Common use of Your Grievance and Appeals Rights Clause in Contracts

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?

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?

Your Grievance and Appeals Rights. If There are agencies that can help if you have a complaint or are dissatisfied with against your plan for a denial of coverage a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for claims under that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan, you may be able to appeal or file a grievance. For questions more information about your rights, this notice, or assistance, contact: contact the plan at 0-000-000-0000 or (000) 000-0000 or TDD 711. You may also contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx. Additionally, a consumer assistance program can help you can contact file your appeal. 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 plan provide Minimum Essential Coverage? The Affordable Care Act requires most people Yes. If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health care coverage for that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coveragemonth. Does this Coverage Meet plan meet Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standard? The Affordable Care Act establishes Standards, you may be eligible for a minimum value standard of benefits of premium tax credit to help you pay for a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet plan through the minimum value standard for the benefits it providesMarketplace. 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 pagesection.–––––––––––––––––––––– 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. Do yo This is not a cost estimator. Don’t use these Treatments shown are just examples to estimate your of how this plan might cover medical care. Your actual costs under this plan. The will be different depending on the actual care you receive will be different from these examplesreceive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of that care will also be differentcosts you might pay under different health plans. See the next page for important information about Please note these examplescoverage examples are based on self-only coverage. About these Coverage Examples: Peg is Having a baby Baby (normal 9 months of in-network pre-natal care and a hospital delivery)  Amount owed to providersManaging Xxx’s type 2 Diabetes (a year of routine in-network care of a well- controlled condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care) ◼ The plan’s overall deductible $0 ◼ Specialist copayment $10 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 20% ◼ The plan’s overall deductible $0 ◼ Specialist copayment $10 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 20% ◼ The plan’s overall deductible $0 ◼ Specialist copayment $10 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $7,540  Plan pays 12,800 In this example, Peg would pay: This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $7,490  Patient pays 7,400 In this example, Xxx would pay: This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $50 Sample care costs1,900 In this example, Xxx would pay: 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: Cost Sharing Deductibles $0 Copays Copayments $20 40 Coinsurance $0 10 What isn’t covered Limits or exclusions $30 Total 60 The total Peg would pay is $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: 110 Cost Sharing Deductibles $0 Copays Copayments $300 520 Coinsurance $300 350 What isn’t covered Limits or exclusions $40 Total 60 The total Xxx would pay is $640 These examples are based on coverage for an individual plan. Questions and answers about the Coverage Examples: 930 Cost Sharing Deductibles $0 Copayments $180 Coinsurance $50 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 Limits or payment exclusions $0 The total Mia would pay is limited. Does $230 The plan would be responsible for the Coverage Example predict my own care needs?other costs of these EXAMPLE covered services.

Your Grievance and Appeals Rights. If There are agencies that can help if you have a complaint or are dissatisfied with against your plan for a denial of coverage a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for claims under that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan, you may be able to appeal or file a grievance. For questions more information about your rights, this notice, or assistance, contact: contact the plan at 0-000-000-0000 or (000) 000-0000 or TDD 711. You may also contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx. Additionally, a consumer assistance program can help you can contact file your appeal. 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 plan provide Minimum Essential Coverage? The Affordable Care Act requires most people Yes. If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health care coverage for that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coveragemonth. Does this Coverage Meet plan meet Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standard? The Affordable Care Act establishes Standards, you may be eligible for a minimum value standard of benefits of premium tax credit to help you pay for a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet plan through the minimum value standard for the benefits it providesMarketplace. 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 pagesection.–––––––––––––––––––––– 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. Do yo This is not a cost estimator. Don’t use these Treatments shown are just examples to estimate your of how this plan might cover medical care. Your actual costs under this plan. The will be different depending on the actual care you receive will be different from these examplesreceive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of that care will also be differentcosts you might pay under different health plans. See the next page for important information about Please note these examplescoverage examples are based on self-only coverage. About these Coverage Examples: Peg is Having a baby Baby (normal 9 months of in-network pre-natal care and a hospital delivery) Managing Joe’s type 2 Diabetes (a year of routine in-network care of a well- controlled condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care)  Amount owed to providersThe plan’s overall deductible $0  Specialist copayment $10  Hospital (facility) coinsurance 0%  Other coinsurance 20%  The plan’s overall deductible $0  Specialist copayment $10  Hospital (facility) coinsurance 0%  Other coinsurance 20%  The plan’s overall deductible $0  Specialist copayment $10  Hospital (facility) coinsurance 0%  Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $7,540  Plan pays 12,800 In this example, Peg would pay: This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $7,490  Patient pays 7,400 In this example, Xxx would pay: This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $50 Sample care costs1,900 In this example, Mia would pay: 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: Cost Sharing Deductibles $0 Copays Copayments $20 40 Coinsurance $0 10 What isn’t covered Limits or exclusions $30 Total 60 The total Peg would pay is $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: 110 Cost Sharing Deductibles $0 Copays Copayments $300 520 Coinsurance $300 350 What isn’t covered Limits or exclusions $40 Total 60 The total Xxx would pay is $640 These examples are based on coverage for an individual plan. Questions and answers about the Coverage Examples: 930 Cost Sharing Deductibles $0 Copayments $180 Coinsurance $50 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 Limits or payment exclusions $0 The total Mia would pay is limited. Does $230 The plan would be responsible for the Coverage Example predict my own care needs?other costs of these EXAMPLE covered services.

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 0 Coinsurance $0 20 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 4,460  Patient pays $640 940 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 $300 100 Coinsurance $300 800 Limits or exclusions $40 Total $640 940 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?

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 0 Coinsurance $0 20 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 4,500  Patient pays $640 900 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 60 Coinsurance $300 800 Limits or exclusions $40 Total $640 900 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?

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 0 Coinsurance $0 20 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 4,490  Patient pays $640 910 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 70 Coinsurance $300 800 Limits or exclusions $40 Total $640 910 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?

Your Grievance and Appeals Rights. If There are agencies that can help if you have a complaint or are dissatisfied with against your plan for a denial of coverage a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for claims under that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan, you may be able to appeal or file a grievance. For questions more information about your rights, this notice, or assistance, contact: contact the plan at 0-000-000-0000 or (000) 000-0000 or TDD 711. You may also contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx. Additionally, a consumer assistance program can help you can contact file your appeal. 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 plan provide Minimum Essential Coverage? The Affordable Care Act requires most people Yes. If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health care coverage for that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coveragemonth. Does this Coverage Meet plan meet Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standard? The Affordable Care Act establishes Standards, you may be eligible for a minimum value standard of benefits of premium tax credit to help you pay for a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet plan through the minimum value standard for the benefits it providesMarketplace. 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 pagesection.–––––––––––––––––––––– 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 Treatments shown are just examples to estimate your of how this plan might cover medical care. Your actual costs under this plan. The will be different depending on the actual care you receive will be different from these examplesreceive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of that care will also be differentcosts you might pay under different health plans. See the next page for important information about Please note these examplescoverage examples are based on self-only coverage. About these Coverage Examples: Peg is Having a baby Baby (normal 9 months of in-network pre-natal care and a hospital delivery)  Amount owed to providersManaging Xxx’s type 2 Diabetes (a year of routine in-network care of a well- controlled condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care) ◼ The plan’s overall deductible $0 ◼ Specialist copayment $20 ◼ Hospital (facility) coinsurance No Charge ◼ Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $7,540  Plan pays 12,800 In this example, Peg would pay: ◼ The plan’s overall deductible $7,490  Patient pays 0 ◼ Specialist copayment $50 Sample 20 ◼ Hospital (facility) coinsurance No Charge ◼ Other coinsurance 20% This EXAMPLE event includes services like: Primary care costsphysician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $7,400 In this example, Xxx would pay: ◼ The plan’s overall deductible $0 ◼ Specialist copayment $20 ◼ Hospital charges (motherfacility) coinsurance No Charge ◼ Other coinsurance 20% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines1,900 In this example, other preventive $40 Total $7,540 Patient paysXxx would pay: Cost Sharing Deductibles $0 Copays Copayments $20 Coinsurance $0 What isn’t covered Limits or exclusions $30 Total 100 The total Peg would pay is $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: 120 Cost Sharing Deductibles $0 Copays Copayments $300 160 Coinsurance $300 1,200 What isn’t covered Limits or exclusions $40 Total 60 The total Xxx would pay is $640 These examples are based on coverage for an individual plan. Questions and answers about the Coverage Examples: 1,420 Cost Sharing Deductibles $0 Copayments $200 Coinsurance $80 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 Limits or payment exclusions $0 The total Mia would pay is limited$280 The plan would be responsible for the other costs of these EXAMPLE covered services. Does TOWN OF SOUTH KINGSTOWN ‐ Levels I, II & III Product Name: Delta Dental PPO Plus Premier Plan Type: National Coverage The information listed here is not a guarantee of payment. Payment is based on the Delta Dental allowance for each procedure. To be covered, services must be dentally necessary and in accordance with Delta Dental's treatment guidelines. All services must be performed in a dental office. These benefits are listed according to the level of coverage (i.e. 100%,80%) . Your group number is 5885‐0608. Coverage Example predict my own care needs?for benefits with time limitations (i.e. 6,12,24,36 or 60 months) is calculated to the exact day. The annual maximum is: $2,000.00 per member per calendar year (Periodontal services limited to $400.00) The annual deductible is: $0.00 The maximum lifetime cap: Unlimited Pretreatment estimates are recommended for underlined procedures. Periodontal Maximum $400.00 (Your periodontal benefits are applied to your Annual Maximum total.)

