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 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: Paramount Insurance Co., Member Service Department at: (000) 000-0000, Toll Free: 1-800-462-3589, or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. 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. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.–––––––––––––––––––––– Coverage for: Single/Family | Plan Type: HMO 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 heath 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, contact Paramount at 0-000-000-0000 or xxx.xxxxxxxxxxxxxxxxxxx.xxx/xxxxxx-xxxxxxxxx. 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.xxxxxxxxxxxxxxxxxxxxxxxxx.xxx or call 0-000-000-0000 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 to submit a claim, appeal appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Paramount Insurance Co., Member Service Department at: contact the plan at 0-000-000-0000 or (000) 000-0000, Toll Free: 1-800-462-3589, 0000 or TDD 711. You may also contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx xxx.xxx.xxx/xxxx/xxxxxxxxxxxx. Additionally, a consumer assistance program can help you file your appeal. Contact your state insurance department at (000) 000-0000 or by email at XxxxxxXxxXxxxxxx@xxxx.xx.xxx. Does this plan provide Minimum Essential Coverage? Yes. If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet 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. Para obtener asistencia en Español, llame al 0-000-000-0000. Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.–––––––––––––––––––––– Coverage for: Single/Family | Plan Type: HMO The Summary This is not a cost estimator. Treatments shown are just examples of Benefits 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 Coverage many other factors. Focus on the cost sharing amounts (SBCdeductibles, copayments and coinsurance) document will help you choose a health 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. (a year of routine in-network care of a well- controlled condition) ◼ The SBC shows you how you plan’s overall deductible $0 ◼ Specialist copayment $10 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 20% ◼ The plan’s overall deductible $0 ◼ Specialist copayment $10 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 20% ◼ The plan’s overall deductible $0 ◼ Specialist copayment $10 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and the blood work) Specialist visit (anesthesia) This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Deductibles $0 Copayments $40 Coinsurance $10 Limits or exclusions $60 Deductibles $0 Copayments $520 Coinsurance $350 Limits or exclusions $60 Deductibles $0 Copayments $180 Coinsurance $50 Limits or exclusions $0 The plan would share be responsible for the cost for other costs of these EXAMPLE covered heath 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, contact Paramount at 0-000-000-0000 or xxx.xxxxxxxxxxxxxxxxxxx.xxx/xxxxxx-xxxxxxxxx. 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.xxxxxxxxxxxxxxxxxxxxxxxxx.xxx or call 0-000-000-0000 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 to submit a claim, appeal appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Paramount Insurance Co., Member Service Department at: (contact the plan at 0-000) -000-0000. You may also contact your state insurance department, Toll Free: 1-800-462-3589, or the U.S. Department of Labor’s , Employee Benefits Security Administration at 10-866000-444000-EBSA (3272) 0000 or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx xxx.xxx.xxx/xxxx/xxxxxxxxxxxx, or the U.S. Department of Health and Human Services at 0-000-000-0000 x00000 or xxx.xxxxx.xxx.xxx. If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. 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. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.–––––––––––––––––––––– Coverage for: Single/Family | Plan Type: HMO The Summary This is not a cost estimator. Treatments shown are just examples of Benefits 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 Coverage many other factors. Focus on the cost sharing amounts (SBCdeductibles, copayments and coinsurance) document will help you choose a health 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. (a year of routine in-network care of a well- controlled condition) ◼ The SBC shows you how you plan’s overall deductible $250 ◼ Specialist copayment $30 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Deductibles $250 Copayments $100 Coinsurance $2,480 Limits or exclusions $60 ◼ The plan’s overall deductible $250 ◼ Specialist copayment $30 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Deductibles $250 Copayments $870 Coinsurance $27 Limits or exclusions $55 ◼ The plan’s overall deductible $250 ◼ Specialist copayment $30 ◼ Hospital (facility) coinsurance 20% ◼ 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) Deductibles $250 Copayments $90 Coinsurance $215 Limits or exclusions $0 Per Covered Person $250 $500 Per Family Unit $500 when two or more family members are covered $1,000 when two or more family members are covered The Calendar Year deductible is waived for the plan would share following Covered Charges: - In-Network Preventive Care Services - In-Network Office Visits and Consultations - In-Network Urgent Care Services Hospital services 20% 40% Primary Care Physician visits $30 40% Specialist visits $30 40% Outpatient services 20% 40% Emergency room $150 $150 The Emergency room copayment