Common use of Your Grievance and Appeals Rights Clause in Contracts

Your Grievance and Appeals Rights. If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact your state insurance department at (000) 000-0000 or by email at XxxxxxXxxXxxxxxx@xxxx.xx.xxx, the U.S. Department of Labor, Employee Benefits Security Administration at 0-000-000-0000 or xxx.xxx.xxx/xxxx, or the U.S. Department of Health and Human Services at 0-000-000-0000 x00000 or xxx.xxxxx.xxx.xxx. The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coverage. The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Para obtener asistencia en Español, llame al 0-000-000-0000. Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– 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. 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.  Amount owed to providers: $7,540  Plan pays $7,490  Patient pays $50 Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Deductibles $0 Copays $0 Coinsurance $20 Limits or exclusions $30  Amount owed to providers: $5,400  Plan pays $4,460  Patient pays $940 Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Deductibles $0 Copays $100 Coinsurance $800 Limits or exclusions $40 These examples are based on coverage for an individual plan.  Costs don’t include premiums.  Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan.  The patient’s condition was not an excluded or preexisting condition.  All services and treatments started and ended in the same coverage period.  There are no other medical expenses for any member covered under this plan.  Out-of-pocket expenses are based only on treating the condition in the example.  The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited.

Your Grievance and Appeals Rights. If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact your state insurance department at (000) 000-0000 or by email at XxxxxxXxxXxxxxxx@xxxx.xx.xxx, the U.S. Department of Labor, Employee Benefits Security Administration at 0-000-000-0000 or xxx.xxx.xxx/xxxx, or the U.S. Department of Health and Human Services at 0-000-000-0000 x00000 or xxx.xxxxx.xxx.xxx. The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coverage. The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Para obtener asistencia en Español, llame al 0-000-000-0000. Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– 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. 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.  ◼ Amount owed to providers: $7,540  ◼ Plan pays $7,490  ◼ Patient pays $50 Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Deductibles $0 Copays $0 20 Coinsurance $20 0 Limits or exclusions $30  ◼ Amount owed to providers: $5,400  ◼ Plan pays $4,460  4,760 ◼ Patient pays $940 640 Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Deductibles $0 Copays $100 300 Coinsurance $800 300 Limits or exclusions $40 These examples are based on coverage for an individual plan.  • Costs don’t include premiums.  • Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan.  • The patient’s condition was not an excluded or preexisting condition.  • All services and treatments started and ended in the same coverage period.  • There are no other medical expenses for any member covered under this plan.  • Out-of-pocket expenses are based only on treating the condition in the example.  • The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited.

Your Grievance and Appeals Rights. If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact your state insurance department at (000) 000-0000 or by email at XxxxxxXxxXxxxxxx@xxxx.xx.xxx, the U.S. Department Blue Cross and Blue Shield of Labor, Employee Benefits Security Administration Illinois at 0-000-000-0000 or xxx.xxx.xxx/xxxxvisit xxx.xxxxxx.xxx, or contact the U.S. U.S Department of Health and Human Services Labor's Employee Benefits Security Administration at 01-866-444-EBSA (3272) or visit xxx.xxx.xxx/xxxx/xxxxxxxxxxxx. Additionally, a consumer assistance program can help you file your appeal. Contact the Illinois Department of Insurance at (000-) 000-0000 x00000 or xxx.xxxxx.xxx.xxxvisit xxxx://xxxxxxxxx.xxxxxxxx.xxx. The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coverage. The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Spanish (Español): Para obtener asistencia en Español, llame al 0-000-000-0000. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. Chinese (中文): 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– 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. 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 $7,490  6,840  Patient pays $50 700 Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Deductibles Total $0 Copays $0 Coinsurance $20 Limits or exclusions $30  7,540  Amount owed to providers: $5,400   Plan pays $4,460  4,720  Patient pays $940 680 Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Deductibles $0 Copays $100 600 Coinsurance $800 0 Limits or exclusions $40 These examples are based on coverage for an individual plan.  80 Total $680 Deductibles $0 Copays $500 Coinsurance $0 Limits or exclusions $200 Total $700 Costs don’t include premiums.  Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan.  The patient’s condition was not an excluded or preexisting condition.  All services and treatments started and ended in the same coverage period.  There are no other medical expenses for any member covered under this plan.  Out-of-of- pocket expenses are based only on treating the condition in the example.  The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited.  No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors. No. Coverage Examples are not cost estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Yes. When you look at the Summary of Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “Patient Pays” box in each example. The smaller that number, the more coverage the plan provides. Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you’ll pay in out-of- pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call 0-000-000-0000 or visit us at xxx.xxxxxx.xxx. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at xxxx://xxx.xxx.xxx/ebsa/pdf/SBCUniformGlossary.pdf or call 1-855-756- 4448 to request a copy. SBC IL Non-HMO LG-2016 City of Naperville: PPO PC0713 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2017 - 12/31/2017 Coverage for: ALL | Plan Type: PPO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www. xxxxxx.xxx or by calling 0-000-000-0000.