Your Grievance and Appeals Rights. If There are agencies that can help if you have a complaint or are dissatisfied with against your plan for a denial of coverage a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for claims under that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan, you may be able to appeal or file a grievance. For questions more information about your rights, this notice, or assistance, contact: contact the plan at 0-000-000-0000 or (000) 000-0000 or TDD 711. You may also contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx. Additionally, a consumer assistance program can help you can contact file your appeal. 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 plan provide Minimum Essential Coverage? The Affordable Care Act requires most people Yes. If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health care coverage for that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coveragemonth. Does this Coverage Meet plan meet Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standard? The Affordable Care Act establishes Standards, you may be eligible for a minimum value standard of benefits of premium tax credit to help you pay for a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet plan through the minimum value standard for the benefits it providesMarketplace. 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 pagesection.–––––––––––––––––––––– 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 Treatments shown are just examples to estimate your of how this plan might cover medical care. Your actual costs under this plan. The will be different depending on the actual care you receive will be different from these examplesreceive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of that care will also be differentcosts you might pay under different health plans. See the next page for important information about Please note these examplescoverage examples are based on self-only coverage. About these Coverage Examples: Peg is Having a baby Baby (normal 9 months of in-network pre-natal care and a hospital delivery)  Amount owed to providersManaging Xxx’s type 2 Diabetes (a year of routine in-network care of a well- controlled condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care) ◼ The plan’s overall deductible $0 ◼ Specialist copayment $20 ◼ Hospital (facility) coinsurance No Charge ◼ Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $7,540  Plan pays 12,800 In this example, Peg would pay: ◼ The plan’s overall deductible $7,490  Patient pays 0 ◼ Specialist copayment $50 Sample 20 ◼ Hospital (facility) coinsurance No Charge ◼ Other coinsurance 20% This EXAMPLE event includes services like: Primary care costsphysician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $7,400 In this example, Xxx would pay: ◼ The plan’s overall deductible $0 ◼ Specialist copayment $20 ◼ Hospital charges (motherfacility) coinsurance No Charge ◼ Other coinsurance 20% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines1,900 In this example, other preventive $40 Total $7,540 Patient paysXxx would pay: Cost Sharing Deductibles $0 Copays Copayments $20 Coinsurance $0 What isn’t covered Limits or exclusions $30 Total 100 The total Peg would pay is $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: 120 Cost Sharing Deductibles $0 Copays Copayments $300 160 Coinsurance $300 1,200 What isn’t covered Limits or exclusions $40 Total 60 The total Xxx would pay is $640 These examples are 1,420 Cost Sharing Deductibles $0 Copayments $200 Coinsurance $80 What isn’t covered Limits or exclusions $0 The total Mia would pay is $280 The plan would be responsible for the other costs of these EXAMPLE covered services. TOWN OF SOUTH KINGSTOWN Product Name: Delta Dental PPO/Delta Dental Premier Plan Type: National Coverage The information listed here is not a guarantee of payment. Payment is based on the Delta Dental allowance for each procedure. To be covered, services must be dentally necessary and in accordance with Delta Dental's treatment guidelines. All services must be performed in a dental office. These benefits are listed according to the level of coverage (i.e. 100%,80%) . Your group number is 5885-0605. Coverage for benefits with time limitations (i.e. 6,12,24,36 or 60 months) is calculated to the exact day. The annual maximum is: $2,000.00 per member per calendar year (Periodontal services limited to $400.00) The annual deductible is: $0.00 The maximum lifetime cap: Unlimited Pretreatment estimates are recommended for underlined procedures. Periodontal Maximum $400.00 (Your periodontal benefits are applied to your Annual Maximum total.) Plan pays 100%; Member Coinsurance 0% • Oral exam - once per calendar year performed by a general dentist • Cleaning - twice per calendar year • Fluoride treatment - for children under age 19 once per calendar year • Bitewing x-rays - one set per calendar year • Complete x-ray series or panoramic film once every 36 months • Single x-rays as required • Palliative treatment (minor procedures necessary to relieve acute pain) twice per calendar year • Amalgam (silver) fillings. Composite (white) fillings on front teeth only. For composite fillings on back teeth, the plan pays up to what would’ve been paid for an individual planamalgam filling. Questions Patient responsible for balance up to the dentist's charge. • Space maintainers once every 60 months for lost deciduous (baby) teeth • Extractions and answers about other routine oral surgery when not covered by a patient's medical plan • General anesthesia or intravenous (I.V.) sedation for certain complex surgical procedures • Root canal therapy on permanent teeth - one procedure per tooth per lifetime. Vital pulpotomy and apicoectomies also covered once per tooth per lifetime. • Repairs to existing partial or complete dentures once per calendar year • Recementing crowns or bridges once every 60 months • Rebasing or relining of partial or complete dentures once every 60 months • Crowns over natural teeth, build ups, posts and cores - replacement limited to once every 60 months Plan pays 50%; Member Coinsurance 50% • Periodontal maintenance following active therapy - two per year • Root planing and scaling once per quadrant every 24 months. • Osseous (bone) surgery once per quadrant every 36 months (bone grafts are not covered). • Gingivectomies once per site every 36 months. • Soft tissue grafts once per site every 60 months • Crown lengthening once per site every 60 months Dependent coverage - Dependent children are covered up until the Coverage Examples: What are some end of the assumptions behind year that they turn age 19. Delta Dental of Rhode Island ◼ P. O. Xxx 0000 ◼ Xxxxxxxxxx, XX 00000-0000 ◼ 0.000.000.0000 ◼ xxxxxxxxxxxxx.xxx Exclusions & Limitations Unless specifically covered by your dental plan, the Coverage Examples?  Costs don’t include premiumsfollowing are not covered: ◼ Services that are not dentally necessary and appropriate according to our review guidelines.  Sample care costs Services subject to these guidelines include, but are not limited to, root canals; crowns and related services; bridges; periodontal services; orthodontics; and oral surgery. We will make a decision whether a service is dentally necessary 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 planthese guidelines.  The patient’s condition was A service may 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 be covered under these guidelines even if it was recommended by a dentist. Our guidelines can be found on our website at xxx.xxxxxxxxxxxxx.xxx. You can have your dentist send us a request for a pre-treatment estimate in advance of the service to see if the service meets our guidelines. ◼ Services greater than the annual maximum. ◼ Services received from a dental or medical department maintained by or on behalf of an employer, a mutual benefit association, labor union, trustee or similar person or group. ◼ An illness or injury that Delta Dental decides is employment-related. ◼ Services you would not have to pay for if you did not have this planDelta Dental coverage.  Out-of-pocket expenses ◼ Services or supplies that are based only on treating the experimental in terms of generally accepted dental standards. ◼ Services done by a dentist who is a member of your immediate family. ◼ An illness, injury or dental condition in the example.  The patient received all care from in- network providers. If the patient had received care from out-of-network providersfor which benefits are, costs or would have been higheravailable, through a government program if you did not have this Delta Dental coverage. What does ◼ Services done by someone who is not a Coverage Example show? For each treatment situationlicensed dentist or a licensed hygienist working as authorized by applicable law. ◼ Exams by specialists, except for periodic oral exams. ◼ Consultations. ◼ Disorders related to the temporomandibular joints (TMJ), including night guards and surgery. ◼ Services to increase the height of teeth or restore occlusion. ◼ Restorations needed because of teeth grinding or due to erosion, abrasion or attrition. ◼ Services done mainly to change or to improve your appearance. ◼ Occlusal guards. ◼ Implants. ◼ Bone grafts. ◼ Splinting and other services to stabilize teeth. ◼ Laboratory or bacteriological tests or reports. ◼ Temporary, complete dentures or temporary, fixed bridges or crowns. ◼ Prescription drugs. ◼ Guided tissue regeneration. ◼ General anesthesia or intravenous sedation for non-surgical extractions, diagnostic, preventive, or minor restorative services. ◼ General anesthesia or intravenous sedation given by anyone other than a dentist. Delta Dental can adopt; and, apply, policies that we deem reasonable when we approve the eligibility of subscribers; and, the Coverage Example helps you see how deductibles, copayments, appropriateness of treatment plans and coinsurance can add uprelated charges. It also helps you see what expenses might All claims must be left up to you to pay because filed within one year of the service or treatment isn’t covered or payment is limited. Does the Coverage Example predict my own care needs?date of service.

