog, maaari kang gumamit ng mga serbisyo ng tulong xx xxxx nang walang bayad. Tumawag sa 0-000-000-0000 (TTY: 711). ไทย (Thai) เรยน: ถา้ คณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟรี โทร 0-000-000-0000 (TTY: 711). ںيم تفم تامدخ یک ددم یک نابز وک پآ وت ،ںيہ ےتلوب ودرا پآ رگا :رادربخ (Urdu) ودرُا .(711 :TTY) 0-000-000-0000 ںيرک لاک ۔ ںيہ بايتسد Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch xx xx trợ xxxx xxx miễn phí xxxx xxx bạn. Gọi số 0-000-000-0000 (TTY: 711). ACA-CATLAR (2018) Yorùbá (Yoruba) AKIYESI: Ti o ba nso ede Yoruba ofe ni iranlowo xxxx xxx wa fun yin o. E pe ero ibanisoro yi 0-000-000-0000 (TTY: 711). TABLE OF CONTENTS SECTION 1 – INTRODUCTION TO YOUR XXXXXX PERMANENTE HEALTH PLAN 1.1 Welcome to Xxxxxx Permanente 1.1 Our Commitment to Diversity and Nondiscrimination 1.1 About This Group Agreement 1.1 How Your Health Plan Works 1.2 Xxxxxx Permanente SignatureSM 1.3 Eligibility for This Plan 1.3 Disabled Dependent Certification 1.4 Rights and Responsibilities of Members: Our Commitment to Each Other 1.5 Payment of Premium 1.7 Payment of Copayments, Coinsurance and Deductibles 1.7 Open Enrollment 1.8 Enrollment Period and Effective Date of Coverage 1.8 Special Enrollment Due to Reemployment After Military Service 1.11 Genetic Testing 1.11

Representation Regarding Waiting Periods. By entering into this Agreement, the Group hereby represents that the Group does not impose a waiting period exceeding ninety (90) days on its employees who meet the Group’s substantive eligibility requirements. For purposes of this requirement, a "waiting period" is the period that must pass before coverage for an individual who is otherwise eligible to enroll under the terms of a group health plan can become effective, in accordance with the waiting period requirements in the Patient Protection and Affordable Care Act and regulations. In addition, the Group represents that eligibility data provided by the Group to the Health Plan will include coverage effective dates for the Group’s employees that correctly account for eligibility in compliance with the waiting period requirements in the Patient Protection and Affordable Care Act and regulations. XXXXXX FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC. BYBy: Xxxx Xxxxxxx Xxxxxxxx Vice President, Marketing, Sales & Business Development XXXXXX XXXXX X XXXXXXX LEVINDALE HEBREW GERIATRIC HOSP(MNCALPERS(MED/PLUS/DEP) 0000 X XXXXXXXXX XXX BALTIMOREPO BOX 942714 SACRAMENTO, MD 21215 CA 94229 guide to YOUR 2020 2021 BENEFITS AND SERVICES xxxxxxxxxxxxxxxx.xxx KAISER FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC. GROUP EVIDENCE OF COVERAGE MARYLAND DISTRICT OF COLUMBIA SELECT CARE DELIVERY SYSTEM This plan has Excellent accreditation from the NCQA See 2020 2021 NCQA Guide for more information on Accreditation Xxxxxx Foundation Health Plan of the Mid-Atlantic States, Inc. 0000 Xxxx Xxxxxxxxx Xxxxxx Xxxxxxxxx, Xxxxxxxx 00000 KFHP-EOC COVER (01/14)MD COVER(01-21)DC HMO NONDISCRIMINATION NOTICE Xxxxxx Foundation Health Plan of the Mid-Atlantic States, Inc. (Kaiser Health Plan) complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We also: • Provide no cost aids and services to people with disabilities to communicate effectively with us, such as: • Qualified sign language interpreters • Written information in other formats, such as large print, audio, and accessible electronic formats • Provide no cost language services to people whose primary language is not English, such as: • Qualified interpreters • Information written in other languages If you need these services, call 0-000-000-0000 (TTY: 711) If you believe that Kaiser Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by mail or phone at: Xxxxxx Permanente, Appeals and Correspondence Department, Attn: Kaiser Civil Rights Coordinator, 0000 Xxxx Xxxxxxxxx Xx., Xxxxxxxxx, XX 00000, telephone number: 0-000-000-0000. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at xxxxx://xxxxxxxxx.xxx.xxx/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 000 Xxxxxxxxxxxx Xxxxxx XX., Xxxx 000X, XXX Xxxxxxxx, Xxxxxxxxxx, XX 00000, 0-000-000-0000, 0-000-000-0000 (TDD). Complaint forms are available at xxxx://xxx.xxx.xxx/ocr/office/file/index.html. HELP IN YOUR LANGUAGE ATTENTION: If you speak EnglishIn the event of dispute, language assistance services, free the provisions of charge, are available to you. Call 0-000-000-0000 (TTY: 711). አማርኛ (Amharic) ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 0-000-000-0000 (TTY: 711). .ناجملاب كل رفاوتت ةيوغللا ةدعاسملا تامدخ نإف ،ةيبرعلا ثدحتت تنك اذإ :ةظوحلم (Arabic) ةيبرعلا .)711 :TTY( 0-000-000-0000 مقرب لصتا Ɓǎsɔ́ ɔ̀ Wùɖù (Bassa) Dè ɖɛ nìà kɛ dyéɖé gbo: Ɔ jǔ ké m̀ Ɓàsɔ́ ɔ̀ -wùɖù-po-nyɔ̀ jǔ ní, nìí, à wuɖu xx xx ɖò po-poɔ̀ ɓɛ́ìn m̀ gbo kpáa. Ɖá 0-000-000-0000 (TTY: 711) বাºলা (Bengali) লBয কªনঃ যদি আপদি বাºলা, কথা বলতে পাতেি, োহতল দি%খেচায় ভাষা সহায়ো পদেতষবা উপলB আতে। ফ াি কªি 0-000-000-0000 (TTY: 711)। ACA-CATLAR (2018) 中文 (Chinese) 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 0-000-000-0000（TTY：711）。 یارب ناگيار تروصب ینابز ت”يهست ،دينک یم وگتفگ یسراف نابز هب رگا :هجوت (Farsi) یسراف .ديريگب سامت (711 :TTY) 0-000-000-0000 اب .دشاب یم مهارف امش Français (French) ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 0-000-000-0000 (TTY: 711). Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, xxxxxx Xxxxx kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 0-000-000-0000 (TTY: 711). ગજુ રાતી (Gujarati) સચ ના: જો તમે ગજ રાતી બોલતા હો, તો નિ:શCુ ક ભાષા સહાય સેવાઓ તમારા માટે ઉપલ‘ધ છે. ફોિ કરો 0-000-000-0000 (TTY: 711). Kreyòl Ayisyen (Haitian Creole) ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis xx xxx xxxx ki disponib gratis pou ou. Rele 0-000-000-0000 (TTY: 711). हिoदी (Hindi) eयान द”: यदि आप द िी बोलते तो आपके ललए मुPत म” भाषा स ायता सेवाए˙ उपलoध । 0-000-000-0000 (TTY: 711) पर कॉल कर”। Igbo (Igbo) NRỤBAMA: Ọ bụrụ na ị na asụ Igbo, ọrụ enyemaka asụsụ, n’efu, dịịrị gị. Kpọọ 0-000-000-0000 (TTY: 711). Italiano (Italian) ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 0-000-000-0000 (TTY: 711). 日本語 (Japanese) 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。0-000-000-0000（TTY: 711）まで、お電話にてご連絡ください。 한국어 (Korean) 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 0-000-000-0000 (TTY: 711) 번으로 전화해 주십시오. Naabeehó (Navajo) D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh, 47 n1 h0l=, koj8’ h0d77lnih 0-000-000-0000 (TTY: 711the approved English version of the form will control.) Português (Portuguese) ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 0-000-000-0000 (TTY: 711). Pусский (Russian) ВНИМАНИЕ: eсли вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 0-000-000-0000 (TTY: 711). Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 0-000-000-0000 (TTY: 711). Tagalog (Tagalog) PAUNAWA: Kung nagsasalita xx xx Tagalog, maaari kang gumamit ng mga serbisyo ng tulong xx xxxx nang walang bayad. Tumawag sa 0-000-000-0000 (TTY: 711). ไทย (Thai) เรยน: ถา้ คณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟรี โทร 0-000-000-0000 (TTY: 711). ںيم تفم تامدخ یک ددم یک نابز وک پآ وت ،ںيہ ےتلوب ودرا پآ رگا :رادربخ (Urdu) ودرُا .(711 :TTY) 0-000-000-0000 ںيرک لاک ۔ ںيہ بايتسد Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch xx xx trợ xxxx xxx miễn phí xxxx xxx bạn. Gọi số 0-000-000-0000 (TTY: 711). ACA-CATLAR (2018) Yorùbá (Yoruba) AKIYESI: Ti o ba nso ede Yoruba ofe ni iranlowo xxxx xxx wa fun yin o. E pe ero ibanisoro yi 0-000-000-0000 (TTY: 711). TABLE OF CONTENTS SECTION 1 – INTRODUCTION TO YOUR XXXXXX PERMANENTE HEALTH PLAN 1.1 Welcome to Xxxxxx Permanente 1.1 Our Commitment to Diversity and Nondiscrimination 1.1 About This Group Agreement 1.1 How Your Health Plan Works 1.2 Xxxxxx Permanente SignatureSM 1.3 Eligibility for This Plan 1.3 Disabled Dependent Certification 1.4 Rights and Responsibilities of Members: Our Commitment to Each Other 1.5 Payment of Premium 1.7 Payment of Copayments, Coinsurance and Deductibles 1.7 Open Enrollment 1.8 Enrollment Period and Effective Date of Coverage 1.8 Special Enrollment Due to Reemployment After Military Service 1.11 Genetic Testing 1.11

Representation Regarding Waiting Periods. By entering into this Agreement, the Group hereby represents that the Group does not impose a waiting period exceeding ninety (90) days on its employees who meet the Group’s substantive eligibility requirements. For purposes of this requirement, a "waiting period" is the period that must pass before coverage for an individual who is otherwise eligible to enroll under the terms of a group health plan can become effective, in accordance with the waiting period requirements in the Patient Protection and Affordable Care Act and regulations. In addition, the Group represents that eligibility data provided by the Group to the Health Plan will include coverage effective dates for the Group’s employees that correctly account for eligibility in compliance with the waiting period requirements in the Patient Protection and Affordable Care Act and regulations. XXXXXX FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC. BYBy: Xxxx Xxxxxxx _ Xxxxxxxx XxXxxxxxx Vice President, Marketing, Sales & Business Development XXXXX X XXXXXX XXXXX XXXXXXX LEVINDALE HEBREW GERIATRIC HOSP(MN) UNIV-BARGAINING UNIT 0000 X XXXXXXXXX XXX X. 00XX XX. SUITE D100 BALTIMORE, MD 21215 21218 guide to YOUR 2020 2024 BENEFITS AND SERVICES xxxxxxxxxxxxxxxx.xxx KAISER FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC. GROUP EVIDENCE OF COVERAGE MARYLAND SELECT CARE DELIVERY SYSTEM This plan has Excellent accreditation from the NCQA See 2020 2024 NCQA Guide for more information on Accreditation accreditation Xxxxxx Foundation Health Plan of the Mid-Atlantic States, Inc. 0000 Xxxx Xxxxxxxxx Xxxxxx Xxxxxxxxx, Xxxxxxxx 00000 KFHP-EOC COVER (01/14)MD COVER(01-23)MD HMO NONDISCRIMINATION NOTICE Xxxxxx Foundation Health Plan OF PROTECTION PROVIDED BY MARYLAND LIFE AND HEALTH INSURANCE GUARANTY CORPORATION This notice provides a brief summary of the MidMaryland Life and Health Insurance Guaranty Corporation (the Corporation) and the protection it provides for policyholders. This safety net was created under Maryland law, which determines who and what is covered and the amounts of coverage. The Corporation is not a department or unit of the State of Maryland and the liabilities or debts of the Life and Health Insurance Guaranty Corporation are not liabilities or debts of the State of Maryland. The Corporation was established to provide protection in the unlikely event that your life, annuity or health insurance company becomes financially unable to meet its obligations and is taken over by its Insurance Department. If this should happen, the Corporation will typically arrange to continue coverage and pay claims, in accordance with Maryland law, with funding from assessments paid by other insurance companies. The basic protections provided by the Corporation are: • Life Insurance o $300,000 in death benefits o $100,000 in cash surrender or withdrawal values • Health Insurance o $500,000 for basic hospital, medical, and