is waived if the cost for covered heath care servicespatient is admitted to the Hospital on an emergency basis. NOTE: Information about the cost of this plan The utilization review administrator, ABS Managed Care Administrators, Inc. must be notified at (called the premium000) 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, contact Paramount at 0-000-000-0000 within 48 hours of the admission, even if the patient is discharged within 48 hours of the admission. Per Covered Person $1,000 $3,000 Per Family Unit $2,000 when or xxx.xxxxxxxxxxxxxxxxxxx.xxx/xxxxxx-xxxxxxxxxtwo or more family members are covered $6,000 when two or more family members are covered Per Covered Person $5,000 $10,000 Per Family Unit $10,000 when two or more family members are covered $20,000 when two or more family members are covered The following charges do not apply toward the out-of-pocket maximum and are never paid at 100%: Cost containment penalties Amounts over Usual and Customary Charges Room and Board 80% after deductible the semiprivate room rate 60% after deductible the semiprivate room rate Intensive Care Unit 80% after deductible Hospital's ICU Charge 60% after deductible Hospital's ICU Charge Ancillary Charges 80% after deductible 60% after deductible Medical Emergency 100% after $150 copayment 100% after $150 copayment Skilled Nursing Facility 80% after deductible the facility's semiprivate room rate 120 days Calendar Year maximum 80% after deductible the facility's semiprivate room rate 120 days Calendar Year maximum Urgent Care Services 100% after $30 copayment 60% after deductible Inpatient visits 80% after deductible 60% after deductible Primary Care office visits 100% after $30 copayment 60% after deductible Specialist office visits 100% after $30 copayment 60% after deductible Surgery 80% after deductible 60% after deductible Allergy testing 100% (no cost-sharing) 60% after deductible Allergy serum and injections 80% after deductible 60% after deductible Diagnostic Testing (X-ray & Lab) 80% after deductible 60% after deductible Imaging Services (MRI, CT/PET Scans, etc.) 80% after deductible 60% after deductible Home Health Care 80% after deductible No Calendar Year maximum 80% after deductible No Calendar Year maximum Outpatient Private Duty Nursing 50% after deductible No Calendar Year maximum 50% after deductible No Calendar Year maximum Hospice Care 100% (no cost-sharing) 100% (no cost-sharing) Ambulance Service 80% after deductible 80% after deductible Wig After Chemotherapy 80% after deductible No Lifetime maximum 80% after deductible No Lifetime maximum Occupational Therapy Note: Occupational, Speech and Physical Therapy visits are combined. For general definitions 80% after deductible 60 visit Calendar Year maximum 60% after deductible 60 visit Calendar Year maximum Speech Therapy Note: Speech, Occupational and Physical Therapy visits are combined. 80% after deductible 60 visit Calendar Year maximum 60% after deductible 60 visit Calendar Year maximum Physical Therapy Note: Physical, Occupational and Speech Therapy visits are combined. 80% after deductible 60 visit Calendar Year maximum 60% after deductible 60 visit Calendar Year maximum Durable Medical Equipment 80% after deductible 80% after deductible Prosthetics /Orthotics 80% after deductible 80% after deductible Spinal Manipulation Chiropractic 100% after $30 copayment 24 visit Calendar Year maximum 60% after deductible 24 visit Calendar Year maximum Inpatient 80% after deductible 60% after deductible Outpatient Office Visits 100% after $30 copayment 60% after deductible Intermediate Outpatient Care 80% after deductible 60% after deductible Inpatient 80% after deductible 60% after deductible Outpatient Office Visits 100% after $30 copayment 60% after deductible Intermediate Outpatient Care 80% after deductible 60% after deductible Routine Well Adult Care 100% (no cost-sharing) Not covered Includes: Standard Preventive Care, office visits, pap smear, mammogram (including 3D tomosythesis), prostate screening, gynecological exam, routine physical examination, x-rays, laboratory tests, immunizations/flu shots, colonoscopies and sigmoidoscopies. Frequency limits for mammogram Ages 40 and over annually Routine Well Newborn Care 80% after deductible 60% after deductible Routine Well Child Care 100% (no cost-sharing) Not covered Includes: Standard Preventive Care, office visits, routine physical examination, laboratory tests, x-rays, immunizations and other preventive care and services required by applicable law if provided by a Network/Participating Provider through age 18. Organ Transplants 100% (no cost-sharing) No Annual maximum 100% (no cost-sharing) No Annual maximum Pregnancy (Pre and Post Natal Care Visits including 1 routine OB Ultrasound per pregnancy) 100% (no cost-sharing) 60% after deductible Lasik Eye Surgery $300 Lifetime maximum benefit per eye. Not subject to in and out of common terms such as allowed amountnetwork deductible or coinsurance. Surgical and Non-Surgical services related to diagnosisof morbid obesity Subject to in and out-of-network cost sharing based on the benefits defined above. Weight Loss Program 50%, balance billing, coinsurance, copayment, not subject to deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxxxxxxxxxxxxxxxxx.xxx or call 0Up to four 12-000-000-0000 to request a copy.week sessions perlifetime through Weight Watchers. Not covered Medtipster® Rx Prescription Drug Coverage