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 01-000800-000639-00002227. Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 01-000800-000639-00002227. 如果需要中文的帮助，请拨打这个号码 01-000800-000639-00002227. Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 01-000800-000639-00002227. ––––––––––––––––––––––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 0 Coinsurance $0 20 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  4,500 ◼ Patient pays $640 900 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 60 Coinsurance $300 800 Limits or exclusions $40 Total $640 900 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?

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 01-000800-000639-00002227. Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 01-000800-000639-00002227. 如果需要中文的帮助，请拨打这个号码 01-000800-000639-00002227. Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 01-000800-000639-00002227. ––––––––––––––––––––––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 0 Coinsurance $0 20 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  4,490 ◼ Patient pays $640 910 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 70 Coinsurance $300 800 Limits or exclusions $40 Total $640 910 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?

Your Grievance and Appeals Rights. If There are agencies that can help if you have a complaint or are dissatisfied with against your plan for a denial of coverage a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for claims under that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan, you may be able to appeal or file a grievance. For questions more information about your rights, this notice, or assistance, contact: contact the plan at 0-000-000-0000 or (000) 000-0000 or TDD 711. You may also contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx. Additionally, a consumer assistance program can help you can contact file your appeal. 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 plan provide Minimum Essential Coverage? The Affordable Care Act requires most people Yes. If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health care coverage for that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coveragemonth. Does this Coverage Meet plan meet Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standard? The Affordable Care Act establishes Standards, you may be eligible for a minimum value standard of benefits of premium tax credit to help you pay for a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet plan through the minimum value standard for the benefits it providesMarketplace. 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 pagesection.–––––––––––––––––––––– 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 Treatments shown are just examples to estimate your of how this plan might cover medical care. Your actual costs under this plan. The will be different depending on the actual care you receive will be different from these examplesreceive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of that care will also be differentcosts you might pay under different health plans. See the next page for important information about Please note these examplescoverage examples are based on self-only coverage. About these Coverage Examples: Peg is Having a baby Baby (normal 9 months of in-network pre-natal care and a hospital delivery)  Amount owed to providersManaging Xxx’s type 2 Diabetes (a year of routine in-network care of a well- controlled condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care) ◼ The plan’s overall deductible $0 ◼ Specialist copayment $15 ◼ Hospital (facility) coinsurance No Charge ◼ Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $7,540  Plan pays 12,800 In this example, Peg would pay: ◼ The plan’s overall deductible $7,490  Patient pays 0 ◼ Specialist copayment $50 Sample 15 ◼ Hospital (facility) coinsurance No Charge ◼ Other coinsurance 20% This EXAMPLE event includes services like: Primary care costsphysician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $7,400 In this example, Xxx would pay: ◼ The plan’s overall deductible $0 ◼ Specialist copayment $15 ◼ Hospital charges (motherfacility) coinsurance No Charge ◼ Other coinsurance 20% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines1,900 In this example, other preventive $40 Total $7,540 Patient paysXxx would pay: Cost Sharing Deductibles $0 Copays Copayments $20 Coinsurance $0 What isn’t covered Limits or exclusions $30 Total 100 The total Peg would pay is $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: 120 Cost Sharing Deductibles $0 Copays Copayments $300 110 Coinsurance $300 1,200 What isn’t covered Limits or exclusions $40 Total 60 The total Xxx would pay is $640 These examples are based on coverage for an individual plan. Questions and answers about the Coverage Examples: 1,370 Cost Sharing Deductibles $0 Copayments $200 Coinsurance $80 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 Limits or payment exclusions $0 The total Mia would pay is limited$280 The plan would be responsible for the other costs of these EXAMPLE covered services. Does TOWN OF SOUTH KINGSTOWN Product Name: Delta Dental PPO Plus Premier Plan Type: National Coverage The information listed here is not a guarantee of payment. Payment is based on the Delta Dental allowance for each procedure. To be covered, services must be dentally necessary and in accordance with Delta Dental's treatment guidelines. All services must be performed in a dental office. These benefits are listed according to the level of coverage (i.e. 100%,80%) . Your group number is 5885-0608. Coverage Example predict my own care needs?for benefits with time limitations (i.e. 6,12,24,36 or 60 months) is calculated to the exact day. The annual maximum is: $2,000.00 per member per calendar year (Periodontal services limited to $400.00) The annual deductible is: $0.00 The maximum lifetime cap: Unlimited Pretreatment estimates are recommended for underlined procedures. Periodontal Maximum $400.00 (Your periodontal benefits are applied to your Annual Maximum total.)