surgical insurance or major medical insurance provided by health benefit plans o $300,000 for disability insurance o $300,000 for long-Atlantic Statesterm care insurance o $100,000 for a type of health insurance not listed above, Inc. (Kaiser Health Plan) complies including any net cash surrender and net cash withdrawal values under the types of health insurance listed above • Annuities o $250,000 in the present value of annuity benefits, including net cash withdrawal values and net cash surrender values o With respect to each payee under a structured settlement annuity, or beneficiary of the payee, $250,000 in present value annuity benefits, in the aggregate, including any net cash surrender and net cash withdrawal values. • The maximum amount of protection for each individual, regardless of the number of policies or contracts, is: o $300,000 in aggregate for all types of coverage listed above, with applicable federal civil rights laws the exception of basic hospital, medical, and surgical insurance or major medical insurance o $500,000 in aggregate for basic hospital, medical, and surgical insurance or major medical insurance NOTE: Certain policies and contracts may not be covered or fully covered. For example, coverage does not discriminate on extend to any portion(s) of a policy or contract that the basis of race, color, national origin, age, disability, or sex. Kaiser Health Plan insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We also: • Provide no cost aids and services to people with disabilities to communicate effectively with us, such as: • Qualified sign language interpreters • Written information in other formatsguarantee, such as large printcertain investment additions to the account value of a variable life insurance policy or a variable annuity contract. There are also various residency requirements and other limitations under Maryland law. To learn more about the above protections, audio, and accessible electronic formats • Provide no cost language services to people whose primary language is not English, such as: • Qualified interpreters • Information written in other languages If you need these services, call 0-000-000-0000 (TTY: 711) If you believe that Kaiser Health Plan has failed to provide these services or discriminated in another way on please visit the basis of race, color, national origin, age, disabilityCorporation’s website at xxx.xxxxxxxx.xxx, or sexcontact: Maryland Life and Health Insurance Guaranty Corporation 0000 Xxxxxx Xxxx Suite 208 Perry Hall, you can file a grievance by mail or phone at: Xxxxxx PermanenteMaryland 21236 410-248-0407 Or, Appeals and Correspondence DepartmentMaryland Insurance Administration 000 Xx. Xxxx Xxxxx, Attn: Kaiser Civil Rights CoordinatorSuite 2700 Baltimore, 0000 Xxxx Xxxxxxxxx Xx., Xxxxxxxxx, XX 00000, telephone number: 0-000-000-0000. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at xxxxx://xxxxxxxxx.xxx.xxx/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 000 Xxxxxxxxxxxx Xxxxxx XX., Xxxx 000X, XXX Xxxxxxxx, Xxxxxxxxxx, XX 00000, Maryland 21202 0-000-000-0000, 0-000-000-0000 (TDD)ext. Complaint forms 2170 Insurance companies and agents are available at xxxx://xxx.xxx.xxx/ocr/office/file/index.htmlnot allowed by Maryland law to use the existence of the Corporation or its coverage to encourage you to purchase any form of insurance. HELP IN YOUR LANGUAGE ATTENTION: When selecting an insurance company, you should not rely on Corporation coverage. If you speak Englishthere is any inconsistency between this notice and Maryland law, language assistance services, free of charge, are available to you. Call 0-000-000-0000 (TTY: 711). አማርኛ (Amharic) ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 0-000-000-0000 (TTY: 711). .ناجملاب كل رفاوتت ةيوغللا ةدعاسملا تامدخ نإف ،ةيبرعلا ثدحتت تنك اذإ :ةظوحلم (Arabic) ةيبرعلا .)711 :TTY( 0-000-000-0000 مقرب لصتا Ɓǎsɔ́ ɔ̀ Wùɖù (Bassa) Dè ɖɛ nìà kɛ dyéɖé gbo: Ɔ jǔ ké m̀ Ɓàsɔ́ ɔ̀ -wùɖù-po-nyɔ̀ jǔ ní, nìí, à wuɖu xx xx ɖò po-poɔ̀ ɓɛ́ìn m̀ gbo kpáa. Ɖá 0-000-000-0000 (TTY: 711) বাºলা (Bengali) লBয কªনঃ যদি আপদি বাºলা, কথা বলতে পাতেি, োহতল দি%খেচায় ভাষা সহায়ো পদেতষবা উপলB আতে। ফ াি কªি 0-000-000-0000 (TTY: 711)। ACA-CATLAR (2018) 中文 (Chinese) 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 0-000-000-0000（TTY：711）。 یارب ناگيار تروصب ینابز ت”يهست ،دينک یم وگتفگ یسراف نابز هب رگا :هجوت (Farsi) یسراف .ديريگب سامت (711 :TTY) 0-000-000-0000 اب .دشاب یم مهارف امش Français (French) ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 0-000-000-0000 (TTY: 711). Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, xxxxxx Xxxxx kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 0-000-000-0000 (TTY: 711). ગજુ રાતી (Gujarati) સચ ના: જો તમે ગજ રાતી બોલતા હો, તો નિ:શCુ ક ભાષા સહાય સેવાઓ તમારા માટે ઉપલ‘ધ છે. ફોિ કરો 0-000-000-0000 (TTY: 711). Kreyòl Ayisyen (Haitian Creole) ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis xx xxx xxxx ki disponib gratis pou ou. Rele 0-000-000-0000 (TTY: 711). हिoदी (Hindi) eयान द”: यदि आप द िी बोलते तो आपके ललए मुPत म” भाषा स ायता सेवाए˙ उपलoध । 0-000-000-0000 (TTY: 711) पर कॉल कर”। Igbo (Igbo) NRỤBAMA: Ọ bụrụ na ị na asụ Igbo, ọrụ enyemaka asụsụ, n’efu, dịịrị gị. Kpọọ 0-000-000-0000 (TTY: 711). Italiano (Italian) ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 0-000-000-0000 (TTY: 711). 日本語 (Japanese) 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。0-000-000-0000（TTY: 711）まで、お電話にてご連絡ください。 한국어 (Korean) 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 0-000-000-0000 (TTY: 711) 번으로 전화해 주십시오. Naabeehó (Navajo) D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh, 47 n1 h0l=, koj8’ h0d77lnih 0-000-000-0000 (TTY: 711then Maryland law will control.) Português (Portuguese) ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 0-000-000-0000 (TTY: 711). Pусский (Russian) ВНИМАНИЕ: eсли вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 0-000-000-0000 (TTY: 711). Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 0-000-000-0000 (TTY: 711). Tagalog (Tagalog) PAUNAWA: Kung nagsasalita xx xx Tagalog, maaari kang gumamit ng mga serbisyo ng tulong xx xxxx nang walang bayad. Tumawag sa 0-000-000-0000 (TTY: 711). ไทย (Thai) เรยน: ถา้ คณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟรี โทร 0-000-000-0000 (TTY: 711). ںيم تفم تامدخ یک ددم یک نابز وک پآ وت ،ںيہ ےتلوب ودرا پآ رگا :رادربخ (Urdu) ودرُا .(711 :TTY) 0-000-000-0000 ںيرک لاک ۔ ںيہ بايتسد Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch xx xx trợ xxxx xxx miễn phí xxxx xxx bạn. Gọi số 0-000-000-0000 (TTY: 711). ACA-CATLAR (2018) Yorùbá (Yoruba) AKIYESI: Ti o ba nso ede Yoruba ofe ni iranlowo xxxx xxx wa fun yin o. E pe ero ibanisoro yi 0-000-000-0000 (TTY: 711). TABLE OF CONTENTS SECTION 1 – INTRODUCTION TO YOUR XXXXXX PERMANENTE HEALTH PLAN 1.1 Welcome to Xxxxxx Permanente 1.1 Our Commitment to Diversity and Nondiscrimination 1.1 About This Group Agreement 1.1 How Your Health Plan Works 1.2 Xxxxxx Permanente SignatureSM 1.3 Eligibility for This Plan 1.3 Disabled Dependent Certification 1.4 Rights and Responsibilities of Members: Our Commitment to Each Other 1.5 Payment of Premium 1.7 Payment of Copayments, Coinsurance and Deductibles 1.7 Open Enrollment 1.8 Enrollment Period and Effective Date of Coverage 1.8 Special Enrollment Due to Reemployment After Military Service 1.11 Genetic Testing 1.11

Representation Regarding Waiting Periods. By entering into this Agreement, the Group hereby represents that the Group does not impose a waiting period exceeding ninety (90) days on its employees who meet the Group’s substantive eligibility requirements. For purposes of this requirement, a "waiting period" is the period that must pass before coverage for an individual who is otherwise eligible to enroll under the terms of a group health plan can become effective, in accordance with the waiting period requirements in the Patient Protection and Affordable Care Act and regulations. In addition, the Group represents that eligibility data provided by the Group to the Health Plan will include coverage effective dates for the Group’s employees that correctly account for eligibility in compliance with the waiting period requirements in the Patient Protection and Affordable Care Act and regulations. XXXXXX FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC. BYBy: Xxxx Xxxxxxx Xxxxxxxxx XxXxxxxxx Vice President, Marketing, Sales & Business Development XXXXX X XXXXXXX LEVINDALE HEBREW GERIATRIC HOSP(MNXXXXXXXX CALIF INSTITUTE OF TECH/JPL(HMO) 0000 X XXXXXXXXX XXX BALTIMOREX. XXXXXXXXXX XXXX MAIL CODE 161-84 PASADENA, MD 21215 CA 91125 guide to YOUR 2020 2022 BENEFITS AND SERVICES xxxxxxxxxxxxxxxx.xxx KAISER <.. image(Back Ground Image for Front Cover ) removed ..> XXXXXX FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC. GROUP EVIDENCE OF COVERAGE MARYLAND DISTRICT OF COLUMBIA SIGNATURE CARE DELIVERY SYSTEM This plan has Excellent accreditation from the NCQA See 2020 2022 NCQA Guide for more information on Accreditation Xxxxxx Foundation Health Plan of the Mid-Atlantic States, Inc. 0000 Xxxx Xxxxxxxxx Xxxxxx Xxxxxxxxx, Xxxxxxxx 00000 KFHP-EOC COVER COVER(01-21)DC HMO Your Rights and Protections Against Surprise Medical Bills When you get emergency care or are treated by an out‐of‐network provider at an in‐network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible. What is “balance billing” (01/14)MD HMO NONDISCRIMINATION NOTICE Xxxxxx Foundation Health Plan of the Mid-Atlantic Statessometimes called “surprise billing”)? When you see a doctor or other health care provider, Inc. (Kaiser Health Plan) complies with applicable federal civil rights laws and you may owe certain out‐of‐pocket costs,like a copayment, coinsurance, or deductible. You may have additional costs or have to pay theentire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network and/or your plan does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We also: • Provide no cost aids and services to people with disabilities to communicate effectively with us, such as: • Qualified sign language interpreters • Written information in other formats, such as large print, audio, and accessible electronic formats • Provide no cost language services to people whose primary language is not English, such as: • Qualified interpreters • Information written in other languages If you need these cover out‐of‐network services, call 0-000-000-0000 (TTY: 711) If you believe that Kaiser Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by mail or phone at: Xxxxxx Permanente, Appeals and Correspondence Department, Attn: Kaiser Civil Rights Coordinator, 0000 Xxxx Xxxxxxxxx Xx., Xxxxxxxxx, XX 00000, telephone number: 0-000-000-0000. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at xxxxx://xxxxxxxxx.xxx.xxx/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 000 Xxxxxxxxxxxx Xxxxxx XX., Xxxx 000X, XXX Xxxxxxxx, Xxxxxxxxxx, XX 00000, 0-000-000-0000, 0-000-000-0000 (TDD). Complaint forms are available at xxxx://xxx.xxx.xxx/ocr/office/file/index.html. HELP IN YOUR LANGUAGE ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 0-000-000-0000 (TTY: 711). አማርኛ (Amharic) ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 0-000-000-0000 (TTY: 711). .