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 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: Paramount Insurance Co., Member Service Department at: (000) 000-0000, Toll Free: 10-800000-462000-35890000, or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. 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. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.–––––––––––––––––––––– Coverage for: Single/Family | Plan Type: HMO 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 heath 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, contact Paramount at 0-000-000-0000 or xxx.xxxxxxxxxxxxxxxxxxx.xxx/xxxxxx-xxxxxxxxx. For general definitions of common terms such as allowed amount, balance billing, coinsurance, copaymentcoinsurance , deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxxxxxxxxxxxxxxxxx.xxx or call 0-000-000-0000 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 to submit a claim, appeal or a grievance for any reason to your plan. For more information about Additionally, a consumer assistance program may help you file your rights, appeal. A list of states with Consumer Assistance Programs is available at xxx.xxx.xxx/xxxx/xxxxxxxxxxxx and xxxx://xxxxx.xxx.xxx/programs/consumer/capgrants/index.html. Does this notice, or assistance, contact: Paramount Insurance Co., Member Service Department at: (000) 000-0000, Toll Free: 1-800-462-3589, or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx plan Provide Minimum Essential Coverage? Yes If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan Meet the Minimum Value Standard? 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. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next sectionpage.–––––––––––––––––––––– Coverage for: Single/Family | Plan Type: HMO The Summary This is not a cost estimator. Treatments shown are just examples of Benefits 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 Coverage many other factors. Focus on the cost sharing amounts (SBCdeductibles, copayments and coinsurance) document will help you choose a health 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) The SBC shows you how you plan's overall deductible $300 Specialist coinsurance 10% Hospital (facility) coinsurance 10% Other coinsurance 10% his EXAMPLE event includes services like: pecialist office visits (prenatal care) hildbirth/Delivery Professional Services hildbirth/Delivery Facility Services iagnostic tests (ultrasounds and the plan would share the cost for covered heath blood work) pecialist visit (anesthesia) Deductibles $300 Copayments $0 Coinsurance $500 Limits or exclusions $0 Managing Joe’s type 2 Diabetes (a year of routine in-network care services. NOTEof a well- controlled condition) The plan's overall deductible $300 Specialist coinsurance 10% Hospital (facility) coinsurance 10% Other coinsurance 10%his EXAMPLE event includes services like: Information about the cost of this plan rimary care physician office visits (called the premiumincluding isease education) will be provided separately. This is only a summary. For more information about your coverage, iagnostic tests (blood work) rescription drugs urable medical equipment (glucose meter) Deductibles* $300 Copayments $0 Coinsurance $500 Limits or to get a copy of the complete terms of coverage, contact Paramount at 0-000-000-0000 or xxx.xxxxxxxxxxxxxxxxxxx.xxx/xxxxxx-xxxxxxxxx. 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.xxxxxxxxxxxxxxxxxxxxxxxxx.xxx or call 0-000-000-0000 to request a copy.exclusions $20    The plan's overall deductible $300    Specialist coinsurance 10%    Hospital (facility) coinsurance 10%    Other coinsurance 10% S P Emergency room care (including medical supplies)

Your Grievance and Appeals Rights. There are agencies that can The Utah Insurance Department has a staff of insurance experts available to help if you understand your insurance coverage and answer your questions. If you have been unable to resolve a complaint against problem with your insurance company or agent, you may contact our staff for assistance, or file a written complaint. If your compliant involves health care insurance, please refer to the section below titled HEALTH INSURANCE COMPLAINTS. Our consumer service personnel are available to assist you between the hours of 8:00 a.m. and 5:00 p.m., Monday through Friday by calling: Salt Lake City area: 000-000-0000 In-state toll-free: 0-000-000-0000 Or by visiting xxxxx://xxxxxxxxx.xxxx.xxx/complaint/ The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan for or policy does provide minimum essential coverage. The Affordable Care Act establishes a denial minimum value standard of benefits of a claimhealth plan. The minimum value standard is 60% (actuarial value). This complaint is called a grievance or appealhealth coverage does meet the minimum value standard for the benefits it provides. For more information about your rightsSpanish (Español): Para obtener asistencia en Español, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information 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: Paramount Insurance Co., Member Service Department at: (llame al 0-000) -000-0000, Toll Free: 1-800-462-3589, or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. 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. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next sectionpage.–––––––––––––––––––––– Having a baby (normal delivery) Arches: Xxxxx City - QHDHP POS Plan Coverage forPeriod: Single/Family | Plan Type: HMO The 07/01/2014 – 06/30/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Large Group |Plan Type: High-Ded. POS Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.  