Common use of Your Grievance and Appeals Rights Clause in Contracts

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of 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 that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, 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 costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing 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 $1,000 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $1,000 ◼ Specialist copayment $30 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $1,000 ◼ Specialist copayment $30 ◼ Hospital (facility) coinsurance 0% ◼ 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 $2,800 In this example, Xxx would pay: Cost Sharing Deductibles $1,000 Copayments $10 Coinsurance $2,300 What isn’t covered Limits or exclusions $60 The total Peg would pay is $3,370 Cost Sharing Deductibles $900 Copayments $800 Coinsurance $0 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,720 Cost Sharing Deductibles $1,000 Copayments $100 Coinsurance $100 What isn’t covered Limits or exclusions $0 The total Mia would pay is $1,200 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copy.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of 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 that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, 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 costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing 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 $1,000 500 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $1,000 500 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $1,000 500 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 0% ◼ 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 $2,800 In this example, Xxx would pay: Cost Sharing Deductibles $1,000 500 Copayments $10 Coinsurance $2,300 2,400 What isn’t covered Limits or exclusions $60 The total Peg would pay is $3,370 2,970 Cost Sharing Deductibles $900 500 Copayments $800 700 Coinsurance $0 80 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,720 1,300 Cost Sharing Deductibles $1,000 500 Copayments $100 70 Coinsurance $100 200 What isn’t covered Limits or exclusions $0 The total Mia would pay is $1,200 770 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copy.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of 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 that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, 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 costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing 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 $1,000 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $1,000 ◼ Specialist copayment $30 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $1,000 ◼ Specialist copayment $30 ◼ Hospital (facility) coinsurance 0% ◼ 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 $2,800 In this example, Xxx would pay: Cost Sharing Deductibles $1,000 Copayments $10 Coinsurance $2,300 What isn’t covered Limits or exclusions $60 The total Peg would pay is $3,370 Cost Sharing Deductibles $900 Copayments $800 Coinsurance $0 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,720 Cost Sharing Deductibles $1,000 Copayments $100 Coinsurance $100 What isn’t covered Limits or exclusions $0 The total Mia would pay is $1,200 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copy.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of 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 that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township Blue Cross® and Blue Shield® of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000Michigan by calling the number on the back of your BCBSM ID card. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan ) Department of Insurance and Financial Services (DIFS) at (000) 000Services, P. O. Xxx 00000, Xxxxxxx, XX 00000-0000. 0000 or xxxx://xxx.xxxxxxxx.xxx/difs or xxxx-XXXXX@xxxxxxxx.xxx Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. (IMPORTANT: Blue Cross Blue Shield of Michigan is assuming that your coverage provides for all Essential Health Benefit (EHB) categories as defined by the State of Michigan. The minimum value of your plan may be affected if your plan does not cover certain EHB categories, such as prescription drugs, or if your plan provides coverage of specific EHB categories, for example prescription drugs, through another carrier.) 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. See Addendum ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section. –––––––––––––––––––––– About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, 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 costs you might pay under different health plans. Please note these coverage examples are based on self- self-only coverage. Managing Xxx’s Type 2 Diabetes (a year of routine in-network care of a well-controlled condition) Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing 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 $1,000 0 ◼ Primary care physician coinsurance 0% Specialist copayment $10 ◼ Hospital (facility) coinsurance 20% copayment $0 ◼ Other coinsurance 20% copayment $0 This EXAMPLE event includes services like: Primary care physician 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 $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $1,000 0 ◼ Specialist copayment $30 10 ◼ Hospital (facility) coinsurance 20% copayment $0 ◼ Other coinsurance 20% copayment $0 This EXAMPLE event includes services like: Specialist Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $1,000 0 ◼ Specialist copayment $30 10 ◼ Hospital (facility) coinsurance 0% copayment $0 ◼ Other coinsurance 20% copayment $0 This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test tests (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Xxx would pay: Cost Sharing Deductibles $1,000 0 Copayments $10 Coinsurance $2,300 0 What isn’t covered Limits or exclusions $60 The total Peg would pay is $3,370 70 Cost Sharing Deductibles $900 0 Copayments $800 300 Coinsurance $0 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,720 320 Cost Sharing Deductibles $1,000 0 Copayments $100 30 Coinsurance $100 0 What isn’t covered Limits or exclusions $0 The total Mia would pay is $1,200 30 If you are also covered by an account-type plan such as an integrated health flexible spending arrangement (FSA), health reimbursement arrangement (HRA), and/or a health savings account (HSA), then you may have access to additional funds to help cover certain out-of-pocket expenses – like the deductible, copayments, or coinsurance, or benefits not otherwise covered. Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2022 CITY OF WESTLAND Community Blue PPOSM ASC PPO 2 Coverage for: Individual/Family | Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx visit xxx.xxxxx.xxx or call (000) 000-0000the number on the back of your BCBSM ID card. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx xxxxx://xxx.xxxxxxxxxx.xxx/sbc-glossary or call Care Coordinators at (000) 000-0000 the number on the back of your BCBSM ID card to request a copy.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of 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 that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township Blue Cross® and Blue Shield® of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000Michigan by calling the number on the back of your BCBSM ID card. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan ) Department of Insurance and Financial Services (DIFS) at (000) 000Services, P. O. Xxx 00000, Xxxxxxx, XX 00000-0000. 0000 or xxxx://xxx.xxxxxxxx.xxx/difs or xxxx-XXXXX@xxxxxxxx.xxx Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. (IMPORTANT: Blue Cross Blue Shield of Michigan is assuming that your coverage provides for all Essential Health Benefit (EHB) categories as defined by the State of Michigan. The minimum value of your plan may be affected if your plan does not cover certain EHB categories, such as prescription drugs, or if your plan provides coverage of specific EHB categories, for example prescription drugs, through another carrier.) 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. See Addendum ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section. –––––––––––––––––––––– About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, 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 costs you might pay under different health plans. Please note these coverage examples are based on self- self-only coverage. Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well-controlled condition) Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing 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 $1,000 100 ◼ Primary care physician coinsurance 0% Specialist copayment $10 ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% This EXAMPLE event includes services like: Primary care physician 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 $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $1,000 100 ◼ Specialist copayment $30 10 ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% This EXAMPLE event includes services like: Specialist Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $1,000 100 ◼ Specialist copayment $30 10 ◼ Hospital (facility) coinsurance 010% ◼ Other coinsurance 2010% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test tests (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Xxx Mia would pay: Cost Sharing Deductibles $1,000 100 Copayments $10 Coinsurance $2,300 1,000 What isn’t covered Limits or exclusions $60 The total Peg would pay is $3,370 1,170 Cost Sharing Deductibles $900 100 Copayments $800 500 Coinsurance $0 80 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,720 700 Cost Sharing Deductibles $1,000 100 Copayments $100 30 Coinsurance $100 200 What isn’t covered Limits or exclusions $0 The total Mia would pay is $1,200 330 If you are also covered by an account-type plan such as an integrated health flexible spending arrangement (FSA), health reimbursement arrangement (HRA), and/or a health savings account (HSA), then you may have access to additional funds to help cover certain out-of-pocket expenses – like the deductible, copayments, or coinsurance, or benefits not otherwise covered. Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2022 CITY OF WESTLAND Community Blue PPOSM ASC Base PPO Coverage for: Individual/Family | Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx visit xxx.xxxxx.xxx or call (000) 000-0000the number on the back of your BCBSM ID card. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx xxxxx://xxx.xxxxxxxxxx.xxx/sbc-glossary or call Care Coordinators at (000) 000-0000 the number on the back of your BCBSM ID card to request a copy.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of 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 that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. About these Coverage Examples: Appendix "D"- Plan #049 - Erie This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, 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 costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing 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 $1,000 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $1,000 ◼ Specialist copayment $30 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $1,000 ◼ Specialist copayment $30 ◼ Hospital (facility) coinsurance 0% ◼ 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 $2,800 In this example, Xxx would pay: Cost Sharing Deductibles $1,000 Copayments $10 Coinsurance $2,300 What isn’t covered Limits or exclusions $60 The total Peg would pay is $3,370 Cost Sharing Deductibles $900 Copayments $800 Coinsurance $0 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,720 Cost Sharing Deductibles $1,000 Copayments $100 Coinsurance $100 What isn’t covered Limits or exclusions $0 The total Mia would pay is $1,200 Appendix "E" - Plan #50 - Michigan The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copy.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of 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 that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. About these Coverage Examples: Appendix "E" This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, 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 costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing 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 $1,000 250 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% This EXAMPLE event includes services like: Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% This EXAMPLE event includes services like: Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 2010% 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 $2,800 In this example, Xxx would pay: Cost Sharing Deductibles $1,000 250 Copayments $10 Coinsurance $2,300 1,200 What isn’t covered Limits or exclusions $60 The total Peg would pay is $3,370 1,520 Cost Sharing Deductibles $900 250 Copayments $800 Coinsurance $0 70 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,720 1,140 Cost Sharing Deductibles $1,000 250 Copayments $100 70 Coinsurance $100 What isn’t covered Limits or exclusions $0 The total Mia would pay is $1,200 The 420 Appendix "F" Delta Dental PPO (Point-of-Service) Summary of Dental Plan Benefits For Group# 7280 Township of Clinton This Summary of Dental Plan Benefits should be read along with your Certificate. Your Certificate provides additional information about your Delta Dental plan, including information about plan exclusions and Coverage limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the dentist's network participation.* Delta Dental PPO Dentist Delta Dental Premier Dentist Plan Pays Plan Pays Control Plan – Delta Dental of Michigan Benefit Year – January 1 through December 31 Covered Services – Nonparticipating Diagnostic & Preventive Dentist Plan Pays* Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers 100% 85% 65% Emergency Palliative Treatment – to temporarily relieve pain 100% 85% 65% Brush Biopsy – to detect oral cancer 100% 85% 65% Radiographs – X-rays 100% 85% 65% Basic Services Minor Restorative Services – fillings and crown repair 80% 65% 65% Endodontic Services – root canals 80% 65% 65% Periodontic Services – to treat gum disease 80% 65% 65% Oral Surgery Services – extractions and dental surgery 80% 65% 65% Other Basic Services – misc. services 80% 65% 65% Relines and Repairs – to prosthetic appliances 80% 65% 65% Major Restorative Services – crowns 75% 60% 60% Major Services Prosthodontic Services – bridges, implants, dentures, and crowns over implants 60% 60% 60% Orthodontic Services Orthodontic Services – braces 60% 60% 60% Orthodontic Age Limit – up to age 19 up to age 19 up to age 19 * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This amount may be less than what the Dentist charges or Delta Dental approves and you are responsible for that difference.  Oral exams (SBCincluding evaluations by a specialist) document will are payable twice in any period of 12 consecutive months.  Prophylaxes (cleanings) are payable twice in any period of 12 consecutive months.  People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment.  Fluoride treatments are payable twice in any period of 12 consecutive months for people age 18 and under.  Bitewing X-rays are payable once in any period of 12 consecutive months and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period.  Composite resin (white) restorations are optional treatment on posterior teeth.  Porcelain and resin facings on crowns are optional treatment on posterior teeth.  Implants are payable once per tooth in any five-year period. Implant related services are Covered Services.  Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services. Having Delta Dental coverage makes it easy for you toAgpepetnddeixnt"aFl"care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summaryschedule care. For more information about information, check our Web site or contact your coverage, or benefits representative to get a copy of our Passport Dental information sheet. Maximum Payment – $2,000 per person total per Benefit Year on all services except orthodontic services. $2,000 per person total per lifetime on orthodontic services. Payment for Orthodontic Service – When orthodontic treatment begins, your Dentist will submit a payment plan to Delta Dental based upon your projected course of treatment. In accordance with the complete terms agreed upon payment plan, Delta Dental will make an initial payment to you or your Participating Dentist equal to Delta Dental's stated Copayment on 30% of coverage, go the Maximum Payment for Orthodontic Services as set forth in this Summary of Dental Plan Benefits. Delta Dental will make additional payments as follows: Delta Dental will pay 60% of the per monthly fee charged by your Dentist based upon the agreed upon payment plan provided by your Dentist to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000Delta Dental. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copyDeductible – None.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of 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 that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. About these Coverage Examples: Appendix "C" - Plan #048 - Ontario This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, 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 costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing 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 $1,000 500 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $1,000 500 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $1,000 500 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 0% ◼ 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 $2,800 In this example, Xxx would pay: Cost Sharing Deductibles $1,000 500 Copayments $10 Coinsurance $2,300 2,400 What isn’t covered Limits or exclusions $60 The total Peg would pay is $3,370 2,970 Cost Sharing Deductibles $900 500 Copayments $800 700 Coinsurance $0 80 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,720 1,300 Cost Sharing Deductibles $1,000 500 Copayments $100 70 Coinsurance $100 200 What isn’t covered Limits or exclusions $0 The total Mia would pay is $1,200 770 Appendix "D"- Plan #049 - Erie The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copy.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of 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 that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township Blue Cross® and Blue Shield® of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000Michigan by calling the number on the back of your BCBSM ID card. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan ) Department of Insurance and Financial Services (DIFS) at (000) 000Services, P. O. Xxx 00000, Xxxxxxx, XX 00000-0000. 0000 or xxxx://xxx.xxxxxxxx.xxx/difs or xxxx-XXXXX@xxxxxxxx.xxx Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. (IMPORTANT: Blue Cross Blue Shield of Michigan is assuming that your coverage provides for all Essential Health Benefit (EHB) categories as defined by the State of Michigan. The minimum value of your plan may be affected if your plan does not cover certain EHB categories, such as prescription drugs, or if your plan provides coverage of specific EHB categories, for example prescription drugs, through another carrier.) 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. See Addendum ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section. –––––––––––––––––––––– About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, 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 costs you might pay under different health plans. Please note these coverage examples are based on self- self-only coverage. Managing Xxx’s Type 2 Diabetes (a year of routine in-network care of a well-controlled condition) Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing 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 $1,000 100 ◼ Primary care physician coinsurance 0% Specialist copayment $10 ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% This EXAMPLE event includes services like: Primary care physician 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 $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $1,000 100 ◼ Specialist copayment $30 10 ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% This EXAMPLE event includes services like: Specialist Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $1,000 100 ◼ Specialist copayment $30 10 ◼ Hospital (facility) coinsurance 010% ◼ Other coinsurance 2010% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test tests (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Xxx would pay: Cost Sharing Deductibles $1,000 100 Copayments $10 Coinsurance $2,300 1,000 What isn’t covered Limits or exclusions $60 The total Peg would pay is $3,370 1,170 Cost Sharing Deductibles $900 100 Copayments $800 500 Coinsurance $0 80 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,720 700 Cost Sharing Deductibles $1,000 100 Copayments $100 30 Coinsurance $100 200 What isn’t covered Limits or exclusions $0 The total Mia would pay is $1,200 330 If you are also covered by an account-type plan such as an integrated health flexible spending arrangement (FSA), health reimbursement arrangement (HRA), and/or a health savings account (HSA), then you may have access to additional funds to help cover certain out-of-pocket expenses – like the deductible, copayments, or coinsurance, or benefits not otherwise covered. Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2022 CITY OF WESTLAND Community Blue PPOSM ASC Base PPO Coverage for: Individual/Family | Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx visit xxx.xxxxx.xxx or call (000) 000-0000the number on the back of your BCBSM ID card. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx xxxxx://xxx.xxxxxxxxxx.xxx/sbc-glossary or call Care Coordinators at (000) 000-0000 the number on the back of your BCBSM ID card to request a copy.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of 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 that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, 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 costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing 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 $1,000 250 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% This EXAMPLE event includes services like: Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% This EXAMPLE event includes services like: Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 2010% 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 $2,800 In this example, Xxx would pay: Cost Sharing Deductibles $1,000 250 Copayments $10 Coinsurance $2,300 1,200 What isn’t covered Limits or exclusions $60 The total Peg would pay is $3,370 1,520 Cost Sharing Deductibles $900 250 Copayments $800 Coinsurance $0 70 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,720 1,140 Cost Sharing Deductibles $1,000 250 Copayments $100 70 Coinsurance $100 What isn’t covered Limits or exclusions $0 The total Mia would pay is $1,200 The 420 Appendix "G" Delta Dental PPO (Point-of-Service) Summary of Dental Plan Benefits For Group# 7280 Township of Clinton This Summary of Dental Plan Benefits should be read along with your Certificate. Your Certificate provides additional information about your Delta Dental plan, including information about plan exclusions and Coverage limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the dentist's network participation.* Delta Dental PPO Dentist Delta Dental Premier Dentist Plan Pays Plan Pays Control Plan – Delta Dental of Michigan Benefit Year – January 1 through December 31 Covered Services – Nonparticipating Diagnostic & Preventive Dentist Plan Pays* Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers 100% 85% 65% Emergency Palliative Treatment – to temporarily relieve pain 100% 85% 65% Brush Biopsy – to detect oral cancer 100% 85% 65% Radiographs – X-rays 100% 85% 65% Basic Services Minor Restorative Services – fillings and crown repair 80% 65% 65% Endodontic Services – root canals 80% 65% 65% Periodontic Services – to treat gum disease 80% 65% 65% Oral Surgery Services – extractions and dental surgery 80% 65% 65% Other Basic Services – misc. services 80% 65% 65% Relines and Repairs – to prosthetic appliances 80% 65% 65% Major Restorative Services – crowns 75% 60% 60% Major Services Prosthodontic Services – bridges, implants, dentures, and crowns over implants 60% 60% 60% Orthodontic Services Orthodontic Services – braces 60% 60% 60% Orthodontic Age Limit – up to age 19 up to age 19 up to age 19 * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This amount may be less than what the Dentist charges or Delta Dental approves and you are responsible for that difference.  Oral exams (SBCincluding evaluations by a specialist) document will are payable twice in any period of 12 consecutive months.  Prophylaxes (cleanings) are payable twice in any period of 12 consecutive months.  People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment.  Fluoride treatments are payable twice in any period of 12 consecutive months for people age 18 and under.  