ناجملاب كل رفاوتت ةيوغللا ةدعاسملا تامدخ نإف ،ةيبرعلا ثدحتت تنك اذإ :ةظوحلم (Arabic) ةيبرعلا .)711 :TTY( 0-000-000-0000 مقرب لصتا Ɓǎsɔ́ ɔ̀ Wùɖù (Bassa) Dè ɖɛ nìà kɛ dyéɖé gbo: Ɔ jǔ ké m̀ Ɓàsɔ́ ɔ̀ -wùɖù-po-nyɔ̀ jǔ ní, nìí, à wuɖu xx xx ɖò po-poɔ̀ ɓɛ́ìn m̀ gbo kpáa. Ɖá 0-000-000-0000 (TTY: 711) বাºলা (Bengali) লBয কªনঃ যদি আপদি বাºলা, কথা বলতে পাতেি, োহতল দি%খেচায় ভাষা সহায়ো পদেতষবা উপলB আতে। ফ াি কªি 0-000-000-0000 (TTY: 711)। ACA-CATLAR (2018) 中文 (Chinese) 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 0-000-000-0000（TTY：711）。 یارب ناگيار تروصب ینابز ت”يهست ،دينک یم وگتفگ یسراف نابز هب رگا :هجوت (Farsi) یسراف .ديريگب سامت (711 :TTY) 0-000-000-0000 اب .دشاب یم مهارف امش Français (French) ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 0-000-000-0000 (TTY: 711). Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, xxxxxx Xxxxx kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 0-000-000-0000 (TTY: 711). ગજુ રાતી (Gujarati) સચ ના: જો તમે ગજ રાતી બોલતા હો, તો નિ:શCુ ક ભાષા સહાય સેવાઓ તમારા માટે ઉપલ‘ધ છે. ફોિ કરો 0-000-000-0000 (TTY: 711). Kreyòl Ayisyen (Haitian Creole) ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis xx xxx xxxx ki disponib gratis pou ou. Rele 0-000-000-0000 (TTY: 711). हिoदी (Hindi) eयान द”: यदि आप द िी बोलते तो आपके ललए मुPत म” भाषा स ायता सेवाए˙ उपलoध । 0-000-000-0000 (TTY: 711) पर कॉल कर”। Igbo (Igbo) NRỤBAMA: Ọ bụrụ na ị na asụ Igbo, ọrụ enyemaka asụsụ, n’efu, dịịrị gị. Kpọọ 0-000-000-0000 (TTY: 711). Italiano (Italian) ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 0-000-000-0000 (TTY: 711). 日本語 (Japanese) 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。0-000-000-0000（TTY: 711）まで、お電話にてご連絡ください。 한국어 (Korean) 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 0-000-000-0000 (TTY: 711) 번으로 전화해 주십시오. Naabeehó (Navajo) D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh, 47 n1 h0l=, koj8’ h0d77lnih 0-000-000-0000 (TTY: 711.) Português (Portuguese) ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 0-000-000-0000 (TTY: 711). Pусский (Russian) ВНИМАНИЕ: eсли вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 0-000-000-0000 (TTY: 711). Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 0-000-000-0000 (TTY: 711). Tagalog (Tagalog) PAUNAWA: Kung nagsasalita xx xx Tagalog, maaari kang gumamit ng mga serbisyo ng tulong xx xxxx nang walang bayad. Tumawag sa 0-000-000-0000 (TTY: 711). ไทย (Thai) เรยน: ถา้ คณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟรี โทร 0-000-000-0000 (TTY: 711). ںيم تفم تامدخ یک ددم یک نابز وک پآ وت ،ںيہ ےتلوب ودرا پآ رگا :رادربخ (Urdu) ودرُا .(711 :TTY) 0-000-000-0000 ںيرک لاک ۔ ںيہ بايتسد Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch xx xx trợ xxxx xxx miễn phí xxxx xxx bạn. Gọi số 0-000-000-0000 (TTY: 711). ACA-CATLAR (2018) Yorùbá (Yoruba) AKIYESI: Ti o ba nso ede Yoruba ofe ni iranlowo xxxx xxx wa fun yin o. E pe ero ibanisoro yi 0-000-000-0000 (TTY: 711). TABLE OF CONTENTS SECTION 1 – INTRODUCTION TO YOUR XXXXXX PERMANENTE HEALTH PLAN 1.1 Welcome to Xxxxxx Permanente 1.1 Our Commitment to Diversity and Nondiscrimination 1.1 About This Group Agreement 1.1 How Your Health Plan Works 1.2 Xxxxxx Permanente SignatureSM 1.3 Eligibility for This Plan 1.3 Disabled Dependent Certification 1.4 Rights and Responsibilities of Members: Our Commitment to Each Other 1.5 Payment of Premium 1.7 Payment of Copayments, Coinsurance and Deductibles 1.7 Open Enrollment 1.8 Enrollment Period and Effective Date of Coverage 1.8 Special Enrollment Due to Reemployment After Military Service 1.11 Genetic Testing 1.11