Amount owed to providers: $7,540  Plan pays $4,890  Patient pays $2,650 Hospital charges (SBCmother) document will help you choose $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40  Amount owed to providers: $5,400  Plan pays $2,900  Patient pays $2,500 Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Deductibles $2,420 Copays $0 Coinsurance $0 Limits or exclusions $80 Deductibles $2,500 Copays $0 Coinsurance $0 Limits or exclusions $150 Arches: Xxxxx City - QHDHP POS Plan Coverage Period: 07/01/2014 – 06/30/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Large Group |Plan Type: High-Ded. POS  Costs don’t include premiums.  Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan.  The SBC shows you how you patient’s condition was not an excluded or preexisting condition.  All services and treatments started and ended in the plan same coverage period.  There are no other medical expenses for any member covered under this plan.  Out-of-pocket expenses are based only on treating the condition in the example.  The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would share the cost for covered heath care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summaryhave been higher. For more information about your coverageeach treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or to get a copy of the complete terms of coverage, contact Paramount at 0-000-000-0000 treatment isn’t covered or xxx.xxxxxxxxxxxxxxxxxxx.xxx/xxxxxx-xxxxxxxxx. 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.xxxxxxxxxxxxxxxxxxxxxxxxx.xxx or call 0-000-000-0000 to request a copypayment is limited.

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 to submit a claim, appeal or a grievance for any reason to your plan. For more information about Additionally, a consumer assistance program may help you file your rights, appeal. A list of states with Consumer Assistance Programs is available at xxx.xxx.xxx/xxxx/xxxxxxxxxxxx and xxxx://xxxxx.xxx.xxx/programs/consumer/capgrants/index.html. Does this notice, or assistance, contact: Paramount Insurance Co., Member Service Department at: (000) 000-0000, Toll Free: 1-800-462-3589, or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx plan Provide Minimum Essential Coverage? Yes If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan Meet the Minimum Value Standard? 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. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next sectionpage.–––––––––––––––––––––– Coverage for: Single/Family | Plan Type: HMO The Summary This is not a cost estimator. Treatments shown are just examples of Benefits 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 Coverage many other factors. Focus on the cost sharing amounts (SBCdeductibles, copayments and coinsurance) document will help you choose a health 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) The SBC shows you how you plan's overall deductible $250 Specialist copayment $20 Hospital (facility) coinsurance 20% Other coinsurance 20% his EXAMPLE event includes services like: pecialist office visits (prenatal care) hildbirth/Delivery Professional Services hildbirth/Delivery Facility Services iagnostic tests (ultrasounds and the plan would share the cost for covered heath blood work) pecialist visit (anesthesia) Deductibles $300 Copayments $20 Coinsurance $2,300 Limits or exclusions $0 Managing Joe’s type 2 Diabetes (a year of routine in-network care services. NOTEof a well- controlled condition) The plan's overall deductible $250 Specialist copayment $20 Hospital (facility) coinsurance 20% Other coinsurance 20%his EXAMPLE event includes services like: Information about the cost of this plan rimary care physician office visits (called the premiumincluding isease education) will be provided separately. This is only a summary. For more information about your coverage, iagnostic tests (blood work) rescription drugs urable medical equipment (glucose meter) Deductibles* $300 Copayments $900 Coinsurance $50 Limits or to get a copy of the complete terms of coverage, contact Paramount at 0-000-000-0000 or xxx.xxxxxxxxxxxxxxxxxxx.xxx/xxxxxx-xxxxxxxxx. 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.xxxxxxxxxxxxxxxxxxxxxxxxx.xxx or call 0-000-000-0000 to request a copy.exclusions $20    The plan's overall deductible $250    Specialist copayment $20    Hospital (facility) coinsurance 20%    Other coinsurance 20% S P Emergency room care (including medical supplies)

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 to submit a claim, appeal or a grievance for any reason to your plan. For more information about Additionally, a consumer assistance program may help you file your rights, appeal. A list of states with Consumer Assistance Programs is available at xxx.XxxxxxXxxx.xxx and xxxx://xxxxx.xxx.xxx/programs/consumer/capgrants/index.html. Does this notice, or assistance, contact: Paramount Insurance Co., Member Service Department at: (000) 000-0000, Toll Free: 1-800-462-3589, or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx plan Provide Minimum Essential Coverage? Yes If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan Meet the Minimum Value Standard? 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. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next sectionpage.