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 0 Coinsurance $0 20 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  4,500 ◼ Patient pays $640 900 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 60 Coinsurance $300 800 Limits or exclusions $40 Total $640 900 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?

Your Grievance and Appeals Rights. If There are agencies that can help if you have a complaint or are dissatisfied with against your plan for a denial of coverage a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for claims under that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan, you may be able to appeal or file a grievance. For questions more information about your rights, this notice, or assistance, contact: contact the plan at 0-000-000-0000 or (000) 000-0000 or TDD 711. You may also contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx. Additionally, a consumer assistance program can help you can contact file your appeal. 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 plan provide Minimum Essential Coverage? The Affordable Care Act requires most people Yes. If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health care coverage for that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coveragemonth. Does this Coverage Meet plan meet Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standard? The Affordable Care Act establishes Standards, you may be eligible for a minimum value standard of benefits of premium tax credit to help you pay for a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet plan through the minimum value standard for the benefits it providesMarketplace. 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 pagesection.–––––––––––––––––––––– 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. Do yo This is not a cost estimator. Don’t use these Treatments shown are just examples to estimate your of how this plan might cover medical care. Your actual costs under this plan. The will be different depending on the actual care you receive will be different from these examplesreceive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of that care will also be differentcosts you might pay under different health plans. See the next page for important information about Please note these examplescoverage examples are based on self-only coverage. About these Coverage Examples: Peg is Having a baby Baby (normal 9 months of in-network pre-natal care and a hospital delivery) Managing Joe’s type 2 Diabetes (a year of routine in-network care of a well- controlled condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care)  Amount owed to providersThe plan’s overall deductible $0  Specialist copayment $10  Hospital (facility) coinsurance 0%  Other coinsurance 20%  The plan’s overall deductible $0  Specialist copayment $10  Hospital (facility) coinsurance 0%  Other coinsurance 20%  The plan’s overall deductible $0  Specialist copayment $10  Hospital (facility) coinsurance 0%  Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $7,540  Plan pays 12,800 In this example, Peg would pay: This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $7,490  Patient pays 7,400 In this example, Xxx would pay: This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $50 Sample care costs1,900 In this example, Mia would pay: 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: Cost Sharing Deductibles $0 Copays Copayments $20 Coinsurance $0 10 What isn’t covered Limits or exclusions $30 Total 60 The total Peg would pay is $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: 90 Cost Sharing Deductibles $0 Copays Copayments $300 100 Coinsurance $300 1200 What isn’t covered Limits or exclusions $40 Total 60 The total Xxx would pay is $640 These examples are based on coverage for an individual plan. Questions and answers about the Coverage Examples: 1360 Cost Sharing Deductibles $0 Copayments $180 Coinsurance $50 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 Limits or payment exclusions $0 The total Mia would pay is limited. Does $230 The plan would be responsible for the Coverage Example predict my own care needs?other costs of these EXAMPLE covered services.

Your Grievance and Appeals Rights. If There are agencies that can help if you have a complaint or are dissatisfied with against your plan for a denial of coverage a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for claims under that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan, you may be able to appeal or file a grievance. For questions more information about your rights, this notice, or assistance, contact: contact the plan at 0-000-000-0000 or (000) 000-0000 or TDD 711. You may also contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx. Additionally, a consumer assistance program can help you can contact file your appeal. 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 plan provide Minimum Essential Coverage? The Affordable Care Act requires most people to have Yes. Minimum Essential Coverage generally includes plans, health care coverage that qualifies as “minimum essential insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage.” This plan or policy does provide minimum essential coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this Coverage Meet plan meet Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standard? The Affordable Care Act establishes Standards, you may be eligible for a minimum value standard of benefits of premium tax credit to help you pay for a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet plan through the minimum value standard for the benefits it providesMarketplace. 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 pagesection.–––––––––––––––––––––– About Other Covered Services (Limitations may apply to 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 plansservices. 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 limiteda complete list. Does the Coverage Example predict my own care needs?Please see your plan document.)

Your Grievance and Appeals Rights. If There are agencies that can help if you have a complaint or are dissatisfied with against your plan for a denial of coverage a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for claims under that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan, you may be able to appeal or file a grievance. For questions more information about your rights, this notice, or assistance, contact: contact the plan at 0-000-000-0000 or (000) 000-0000 or TDD 711. You may also contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx. Additionally, a consumer assistance program can help you can contact file your appeal. 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 plan provide Minimum Essential Coverage? The Affordable Care Act requires most people Yes. If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health care coverage for that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coveragemonth. Does this Coverage Meet plan meet Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standard? The Affordable Care Act establishes Standards, you may be eligible for a minimum value standard of benefits of premium tax credit to help you pay for a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet plan through the minimum value standard for the benefits it providesMarketplace. 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 pagesection.–––––––––––––––––––––– 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 Treatments shown are just examples to estimate your of how this plan might cover medical care. Your actual costs under this plan. The will be different depending on the actual care you receive will be different from these examplesreceive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of that care will also be differentcosts you might pay under different health plans. See the next page for important information about Please note these examplescoverage examples are based on self-only coverage. About these Coverage Examples: Peg is Having a baby Baby (normal 9 months of in-network pre-natal care and a hospital delivery)  Amount owed to providersManaging Xxx’s type 2 Diabetes (a year of routine in-network care of a well- controlled condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care) ◼ The plan’s overall deductible $0 ◼ Specialist copayment $10 ◼ Hospital (facility) coinsurance No Charge ◼ Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $7,540  Plan pays 12,800 In this example, Peg would pay: ◼ The plan’s overall deductible $7,490  Patient pays 0 ◼ Specialist copayment $50 Sample 10 ◼ Hospital (facility) coinsurance No Charge ◼ Other coinsurance 20% This EXAMPLE event includes services like: Primary care costsphysician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $7,400 In this example, Xxx would pay: ◼ The plan’s overall deductible $0 ◼ Specialist copayment $10 ◼ Hospital charges (motherfacility) coinsurance No Charge ◼ Other coinsurance 20% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines1,900 In this example, other preventive $40 Total $7,540 Patient paysXxx would pay: Cost Sharing Deductibles $0 Copays Copayments $20 10 Coinsurance $0 What isn’t covered Limits or exclusions $30 Total 100 The total Peg would pay is $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: 110 Cost Sharing Deductibles $0 Copays Copayments $300 100 Coinsurance $300 1,200 What isn’t covered Limits or exclusions $40 Total 60 The total Xxx would pay is $640 These examples are based on coverage for an individual plan. Questions and answers about the Coverage Examples: 1,360 Cost Sharing Deductibles $0 Copayments $100 Coinsurance $80 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 Limits or payment exclusions $0 The total Mia would pay is limited. Does the Coverage Example predict my own care needs?$180

Your Grievance and Appeals Rights. If There are agencies that can help if you have a complaint or are dissatisfied with against your plan for a denial of coverage a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for claims under that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan, you may be able to appeal or file a grievance. For questions more information about your rights, this notice, or assistance, contact: contact the plan at 0-000-000-0000 or (000) 000-0000 or TDD 711. You may also contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx. Additionally, a consumer assistance program can help you can contact file your appeal. 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 plan provide Minimum Essential Coverage? The Affordable Care Act requires most people Yes. If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health care coverage for that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coveragemonth. Does this Coverage Meet plan meet Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standard? The Affordable Care Act establishes Standards, you may be eligible for a minimum value standard of benefits of premium tax credit to help you pay for a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet plan through the minimum value standard for the benefits it providesMarketplace. Language Access Services: Para obtener asistencia en Español, llame al 01-000800-000639-00002227. Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 01-000800-000639-00002227. 如果需要中文的帮助，请拨打这个号码 01-000800-000639-00002227. Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 01-000800-000639-00002227. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next pagesection.–––––––––––––––––––––– 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. Do yo This is not a cost estimator. Don’t use these Treatments shown are just examples to estimate your of how this plan might cover medical care. Your actual costs under this plan. The will be different depending on the actual care you receive will be different from these examplesreceive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of that care will also be differentcosts you might pay under different health plans. See the next page for important information about Please note these examplescoverage examples are based on self-only coverage. About these Coverage Examples: Peg is Having a baby Baby (normal 9 months of in-network pre-natal care and a hospital delivery)  Amount owed to providersManaging Xxx’s type 2 Diabetes (a year of routine in-network care of a well- controlled condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care) ◼ The plan’s overall deductible $0 ◼ Specialist copayment $10 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 20% ◼ The plan’s overall deductible $0 ◼ Specialist copayment $10 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 20% ◼ The plan’s overall deductible $0 ◼ Specialist copayment $10 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $7,540  Plan pays 12,800 In this example, Peg would pay: This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $7,490  Patient pays 7,400 In this example, Xxx would pay: This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $50 Sample care costs1,900 In this example, Xxx would pay: 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: Cost Sharing Deductibles $0 Copays Copayments $20 Coinsurance $0 10 What isn’t covered Limits or exclusions $30 Total 60 The total Peg would pay is $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: 90 Cost Sharing Deductibles $0 Copays Copayments $300 100 Coinsurance $300 1200 What isn’t covered Limits or exclusions $40 Total 60 The total Xxx would pay is $640 These examples are based on coverage for an individual plan. Questions and answers about the Coverage Examples: 1360 Cost Sharing Deductibles $0 Copayments $180 Coinsurance $50 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 Limits or payment exclusions $0 The total Mia would pay is limited. Does $230 The plan would be responsible for the Coverage Example predict my own care needs?other costs of these EXAMPLE covered services.

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 0 Coinsurance $0 20 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  4,460 ◼ Patient pays $640 940 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 $300 100 Coinsurance $300 800 Limits or exclusions $40 Total $640 940 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?

Your Grievance and Appeals Rights. If There are agencies that can help if you have a complaint or are dissatisfied with against your plan for a denial of coverage a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for claims under that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan, you may be able to appeal or file a grievance. For questions more information about your rights, this notice, or assistance, contact: contact the plan at 0-000-000-0000 or (000) 000-0000 or TDD 711. You may also contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx. Additionally, a consumer assistance program can help you can contact file your appeal. 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 plan provide Minimum Essential Coverage? The Affordable Care Act requires most people Yes. If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health care coverage for that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coveragemonth. Does this Coverage Meet plan meet Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standard? The Affordable Care Act establishes Standards, you may be eligible for a minimum value standard of benefits of premium tax credit to help you pay for a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet plan through the minimum value standard for the benefits it providesMarketplace. 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 pagesection.–––––––––––––––––––––– 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. Do yo This is not a cost estimator. Don’t use these Treatments shown are just examples to estimate your of how this plan might cover medical care. Your actual costs under this plan. The will be different depending on the actual care you receive will be different from these examplesreceive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of that care will also be differentcosts you might pay under different health plans. See the next page for important information about Please note these examplescoverage examples are based on self-only coverage. About these Coverage Examples: Peg is Having a baby Baby (normal 9 months of in-network pre-natal care and a hospital delivery) Managing Joe’s type 2 Diabetes (a year of routine in-network care of a well- controlled condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care)  Amount owed to providersThe plan’s overall deductible $0  Specialist copayment $20  Hospital (facility) coinsurance 0%  Other coinsurance 20%  The plan’s overall deductible $0  Specialist copayment $20  Hospital (facility) coinsurance 0%  Other coinsurance 20%  The plan’s overall deductible $0  Specialist copayment $20  Hospital (facility) coinsurance 0%  Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $7,540  Plan pays 12,800 In this example, Peg would pay: This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $7,490  Patient pays 7,400 In this example, Xxx would pay: This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $50 Sample care costs1,900 In this example, Mia would pay: 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: Cost Sharing Deductibles $0 Copays Copayments $20 30 Coinsurance $0 10 What isn’t covered 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 60 The total Peg would pay is $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Cost Sharing Deductibles $0 Copays Copayments $300 160 Coinsurance $300 1200 What isn’t covered Limits or exclusions $40 Total 60 The total Xxx would pay is $640 These examples are based on coverage for an individual plan. Questions and answers about the Coverage Examples: 1420 Cost Sharing Deductibles $0 Copayments $210 Coinsurance $50 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 Limits or payment exclusions $0 The total Mia would pay is limited. Does $260 The plan would be responsible for the Coverage Example predict my own care needs?other costs of these EXAMPLE covered services.

Your Grievance and Appeals Rights. If There are agencies that can help if you have a complaint or are dissatisfied with against your plan for a denial of coverage a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for claims under that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan, you may be able to appeal or file a grievance. For questions more information about your rights, this notice, or assistance, contact: contact the plan at 0-000-000-0000 or (000) 000-0000 or TDD 711. You may also contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx. Additionally, a consumer assistance program can help you can contact file your appeal. 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 plan provide Minimum Essential Coverage? The Affordable Care Act requires most people Yes. If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health care coverage for that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coveragemonth. Does this Coverage Meet plan meet Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standard? The Affordable Care Act establishes Standards, you may be eligible for a minimum value standard of benefits of premium tax credit to help you pay for a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet plan through the minimum value standard for the benefits it providesMarketplace. Language Access Services: Para obtener asistencia en Español, llame al 01-000800-000639-00002227. Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 01-000800-000639-00002227. 如果需要中文的帮助，请拨打这个号码 01-000800-000639-00002227. Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 01-000800-000639-00002227. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next pagesection.–––––––––––––––––––––– 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. Do yo This is not a cost estimator. Don’t use these Treatments shown are just examples to estimate your of how this plan might cover medical care. Your actual costs under this plan. The will be different depending on the actual care you receive will be different from these examplesreceive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of that care will also be differentcosts you might pay under different health plans. See the next page for important information about Please note these examplescoverage examples are based on self-only coverage. About these Coverage Examples: Peg is Having a baby Baby (normal 9 months of in-network pre-natal care and a hospital delivery)  Amount owed to providersManaging Xxx’s type 2 Diabetes (a year of routine in-network care of a well- controlled condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care) ◼ The plan’s overall deductible $0 ◼ Specialist copayment $15 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 20% ◼ The plan’s overall deductible $0 ◼ Specialist copayment $15 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 20% ◼ The plan’s overall deductible $0 ◼ Specialist copayment $15 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $7,540  Plan pays 12,800 In this example, Peg would pay: This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $7,490  Patient pays 7,400 In this example, Xxx would pay: This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $50 Sample care costs1,900 In this example, Xxx would pay: 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: Cost Sharing Deductibles $0 Copays Copayments $20 Coinsurance $0 10 What isn’t covered Limits or exclusions $30 Total 60 The total Peg would pay is $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: 90 Cost Sharing Deductibles $0 Copays Copayments $300 110 Coinsurance $300 1200 What isn’t covered Limits or exclusions $40 Total 60 The total Xxx would pay is $640 These examples are based on coverage for an individual plan. Questions and answers about the Coverage Examples: 1370 Cost Sharing Deductibles $0 Copayments $200 Coinsurance $50 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 Limits or payment exclusions $0 The total Mia would pay is limited. Does $250 The plan would be responsible for the Coverage Example predict my own care needs?other costs of these EXAMPLE covered services.