Bitewing X-rays are payable once in any period of 12 consecutive months and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period.  Composite resin (white) restorations are optional treatment on posterior teeth.  Porcelain and resin facings on crowns are optional treatment on posterior teeth.  Implants are payable once per tooth in any five-year period. Implant related services are Covered Services.  Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services. Having Delta Dental coverage makes it easy for you toAgppeetnddeixn"taGl"care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summaryschedule care. For more information about information, check our Web site or contact your coverage, or benefits representative to get a copy of our Passport Dental information sheet. Maximum Payment – $2,000 per person total per Benefit Year on all services except orthodontic services. $2,000 per person total per lifetime on orthodontic services. Payment for Orthodontic Service – When orthodontic treatment begins, your Dentist will submit a payment plan to Delta Dental based upon your projected course of treatment. In accordance with the complete terms agreed upon payment plan, Delta Dental will make an initial payment to you or your Participating Dentist equal to Delta Dental's stated Copayment on 30% of coverage, go the Maximum Payment for Orthodontic Services as set forth in this Summary of Dental Plan Benefits. Delta Dental will make additional payments as follows: Delta Dental will pay 60% of the per monthly fee charged by your Dentist based upon the agreed upon payment plan provided by your Dentist to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000Delta Dental. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copyDeductible – None.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of 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 that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township Blue Cross® and Blue Shield® of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000Michigan by calling the number on the back of your BCBSM ID card. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan ) Department of Insurance and Financial Services (DIFS) at (000) 000Services, P. O. Xxx 00000, Xxxxxxx, XX 00000-0000. 0000 or xxxx://xxx.xxxxxxxx.xxx/difs or xxxx-XXXXX@xxxxxxxx.xxx Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. (IMPORTANT: Blue Cross Blue Shield of Michigan is assuming that your coverage provides for all Essential Health Benefit (EHB) categories as defined by the State of Michigan. The minimum value of your plan may be affected if your plan does not cover certain EHB categories, such as prescription drugs, or if your plan provides coverage of specific EHB categories, for example prescription drugs, through another carrier.) 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. See Addendum ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section. –––––––––––––––––––––– About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, 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 costs you might pay under different health plans. Please note these coverage examples are based on self- self-only coverage. Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well-controlled condition) Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing 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 $1,000 250 ◼ Primary care physician coinsurance 0% Specialist copayment $20 ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% This EXAMPLE event includes services like: Primary care physician 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 $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% This EXAMPLE event includes services like: Specialist Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 010% ◼ Other coinsurance 2010% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test tests (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Xxx Mia would pay: Cost Sharing Deductibles $1,000 250 Copayments $10 Coinsurance $2,300 1,000 What isn’t covered Limits or exclusions $60 The total Peg would pay is $3,370 1,320 Cost Sharing Deductibles $900 250 Copayments $800 600 Coinsurance $0 70 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,720 940 Cost Sharing Deductibles $1,000 250 Copayments $100 Coinsurance $100 What isn’t covered Limits or exclusions $0 The total Mia would pay is $1,200 450 If you are also covered by an account-type plan such as an integrated health flexible spending arrangement (FSA), health reimbursement arrangement (HRA), and/or a health savings account (HSA), then you may have access to additional funds to help cover certain out-of-pocket expenses – like the deductible, copayments, or coinsurance, or benefits not otherwise covered. Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2022 CITY OF WESTLAND Community Blue PPOSM ASC Value PPO Coverage for: Individual/Family | Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx visit xxx.xxxxx.xxx or call (000) 000-0000the number on the back of your BCBSM ID card. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx xxxxx://xxx.xxxxxxxxxx.xxx/sbc-glossary or call Care Coordinators at (000) 000-0000 the number on the back of your BCBSM ID card to request a copy.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of 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 that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. About these Coverage Examples: Appendix "F" This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, 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 costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing 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 $1,000 250 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% This EXAMPLE event includes services like: Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% This EXAMPLE event includes services like: Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 2010% 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 $2,800 In this example, Xxx would pay: Cost Sharing Deductibles $1,000 250 Copayments $10 Coinsurance $2,300 1,200 What isn’t covered Limits or exclusions $60 The total Peg would pay is $3,370 1,520 Cost Sharing Deductibles $900 250 Copayments $800 Coinsurance $0 70 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,720 1,140 Cost Sharing Deductibles $1,000 250 Copayments $100 70 Coinsurance $100 What isn’t covered Limits or exclusions $0 The total Mia would pay is $1,200 The 420 Appendix "G" Delta Dental PPO (Point-of-Service) Summary of Dental Plan Benefits For Group# 7280 Township of Clinton This Summary of Dental Plan Benefits should be read along with your Certificate. Your Certificate provides additional information about your Delta Dental plan, including information about plan exclusions and Coverage limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the dentist's network participation.* Delta Dental PPO Dentist Delta Dental Premier Dentist Plan Pays Plan Pays Control Plan – Delta Dental of Michigan Benefit Year – January 1 through December 31 Covered Services – Nonparticipating Diagnostic & Preventive Dentist Plan Pays* Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers 100% 85% 65% Emergency Palliative Treatment – to temporarily relieve pain 100% 85% 65% Brush Biopsy – to detect oral cancer 100% 85% 65% Radiographs – X-rays 100% 85% 65% Basic Services Minor Restorative Services – fillings and crown repair 80% 65% 65% Endodontic Services – root canals 80% 65% 65% Periodontic Services – to treat gum disease 80% 65% 65% Oral Surgery Services – extractions and dental surgery 80% 65% 65% Other Basic Services – misc. services 80% 65% 65% Relines and Repairs – to prosthetic appliances 80% 65% 65% Major Restorative Services – crowns 75% 60% 60% Major Services Prosthodontic Services – bridges, implants, dentures, and crowns over implants 60% 60% 60% Orthodontic Services Orthodontic Services – braces 60% 60% 60% Orthodontic Age Limit – up to age 19 up to age 19 up to age 19 * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This amount may be less than what the Dentist charges or Delta Dental approves and you are responsible for that difference.  Oral exams (SBCincluding evaluations by a specialist) document will are payable twice in any period of 12 consecutive months.  Prophylaxes (cleanings) are payable twice in any period of 12 consecutive months.  People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment.  Fluoride treatments are payable twice in any period of 12 consecutive months for people age 18 and under.  Bitewing X-rays are payable once in any period of 12 consecutive months and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period.  Composite resin (white) restorations are optional treatment on posterior teeth.  Porcelain and resin facings on crowns are optional treatment on posterior teeth.  Implants are payable once per tooth in any five-year period. Implant related services are Covered Services.  Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services. Having Delta Dental coverage makes it easy for you toAgppeetnddeixn"taGl"care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summaryschedule care. For more information about information, check our Web site or contact your coverage, or benefits representative to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000our Passport Dental information sheet. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the GlossaryMaximum Payment – $2,000 per person total per Benefit Year on all services except orthodontic services. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copy$2,000 per person total per lifetime on orthodontic services.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of 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 that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. About these Coverage Examples: Appendix "E" This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, 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 costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing 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 $1,000 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $1,000 ◼ Specialist copayment $30 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $1,000 ◼ Specialist copayment $30 ◼ Hospital (facility) coinsurance 0% ◼ 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 $2,800 In this example, Xxx would pay: Cost Sharing Deductibles $1,000 Copayments $10 Coinsurance $2,300 What isn’t covered Limits or exclusions $60 The total Peg would pay is $3,370 Cost Sharing Deductibles $900 Copayments $800 Coinsurance $0 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,720 Cost Sharing Deductibles $1,000 Copayments $100 Coinsurance $100 What isn’t covered Limits or exclusions $0 The total Mia would pay is $1,200 Appendix "F" The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copy.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of 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 that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. About these Coverage Examples: Appendix "E" - Plan #50 - Michigan This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, 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 costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing 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 $1,000 250 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% This EXAMPLE event includes services like: Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% This EXAMPLE event includes services like: Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 2010% 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 $2,800 In this example, Xxx would pay: Cost Sharing Deductibles $1,000 250 Copayments $10 Coinsurance $2,300 1,200 What isn’t covered Limits or exclusions $60 The total Peg would pay is $3,370 1,520 Cost Sharing Deductibles $900 250 Copayments $800 Coinsurance $0 70 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,720 1,140 Cost Sharing Deductibles $1,000 250 Copayments $100 70 Coinsurance $100 What isn’t covered Limits or exclusions $0 The total Mia would pay is $1,200 The 420 Appendix "F" Delta Dental PPO (Point-of-Service) Summary of Dental Plan Benefits For Group# 7280 Township of Clinton This Summary of Dental Plan Benefits should be read along with your Certificate. Your Certificate provides additional information about your Delta Dental plan, including information about plan exclusions and Coverage limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the dentist's network participation.* Delta Dental PPO Dentist Delta Dental Premier Dentist Plan Pays Plan Pays Control Plan – Delta Dental of Michigan Benefit Year – January 1 through December 31 Covered Services – Nonparticipating Diagnostic & Preventive Dentist Plan Pays* Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers 100% 85% 65% Emergency Palliative Treatment – to temporarily relieve pain 100% 85% 65% Brush Biopsy – to detect oral cancer 100% 85% 65% Radiographs – X-rays 100% 85% 65% Basic Services Minor Restorative Services – fillings and crown repair 80% 65% 65% Endodontic Services – root canals 80% 65% 65% Periodontic Services – to treat gum disease 80% 65% 65% Oral Surgery Services – extractions and dental surgery 80% 65% 65% Other Basic Services – misc. services 80% 65% 65% Relines and Repairs – to prosthetic appliances 80% 65% 65% Major Restorative Services – crowns 75% 60% 60% Major Services Prosthodontic Services – bridges, implants, dentures, and crowns over implants 60% 60% 60% Orthodontic Services Orthodontic Services – braces 60% 60% 60% Orthodontic Age Limit – up to age 19 up to age 19 up to age 19 * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This amount may be less than what the Dentist charges or Delta Dental approves and you are responsible for that difference.  Oral exams (SBCincluding evaluations by a specialist) document will are payable twice in any period of 12 consecutive months.  Prophylaxes (cleanings) are payable twice in any period of 12 consecutive months.  People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment.  Fluoride treatments are payable twice in any period of 12 consecutive months for people age 18 and under.  Bitewing X-rays are payable once in any period of 12 consecutive months and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period.  Composite resin (white) restorations are optional treatment on posterior teeth.  Porcelain and resin facings on crowns are optional treatment on posterior teeth.  Implants are payable once per tooth in any five-year period. Implant related services are Covered Services.  Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services. Having Delta Dental coverage makes it easy for you toAgpepetnddeixnt"aFl"care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summaryschedule care. For more information about information, check our Web site or contact your coverage, or benefits representative to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000our Passport Dental information sheet. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the GlossaryMaximum Payment – $2,000 per person total per Benefit Year on all services except orthodontic services. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copy$2,000 per person total per lifetime on orthodontic services.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of 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 that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. About these Coverage Examples: Appendix "D" This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, 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 costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing 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 $1,000 500 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $1,000 500 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $1,000 500 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 0% ◼ 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 $2,800 In this example, Xxx would pay: Cost Sharing Deductibles $1,000 500 Copayments $10 Coinsurance $2,300 2,400 What isn’t covered Limits or exclusions $60 The total Peg would pay is $3,370 2,970 Cost Sharing Deductibles $900 500 Copayments $800 700 Coinsurance $0 80 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,720 1,300 Cost Sharing Deductibles $1,000 500 Copayments $100 70 Coinsurance $100 200 What isn’t covered Limits or exclusions $0 The total Mia would pay is $1,200 770 Appendix "E" The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copy.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of 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 that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. About these Coverage Examples: Appendix "G" This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, 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 costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing 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 $1,000 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $1,000 ◼ Specialist copayment $30 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $1,000 ◼ Specialist copayment $30 ◼ Hospital (facility) coinsurance 0% ◼ 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 $2,800 In this example, Xxx would pay: Cost Sharing Deductibles $1,000 Copayments $10 Coinsurance $2,300 What isn’t covered Limits or exclusions $60 The total Peg would pay is $3,370 Cost Sharing Deductibles $900 Copayments $800 Coinsurance $0 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,720 Cost Sharing Deductibles $1,000 Copayments $100 Coinsurance $100 What isn’t covered Limits or exclusions $0 The total Mia would pay is $1,200 Appendix "H" The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copy.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of 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 that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township Blue Cross® and Blue Shield® of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000Michigan by calling the number on the back of your BCBSM ID card. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan ) Department of Insurance and Financial Services (DIFS) at (000) 000Services, P. O. Xxx 00000, Xxxxxxx, XX 00000-0000. 0000 or xxxx://xxx.xxxxxxxx.xxx/difs or xxxx-XXXXX@xxxxxxxx.xxx Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. (IMPORTANT: Blue Cross Blue Shield of Michigan is assuming that your coverage provides for all Essential Health Benefit (EHB) categories as defined by the State of Michigan. The minimum value of your plan may be affected if your plan does not cover certain EHB categories, such as prescription drugs, or if your plan provides coverage of specific EHB categories, for example prescription drugs, through another carrier.) 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. See Addendum ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section. –––––––––––––––––––––– About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, 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 costs you might pay under different health plans. Please note these coverage examples are based on self- self-only coverage. Managing Xxx’s Type 2 Diabetes (a year of routine in-network care of a well-controlled condition) Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing 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 $1,000 250 ◼ Primary care physician coinsurance 0% Specialist copayment $20 ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% This EXAMPLE event includes services like: Primary care physician 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 $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% This EXAMPLE event includes services like: Specialist Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 010% ◼ Other coinsurance 2010% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test tests (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Xxx would pay: Cost Sharing Deductibles $1,000 250 Copayments $10 Coinsurance $2,300 1,000 What isn’t covered Limits or exclusions $60 The total Peg would pay is $3,370 1,320 Cost Sharing Deductibles $900 250 Copayments $800 600 Coinsurance $0 70 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,720 940 Cost Sharing Deductibles $1,000 250 Copayments $100 Coinsurance $100 What isn’t covered Limits or exclusions $0 The total Mia would pay is $1,200 450 If you are also covered by an account-type plan such as an integrated health flexible spending arrangement (FSA), health reimbursement arrangement (HRA), and/or a health savings account (HSA), then you may have access to additional funds to help cover certain out-of-pocket expenses – like the deductible, copayments, or coinsurance, or benefits not otherwise covered. Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2022 CITY OF WESTLAND Community Blue PPOSM ASC Value PPO Coverage for: Individual/Family | Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx visit xxx.xxxxx.xxx or call (000) 000-0000the number on the back of your BCBSM ID card. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx xxxxx://xxx.xxxxxxxxxx.xxx/sbc-glossary or call Care Coordinators at (000) 000-0000 the number on the back of your BCBSM ID card to request a copy.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of 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 that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. About these Coverage Examples: Appendix "D" This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, 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 costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing 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 $1,000 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $1,000 ◼ Specialist copayment $30 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $1,000 ◼ Specialist copayment $30 ◼ Hospital (facility) coinsurance 0% ◼ 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 $2,800 In this example, Xxx would pay: Cost Sharing Deductibles $1,000 Copayments $10 Coinsurance $2,300 What isn’t covered Limits or exclusions $60 The total Peg would pay is $3,370 Cost Sharing Deductibles $900 Copayments $800 Coinsurance $0 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,720 Cost Sharing Deductibles $1,000 Copayments $100 Coinsurance $100 What isn’t covered Limits or exclusions $0 The total Mia would pay is $1,200 Appendix "E" The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copy.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of 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 that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, 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 costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing 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 $1,000 250 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% This EXAMPLE event includes services like: Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% This EXAMPLE event includes services like: Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 2010% 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 $2,800 In this example, Xxx would pay: Cost Sharing Deductibles $1,000 250 Copayments $10 Coinsurance $2,300 1,200 What isn’t covered Limits or exclusions $60 The total Peg would pay is $3,370 1,520 Cost Sharing Deductibles $900 250 Copayments $800 Coinsurance $0 70 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,720 1,140 Cost Sharing Deductibles $1,000 250 Copayments $100 70 Coinsurance $100 What isn’t covered Limits or exclusions $0 The total Mia would pay is $1,200 The 420 Appendix "H" Delta Dental PPO (Point-of-Service) Summary of Dental Plan Benefits For Group# 7280 Township of Clinton This Summary of Dental Plan Benefits should be read along with your Certificate. Your Certificate provides additional information about your Delta Dental plan, including information about plan exclusions and Coverage limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the dentist's network participation.* Delta Dental PPO Dentist Delta Dental Premier Dentist Plan Pays Plan Pays Control Plan – Delta Dental of Michigan Benefit Year – January 1 through December 31 Covered Services – Nonparticipating Diagnostic & Preventive Dentist Plan Pays* Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers 100% 85% 65% Emergency Palliative Treatment – to temporarily relieve pain 100% 85% 65% Brush Biopsy – to detect oral cancer 100% 85% 65% Radiographs – X-rays 100% 85% 65% Basic Services Minor Restorative Services – fillings and crown repair 80% 65% 65% Endodontic Services – root canals 80% 65% 65% Periodontic Services – to treat gum disease 80% 65% 65% Oral Surgery Services – extractions and dental surgery 80% 65% 65% Other Basic Services – misc. services 80% 65% 65% Relines and Repairs – to prosthetic appliances 80% 65% 65% Major Restorative Services – crowns 75% 60% 60% Major Services Prosthodontic Services – bridges, implants, dentures, and crowns over implants 60% 60% 60% Orthodontic Services Orthodontic Services – braces 60% 60% 60% Orthodontic Age Limit – up to age 19 up to age 19 up to age 19 * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This amount may be less than what the Dentist charges or Delta Dental approves and you are responsible for that difference.  