–––––––––––––––––––––– Coverage for: Single/Family | Plan Type: HMO The Summary This is not a cost estimator. Treatments shown are just examples of Benefits 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 Coverage many other factors. Focus on the cost sharing amounts (SBCdeductibles, copayments and coinsurance) document will help you choose a health 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. (a year of routine in-network care of a well- controlled condition) ◼ The SBC shows plan's overall deductible $200 ◼ Specialist coinsurance 20% ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) $400 $200 Deductibles Copayments Coinsurance $100 Limits or exclusions ◼ The plan's overall deductible $200 ◼ Specialist coinsurance 20% ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) $200 $200 Deductibles* Copayments Coinsurance $6,000 Limits or exclusions ◼ The plan's overall deductible $200 ◼ Specialist coinsurance 20% ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic tests (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Deductibles* $200 Copayments $0 Coinsurance $300 Limits or exclusions $0 Note: These numbers assume the patient does not participate in the plan’s wellness program. If you how participate in the plan’s wellness program, you and the plan would share the cost for covered heath care services. NOTE: Information about the cost of this plan (called the premium) will may be provided separately. This is only a summaryable to reduce your costs. For more information about your coveragethe wellness program, or to get a copy of the complete terms of coverage, contact Paramount at 0-000-000-0000 or xxx.xxxxxxxxxxxxxxxxxxx.xxx/xxxxxx-xxxxxxxxx. 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.xxxxxxxxxxxxxxxxxxxxxxxxx.xxx please contact: xxx.xxx.xxx or call 0-000-000-0000 0000. *Note: This plan has other deductibles for specific services included in this coverage example. See "Are there other deductibles for specific services?”" row above. Name Teaching Field College or University Attending Dates of Attendance List Course or Courses to request be Taken this Semester (up to 3 hrs.)* Sem. Cr. Hrs. *If more than 3 semester hours are requested per semester, please complete a copyseparate application that will be considered for reimbursement for extra hours in October. (Current year is considered class start dates between July 1 – June 30.) Semester II Extra Date Application Received Approved Disapproved Administrative Signature For Treasurer’s Office Use ********************************************************************* Date Transcript Received Verifying Completion Date of Payment Name Date School Assault leave has been taken in accordance with Section 3319.143 of the Ohio Revised Code and the Assault Leave Policy of the Agreement between the Fredericktown Local Board of Education and the Fredericktown Education Association. day(s) of assault leave was/were taken beginning at on / , 20 and ending at on day month time / , 20 day month The following information must be stated: Duration of Medical Attention Name of Physician Office Address Unit Member’s Signature Principal Superintendent SUPERVISOR: DATE START TIME END TIME REGULAR HOURS HOURS Date Date Date Date Date Date Date Please log your time in attendance for any voluntary in-service or other mandated meeting or other work which is held during non- school hours. In accordance with the negotiated agreement, you will be paid at the per diem rate prorated to the time of such in- service. Complete this form and return to your building Principal for approval.

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 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: Paramount Insurance Co., Member Service Department at: (000) 000-0000, Toll Free: 1-800-462-3589, or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. 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. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.–––––––––––––––––––––– Coverage for: Single/Family | Plan Type: HMO 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 heath 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, contact Paramount at 0-000-000-0000 or xxx.xxxxxxxxxxxxxxxxxxx.xxx/xxxxxx-xxxxxxxxx. For general definitions of common terms such as allowed amount, balance billing, coinsurance, copaymentcoinsurance , deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxxxxxxxxxxxxxxxxx.xxx or call 0-000-000-0000 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 to submit a claim, appeal appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Paramount Insurance Co.ATTN: Grievances and Appeals, Member Service Department at: (000) 000-X.X. Xxx 0000, Toll Free: 1Xxxxx Xxxxx, XX 00000-800-462-3589, or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx 0000 If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. 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. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.–––––––––––––––––––––– Coverage for: Single/Family | Plan Type: HMO The Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services 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 heath care services. NOTEPeriod: Information about the cost of this plan 7/1/19 Coverage for: Individual + Family | (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, contact Paramount at 0-000-000-0000 or xxx.xxxxxxxxxxxxxxxxxxx.xxx/xxxxxx-xxxxxxxxxxxxxx://xxx.xxxxxx.xxx/eocdps/aso. For general definitions of common terms 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.xxxxxxxxxxxxxxxxxxxxxxxxx.xxx xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx/ or call 0-(000-) 000-0000 to request a copy.