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 0 Coinsurance $0 20 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  4,490 ◼ Patient pays $640 910 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 70 Coinsurance $300 800 Limits or exclusions $40 Total $640 910 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?

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 Blue Cross and Blue Shield of Labor, Employee Benefits Security Administration Illinois at 0-000-000-0000 or xxx.xxx.xxx/xxxxvisit xxx.xxxxxx.xxx, or contact the U.S. U.S Department of Health and Human Services Labor's Employee Benefits Security Administration at 01-866-444-EBSA (3272) or visit xxx.xxx.xxx/xxxx/xxxxxxxxxxxx. Additionally, a consumer assistance program can help you file your appeal. Contact the Illinois Department of Insurance at (000-) 000-0000 x00000 or xxx.xxxxx.xxx.xxxvisit xxxx://xxxxxxxxx.xxxxxxxx.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: Spanish (Español): Para obtener asistencia en Español, llame al 0-000-000-0000. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. Chinese (中文): 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Navajo (Dine): 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. 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. Having a baby (normal delivery)   Amount owed to providers: $7,540   Plan pays $7,490  6,840  Patient pays $50 700 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  4,720  Patient pays $640 680 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 Deductibles $0 Copays $600 Coinsurance $0 Limits or exclusions $80 Total $680 Patient pays: Deductibles $0 Copays $300 500 Coinsurance $300 0 Limits or exclusions $40 200 Total $640 These examples are based on coverage for an individual plan. 700 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-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??  No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “Patient Pays” box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you’ll pay in out-of- pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call 0-000-000-0000 or visit us at xxx.xxxxxx.xxx. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at xxxx://xxx.xxx.xxx/ebsa/pdf/SBCUniformGlossary.pdf or call 1-855-756- 4448 to request a copy. SBC IL Non-HMO LG-2016 City of Naperville: PPO PC0713 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2017 - 12/31/2017 Coverage for: ALL | Plan Type: PPO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www. xxxxxx.xxx or by calling 0-000-000-0000.

Your Grievance and Appeals Rights. If There are agencies that can help if you have a complaint or are dissatisfied with against your plan for a denial of coverage a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for claims under that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan, you may be able to appeal or file a grievance. For questions more information about your rights, this notice, or assistance, contact: contact the plan at 0-000-000-0000 or (000) 000-0000 or TDD 711. You may also contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx. Additionally, a consumer assistance program can help you can contact file your appeal. 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 plan provide Minimum Essential Coverage? The Affordable Care Act requires most people Yes. If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health care coverage for that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coveragemonth. Does this Coverage Meet plan meet Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standard? The Affordable Care Act establishes Standards, you may be eligible for a minimum value standard of benefits of premium tax credit to help you pay for a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet plan through the minimum value standard for the benefits it providesMarketplace. 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 pagesection.–––––––––––––––––––––– 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. Do yo This is not a cost estimator. Don’t use these Treatments shown are just examples to estimate your of how this plan might cover medical care. Your actual costs under this plan. The will be different depending on the actual care you receive will be different from these examplesreceive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of that care will also be differentcosts you might pay under different health plans. See the next page for important information about Please note these examplescoverage examples are based on self-only coverage. About these Coverage Examples: Peg is Having a baby Baby (normal 9 months of in-network pre-natal care and a hospital delivery) Managing Joe’s type 2 Diabetes (a year of routine in-network care of a well- controlled condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care)  Amount owed to providersThe plan’s overall deductible $0  Specialist copayment $15  Hospital (facility) coinsurance 0%  Other coinsurance 20%  The plan’s overall deductible $0  Specialist copayment $15  Hospital (facility) coinsurance 0%  Other coinsurance 20%  The plan’s overall deductible $0  Specialist copayment $15  Hospital (facility) coinsurance 0%  Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $7,540  Plan pays 12,800 In this example, Peg would pay: This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $7,490  Patient pays 7,400 In this example, Xxx would pay: This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $50 Sample care costs1,900 In this example, Mia would pay: 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: Cost Sharing Deductibles $0 Copays Copayments $20 Coinsurance $0 10 What isn’t covered Limits or exclusions $30 Total 60 The total Peg would pay is $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: 90 Cost Sharing Deductibles $0 Copays Copayments $300 110 Coinsurance $300 1200 What isn’t covered Limits or exclusions $40 Total 60 The total Xxx would pay is $640 These examples are based on coverage for an individual plan. Questions and answers about the Coverage Examples: 1370 Cost Sharing Deductibles $0 Copayments $200 Coinsurance $50 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 Limits or payment exclusions $0 The total Mia would pay is limited. Does $250 The plan would be responsible for the Coverage Example predict my own care needs?other costs of these EXAMPLE covered services.