Oral exams (SBCincluding evaluations by a specialist) document will are payable twice in any period of 12 consecutive months.  Prophylaxes (cleanings) are payable twice in any period of 12 consecutive months.  People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment.  Fluoride treatments are payable twice in any period of 12 consecutive months for people age 18 and under.  Bitewing X-rays are payable once in any period of 12 consecutive months and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period.  Composite resin (white) restorations are optional treatment on posterior teeth.  Porcelain and resin facings on crowns are optional treatment on posterior teeth.  Implants are payable once per tooth in any five-year period. Implant related services are Covered Services.  Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services. Having Delta Dental coverage makes it easy for you toAgppeetnddeixn"taHl"care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summaryschedule care. For more information about information, check our Web site or contact your coverage, or benefits representative to get a copy of our Passport Dental information sheet. Maximum Payment – $2,000 per person total per Benefit Year on all services except orthodontic services. $2,000 per person total per lifetime on orthodontic services. Payment for Orthodontic Service – When orthodontic treatment begins, your Dentist will submit a payment plan to Delta Dental based upon your projected course of treatment. In accordance with the complete terms agreed upon payment plan, Delta Dental will make an initial payment to you or your Participating Dentist equal to Delta Dental's stated Copayment on 30% of coverage, go the Maximum Payment for Orthodontic Services as set forth in this Summary of Dental Plan Benefits. Delta Dental will make additional payments as follows: Delta Dental will pay 60% of the per monthly fee charged by your Dentist based upon the agreed upon payment plan provided by your Dentist to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000Delta Dental. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copyDeductible – None.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of 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 that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township Blue Cross® and Blue Shield® of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000Michigan by calling the number on the back of your BCBSM ID card. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan ) Department of Insurance and Financial Services (DIFS) at (000) 000Services, P. O. Xxx 00000, Xxxxxxx, XX 00000-0000. 0000 or xxxx://xxx.xxxxxxxx.xxx/difs or xxxx-XXXXX@xxxxxxxx.xxx Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. (IMPORTANT: Blue Cross Blue Shield of Michigan is assuming that your coverage provides for all Essential Health Benefit (EHB) categories as defined by the State of Michigan. The minimum value of your plan may be affected if your plan does not cover certain EHB categories, such as prescription drugs, or if your plan provides coverage of specific EHB categories, for example prescription drugs, through another carrier.) 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. See Addendum ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section. –––––––––––––––––––––– About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, 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 costs you might pay under different health plans. Please note these coverage examples are based on self- self-only coverage. Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well-controlled condition) Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing 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 $1,000 0 ◼ Primary care physician coinsurance 0% Specialist copayment $10 ◼ Hospital (facility) coinsurance 20% copayment $0 ◼ Other coinsurance 20% copayment $0 This EXAMPLE event includes services like: Primary care physician 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 $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $1,000 0 ◼ Specialist copayment $30 10 ◼ Hospital (facility) coinsurance 20% copayment $0 ◼ Other coinsurance 20% copayment $0 This EXAMPLE event includes services like: Specialist Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $1,000 0 ◼ Specialist copayment $30 10 ◼ Hospital (facility) coinsurance 0% copayment $0 ◼ Other coinsurance 20% copayment $0 This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test tests (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Xxx Mia would pay: Cost Sharing Deductibles $1,000 0 Copayments $10 Coinsurance $2,300 0 What isn’t covered Limits or exclusions $60 The total Peg would pay is $3,370 70 Cost Sharing Deductibles $900 0 Copayments $800 300 Coinsurance $0 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,720 320 Cost Sharing Deductibles $1,000 0 Copayments $100 30 Coinsurance $100 0 What isn’t covered Limits or exclusions $0 The total Mia would pay is $1,200 30 If you are also covered by an account-type plan such as an integrated health flexible spending arrangement (FSA), health reimbursement arrangement (HRA), and/or a health savings account (HSA), then you may have access to additional funds to help cover certain out-of-pocket expenses – like the deductible, copayments, or coinsurance, or benefits not otherwise covered. Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2022 CITY OF WESTLAND Community Blue PPOSM ASC PPO 2 Coverage for: Individual/Family | Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx visit xxx.xxxxx.xxx or call (000) 000-0000the number on the back of your BCBSM ID card. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx xxxxx://xxx.xxxxxxxxxx.xxx/sbc-glossary or call Care Coordinators at (000) 000-0000 the number on the back of your BCBSM ID card to request a copy.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of 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 that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. About these Coverage Examples: Appendix "F" This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, 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 costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing 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 $1,000 500 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $1,000 500 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $1,000 500 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 0% ◼ 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 $2,800 In this example, Xxx would pay: Cost Sharing Deductibles $1,000 500 Copayments $10 Coinsurance $2,300 2,400 What isn’t covered Limits or exclusions $60 The total Peg would pay is $3,370 2,970 Cost Sharing Deductibles $900 500 Copayments $800 700 Coinsurance $0 80 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,720 1,300 Cost Sharing Deductibles $1,000 500 Copayments $100 70 Coinsurance $100 200 What isn’t covered Limits or exclusions $0 The total Mia would pay is $1,200 770 Appendix "G" The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copy.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of 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 that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township Blue Cross® and Blue Shield® of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000Michigan by calling the number on the back of your BCBSM ID card. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan ) Department of Insurance and Financial Services (DIFS) at (000) 000Services, P. O. Xxx 00000, Xxxxxxx, XX 00000-0000. 0000 or xxxx://xxx.xxxxxxxx.xxx/difs or xxxx-XXXXX@xxxxxxxx.xxx Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. (IMPORTANT: Blue Cross Blue Shield of Michigan is assuming that your coverage provides for all Essential Health Benefit (EHB) categories as defined by the State of Michigan. The minimum value of your plan may be affected if your plan does not cover certain EHB categories, such as prescription drugs, or if your plan provides coverage of specific EHB categories, for example prescription drugs, through another carrier.) 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. See Addendum ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section. –––––––––––––––––––––– About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, 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 costs you might pay under different health plans. Please note these coverage examples are based on self- self-only coverage. Managing Xxx’s Type 2 Diabetes (a year of routine in-network care of a well-controlled condition) Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing 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 $1,000 0 ◼ Primary care physician coinsurance 0% Specialist copayment $20 ◼ Hospital (facility) coinsurance 20% copayment $0 ◼ Other coinsurance 20% copayment $0 This EXAMPLE event includes services like: Primary care physician 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 $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $1,000 0 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 20% copayment $0 ◼ Other coinsurance 20% copayment $0 This EXAMPLE event includes services like: Specialist Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $1,000 0 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 0% copayment $0 ◼ Other coinsurance 20% copayment $0 This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test tests (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Xxx would pay: Cost Sharing Deductibles $1,000 0 Copayments $10 Coinsurance $2,300 What isn’t covered Limits or exclusions $60 The total Peg would pay is $3,370 Cost Sharing Deductibles $900 Copayments $800 0 Coinsurance $0 What isn’t covered Limits or exclusions $20 70 The total Xxx Peg would pay is $1,720 70 Cost Sharing Deductibles $1,000 0 Copayments $100 Coinsurance $100 0 What isn’t covered Limits or exclusions $3,500 The total Xxx would pay is $3,600 Cost Sharing Deductibles $0 Copayments $40 Coinsurance $0 What isn’t covered Limits or exclusions $10 The total Mia would pay is $1,200 50 If you are also covered by an account-type plan such as an integrated health flexible spending arrangement (FSA), health reimbursement arrangement (HRA), and/or a health savings account (HSA), then you may have access to additional funds to help cover certain out-of-pocket expenses – like the deductible, copayments, or coinsurance, or benefits not otherwise covered. 1400-2800 Note to ASC groups: Before completing this template, please reference the disclaimer on the attached cover page. Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 10/01/2021 MML/VAN BUREN PUBLIC SCHOOLS Simply Blue PPO HSASM ASC Coverage for: Individual/Family | Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx visit xxx.xxxxx.xxx or call (000) 000-0000the number on the back of your BCBSM ID card. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx xxxxx://xxx.xxxxxxxxxx.xxx/sbc-glossary or call Care Coordinators at (000) 000-0000 the number on the back of your BCBSM ID card to request a copy.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of 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 that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. About these Coverage Examples: Appendix "H" This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, 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 costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing 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 $1,000 250 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% This EXAMPLE event includes services like: Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% This EXAMPLE event includes services like: Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 2010% 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 $2,800 In this example, Xxx would pay: Cost Sharing Deductibles $1,000 250 Copayments $10 Coinsurance $2,300 1,200 What isn’t covered Limits or exclusions $60 The total Peg would pay is $3,370 1,520 Cost Sharing Deductibles $900 250 Copayments $800 Coinsurance $0 70 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,720 1,140 Cost Sharing Deductibles $1,000 250 Copayments $100 70 Coinsurance $100 What isn’t covered Limits or exclusions $0 The total Mia would pay is $1,200 The 420 Appendix "I" Delta Dental PPO (Point-of-Service) Summary of Dental Plan Benefits For Group# 7280 Township of Clinton This Summary of Dental Plan Benefits should be read along with your Certificate. Your Certificate provides additional information about your Delta Dental plan, including information about plan exclusions and Coverage limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the dentist's network participation.* Delta Dental PPO Dentist Delta Dental Premier Dentist Plan Pays Plan Pays Control Plan – Delta Dental of Michigan Benefit Year – January 1 through December 31 Covered Services – Nonparticipating Diagnostic & Preventive Dentist Plan Pays* Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers 100% 85% 65% Emergency Palliative Treatment – to temporarily relieve pain 100% 85% 65% Brush Biopsy – to detect oral cancer 100% 85% 65% Radiographs – X-rays 100% 85% 65% Basic Services Minor Restorative Services – fillings and crown repair 80% 65% 65% Endodontic Services – root canals 80% 65% 65% Periodontic Services – to treat gum disease 80% 65% 65% Oral Surgery Services – extractions and dental surgery 80% 65% 65% Other Basic Services – misc. services 80% 65% 65% Relines and Repairs – to prosthetic appliances 80% 65% 65% Major Restorative Services – crowns 75% 60% 60% Major Services Prosthodontic Services – bridges, implants, dentures, and crowns over implants 60% 60% 60% Orthodontic Services Orthodontic Services – braces 60% 60% 60% Orthodontic Age Limit – up to age 19 up to age 19 up to age 19 * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This amount may be less than what the Dentist charges or Delta Dental approves and you are responsible for that difference.  Oral exams (SBCincluding evaluations by a specialist) document will are payable twice in any period of 12 consecutive months.  Prophylaxes (cleanings) are payable twice in any period of 12 consecutive months.  People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment.  Fluoride treatments are payable twice in any period of 12 consecutive months for people age 18 and under.  Bitewing X-rays are payable once in any period of 12 consecutive months and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period.  Composite resin (white) restorations are optional treatment on posterior teeth.  Porcelain and resin facings on crowns are optional treatment on posterior teeth.  Implants are payable once per tooth in any five-year period. Implant related services are Covered Services.  Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services. 50 Having Delta Dental coverage makes it easy for you toAgpeptenddeixnt"aI"l care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summaryschedule care. For more information about information, check our Web site or contact your coverage, or benefits representative to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000our Passport Dental information sheet. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the GlossaryMaximum Payment – $2,000 per person total per Benefit Year on all services except orthodontic services. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copy$2,000 per person total per lifetime on orthodontic services.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of 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 that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. About these Coverage Examples: Appendix "C" This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, 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 costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing 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 $1,000 500 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $1,000 500 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $1,000 500 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 0% ◼ 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 $2,800 In this example, Xxx would pay: Cost Sharing Deductibles $1,000 500 Copayments $10 Coinsurance $2,300 2,400 What isn’t covered Limits or exclusions $60 The total Peg would pay is $3,370 2,970 Cost Sharing Deductibles $900 500 Copayments $800 700 Coinsurance $0 80 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,720 1,300 Cost Sharing Deductibles $1,000 500 Copayments $100 70 Coinsurance $100 200 What isn’t covered Limits or exclusions $0 The total Mia would pay is $1,200 770 Appendix "D" The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copy.