Your Grievance and Appeals Rights. If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact contact: Anthem Blue Cross & Blue Shield Appeals 000 Xxxxxx Xxxx, Xxxxxxxxxxx XX 00000 Department of Labor’s Employee Benefits Security Administration 1-866-444-EBSA (3272) xxx.xxx.xxx/xxxx/xxxxxxxxxxxx Connecticut Insurance Department 000 Xxxxxx Xxxxxx, 0xx Xxxxx, Xxxxxxxx, XX 00000 Additionally, a consumer assistance program can help you file your state insurance department at appeal. Contact: Connecticut Office of the Healthcare Advocate X.X. Xxx 1543 Hartford, CT 00000 (000) 000-0000 or by email at XxxxxxXxxXxxxxxx@xxxx.xx.xxx, the U.S. Department of Labor, Employee Benefits Security Administration at 0-000-000-0000 or xxx.xxx.xxx/xxxx, or the U.S. Department of Health and Human Services at 0-000-000-0000 x00000 or xxx.xxxxx.xxx.xxx. xxx.xx.xxx/xxx xxxxxxxxxx.xxxxxxxx@xx.xxx The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coverage. The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Para obtener asistencia en Español, llame al 0-000-000-0000. Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– 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. 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  15,540 ◼ Plan pays $7,490  15,010 ◼ Patient pays $50 300 Hospital charges (mother) $2,700 10,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Deductibles $0 Copays $0 Coinsurance $20 Limits or exclusions $30  ◼ Amount owed to providers: $5,400  1,600 ◼ Plan pays $4,460  1,510 ◼ Patient pays $940 175 Prescriptions $2,900 500 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Deductibles $0 Copays $100 175 Coinsurance $800 0 Limits or exclusions $40 These examples are based on coverage for an individual plan.  0 Deductibles $0 Copays $300 Coinsurance $0 Limits or exclusions $0 Coverage Examples Coverage for: Individual/Family | Plan Type: PPO • Costs don’t include premiums.  • Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan.  • The patient’s condition was not an excluded or preexisting condition.  • All services and treatments started and ended in the same coverage period.  • There are no other medical expenses for any member covered under this plan.  • Out-of-pocket expenses are based only on treating the condition in the example.  • The patient received all care from in- in-network providers. If the patient had received care from out-of-network providers, costs would have been higher. Coverage Examples Coverage for: Individual/Family | Plan Type: PPO For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited.

Your Grievance and Appeals Rights. If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact your state insurance department at (000) 000-0000 or by email at XxxxxxXxxXxxxxxx@xxxx.xx.xxx, the U.S. Department of Labor, Employee Benefits Security Administration at 0-000-000-0000 or xxx.xxx.xxx/xxxx, or the U.S. Department of Health and Human Services at 0-000-000-0000 x00000 or xxx.xxxxx.xxx.xxx. The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coverage. The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Para obtener asistencia en Español, llame al 0-000-000-0000. Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– 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. 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.  ◼ Amount owed to providers: $7,540  ◼ Plan pays $7,490  ◼ Patient pays $50 Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Deductibles $0 Copays $0 Coinsurance $20 Limits or exclusions $30  ◼ Amount owed to providers: $5,400  ◼ Plan pays $4,460  4,490 ◼ Patient pays $940 910 Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Deductibles $0 Copays $100 70 Coinsurance $800 Limits or exclusions $40 These examples are based on coverage for an individual plan.  • Costs don’t include premiums.  • Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan.  • The patient’s condition was not an excluded or preexisting condition.  • All services and treatments started and ended in the same coverage period.  • There are no other medical expenses for any member covered under this plan.  • Out-of-pocket expenses are based only on treating the condition in the example.  • The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited.

Your Grievance and Appeals Rights. If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact your state insurance department at (000) 000-0000 or by email at XxxxxxXxxXxxxxxx@xxxx.xx.xxx, the U.S. Department of Labor, Employee Benefits Security Administration at 0-000-000-0000 or xxx.xxx.xxx/xxxx, or the U.S. Department of Health and Human Services at 0-000-000-0000 x00000 or xxx.xxxxx.xxx.xxx. The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coverage. The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Para obtener asistencia en Español, llame al 01-000800-000639-00002227. Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 01-000800-000639-00002227. 如果需要中文的帮助，请拨打这个号码 01-000800-000639-00002227. Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 01-000800-000639-00002227. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– 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. 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.  ◼ Amount owed to providers: $7,540  ◼ Plan pays $7,490  ◼ Patient pays $50 Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Deductibles $0 Copays $0 Coinsurance $20 Limits or exclusions $30  ◼ Amount owed to providers: $5,400  ◼ Plan pays $4,460  4,500 ◼ Patient pays $940 900 Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Deductibles $0 Copays $100 60 Coinsurance $800 Limits or exclusions $40 These examples are based on coverage for an individual plan.  • Costs don’t include premiums.  • Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan.  • The patient’s condition was not an excluded or preexisting condition.  • All services and treatments started and ended in the same coverage period.  • There are no other medical expenses for any member covered under this plan.  • Out-of-pocket expenses are based only on treating the condition in the example.  • The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited.

Your Grievance and Appeals Rights. If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact your state insurance department at (000) 000-0000 or by email at XxxxxxXxxXxxxxxx@xxxx.xx.xxx, the U.S. Department of Labor, Employee Benefits Security Administration at 0-000-000-0000 or xxx.xxx.xxx/xxxx, or the U.S. Department of Health and Human Services at 0-000-000-0000 x00000 or xxx.xxxxx.xxx.xxx. The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coverage. The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Para obtener asistencia en Español, llame al 0-000-000-0000. Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– 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. 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.  Amount owed to providers: $7,540  Plan pays $7,490  Patient pays $50 Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Deductibles $0 Copays $0 20 Coinsurance $20 0 Limits or exclusions $30  Amount owed to providers: $5,400  Plan pays $4,460 4,760  Patient pays $940 640 Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Deductibles $0 Copays $100 300 Coinsurance $800 300 Limits or exclusions $40 These examples are based on coverage for an individual plan.  Costs don’t include premiums.  Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan.  The patient’s condition was not an excluded or preexisting condition.  All services and treatments started and ended in the same coverage period.  There are no other medical expenses for any member covered under this plan.  Out-of-pocket expenses are based only on treating the condition in the example.  The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited.

Your Grievance and Appeals Rights. If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact your state insurance department at (000) 000-0000 or by email at XxxxxxXxxXxxxxxx@xxxx.xx.xxx, the U.S. Department of Labor, Employee Benefits Security Administration at 0-000-000-0000 or xxx.xxx.xxx/xxxx, or the U.S. Department of Health and Human Services at 0-000-000-0000 x00000 or xxx.xxxxx.xxx.xxx. The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coverage. The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Para obtener asistencia en Español, llame al 0-000-000-0000. Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– 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. 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.  Amount owed to providers: $7,540  Plan pays $7,490  Patient pays $50 Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Deductibles $0 Copays $0 Coinsurance $20 Limits or exclusions $30  Amount owed to providers: $5,400  Plan pays $4,460 4,500  Patient pays $940 900 Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Deductibles $0 Copays $100 60 Coinsurance $800 Limits or exclusions $40 These examples are based on coverage for an individual plan.  Costs don’t include premiums.  Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan.  The patient’s condition was not an excluded or preexisting condition.  All services and treatments started and ended in the same coverage period.  There are no other medical expenses for any member covered under this plan.  Out-of-pocket expenses are based only on treating the condition in the example.  The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited.

Your Grievance and Appeals Rights. If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact your state insurance department at (000) 000-0000 or by email at XxxxxxXxxXxxxxxx@xxxx.xx.xxx, the U.S. Department of Labor, Employee Benefits Security Administration at 0-000-000-0000 or xxx.xxx.xxx/xxxx, or the U.S. Department of Health and Human Services at 0-000-000-0000 x00000 or xxx.xxxxx.xxx.xxx. The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coverage. The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Para obtener asistencia en Español, llame al 0-000-000-0000. Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– 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. 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.  Amount owed to providers: $7,540  Plan pays $7,490  Patient pays $50 Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Deductibles $0 Copays $0 Coinsurance $20 Limits or exclusions $30  Amount owed to providers: $5,400  Plan pays $4,460 4,490  Patient pays $940 910 Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Deductibles $0 Copays $100 70 Coinsurance $800 Limits or exclusions $40 These examples are based on coverage for an individual plan.  Costs don’t include premiums.  Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan.  The patient’s condition was not an excluded or preexisting condition.  All services and treatments started and ended in the same coverage period.  There are no other medical expenses for any member covered under this plan.  Out-of-pocket expenses are based only on treating the condition in the example.  The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited.