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: Blue Cross and Blue Shield of Illinois at 0-000-000-0000 or visit xxx.xxxxxx.xxx, or contact the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-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 or visit xxxx://xxxxxxxxx.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. 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.

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: Blue Cross and Blue Shield of Illinois at 0-000-000-0000 or visit xxx.xxxxxx.xxx, or contact the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-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 or visit xxxx://xxxxxxxxx.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. 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.

Your Grievance and Appeals Rights. There are agencies that can help if If you have a complaint against your plan for or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a claim. This complaint is called a grievance or appealgrievance. 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 questions about your rights, this notice, or assistance, contact: Blue Cross and Blue Shield of Illinois you can contact Cigna Customer service at 01-000800-000-0000 or visit xxx.xxxxxx.xxx, or Cigna24. You may also contact the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-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 or visit xxxx://xxxxxxxxx.xxxxxxxx.xxx. Does this plan provide Coverage Provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, The Affordable Care Act requires most people to have health insurance available through the Marketplace care coverage that qualifies as “minimum essential coverage.” This plan or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other policy does provide minimum essential coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet Coverage Meet the Minimum Value StandardsStandard? Yes If your plan doesn’t 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 Standards, you may be eligible minimum value standard for a premium tax credit to help you pay for a plan through the Marketplacebenefits it provides. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 0-000-000-0000. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. Chinese (中文): 如果需要中文的帮助，请拨打这个号码 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 ----------------------To see examples of how this plan might cover costs for a sample medical situation, see the next section.page.----------- Coverage Examples About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Having a baby (normal delivery) Managing type 2 diabetes (routine maintenance of a well-controlled condition)  Amount owed to providers: $7,540  Plan pays: $3,510  Patient pays: $4,030 Sample care costs:  Amount owed to providers: $5,400  Plan pays: $1,120  Patient pays: $4,280 Sample care costs: This is not a cost estimator Don't use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Note: These numbers assume enrollment in individual-only coverage. Hospital charges (mother) $2,700 Prescriptions $2,900 Routine Obstetric Care $2,100 Medical equipment and supplies $1,300 Hospital charges (baby) $900 Office visits & procedures $700 Anesthesia $900 Education $300 Laboratory tests $500 Laboratory tests $100 Prescriptions $200 Vaccines, other preventive $100 Radiology $200 Total $5,400 Vaccines, other preventive $40 Total $7,540 Patient pays: Patient pays: Deductible $4,000 Deductible $4,000 Co-pays $0 Co-pays $0 Co-insurance $0 Co-insurance $0 Limits or exclusions $280 Limits or exclusions $30 Total $4,280 Total $4,030 Questions and answers about the Coverage Examples:

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: Blue Cross and Blue Shield the Member Service number listed on the back of Illinois at 0-000-000-0000 your ID card or visit xxx.xxxxxx.xxx, or contact the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or visit xxx.xxx.xxx/xxxx/xxxxxxxxxxxxxxxxx.xxx. Additionally, a consumer assistance program can may help you file your appeal. Contact the Illinois Department of Insurance at (000) 000-0000 or visit xxxx://xxxxxxxxx.xxxxxxxx.xxxxxx.xxx/xxxx/xxxxxxxxxxxx. 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 sectionsection 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. About these Coverage Examples: 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 $500 ◼ The plan’s overall deductible $500 ◼ The plan’s overall deductible $500 ◼ Specialist copay $50 ◼ Specialist copay $50 ◼ Specialist copay $50 ◼ Hospital (facility) coinsurance 20% ◼ Hospital (facility) coinsurance 20% ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% ◼ Other coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (pre-natal 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: This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) $2,800 Total Example Cost In this example, Xxx would pay: Cost Sharing Deductibles $500 Copayments $0 Coinsurance $500 What isn’t covered Limits or exclusions $60 The total Peg would pay is $1,060 Cost Sharing Deductibles $200 Copayments $800 Coinsurance $20 What isn’t covered Limits or exclusions $30 The total Xxx would pay is $1,050 Cost Sharing Deductibles $500 Copayments $300 Coinsurance $60 What isn’t covered Limits or exclusions $0 The total Mia would pay is $860 APPENDIX E Delta Dental PPO™ (Point-of-Service) Summary of Dental Plan Benefits For Group# 2344-1000, 1099 Pickaway County Public Employee Benefits Program Circleville City Schools 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 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.* Control Plan – Delta Dental of Ohio Benefit Year – January 1 through December 31 Delta Dental PPO™ Dentist Covered Services – Delta Dental Premier® Dentist Nonparticipating Dentist Plan Pays Plan Pays Plan Pays* Diagnostic & Preventive Diagnostic and Preventive Services – exams, cleanings, and fluoride 100% 100% 100% Emergency Palliative Treatment – to temporarily relieve pain 100% 100% 100% Sealants – to prevent decay of permanent teeth 100% 100% 100% Brush Biopsy – to detect oral cancer 100% 100% 100% Radiographs – X-rays 100% 100% 100% Basic Services Space Maintainers – appliances to prevent tooth movement 80% 80% 80% Minor Restorative Services – fillings and crown repair 80% 80% 80% Endodontic Services – root canals 80% 80% 80% Periodontic Services – to treat gum disease 80% 80% 80% Oral Surgery Services – extractions and dental surgery 80% 80% 80% Other Basic Services – misc. services 80% 80% 80% Relines and Repairs – to prosthetic appliances 80% 80% 80% Major Services Major Restorative Services – crowns 50% 50% 50% Prosthodontic Services – bridges, implants, dentures, and crowns over implants 50% 50% 50% Orthodontic Services Orthodontic Services – braces 50% 50% 50% Orthodontic Age Limit – through age 18 and under through age 18 and under through age 18 and under * 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 and you are responsible for that difference. ⮚ Oral exams (including evaluations by a specialist) are payable twice per calendar year. ⮚ Prophylaxes (cleanings) are payable twice per calendar year. ⮚ 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 once per calendar year with no age limit. ⮚ Space maintainers are payable once per area per lifetime for people age 17 and under. ⮚ Bitewing X-rays are payable twice per calendar year and full-mouth X-rays (which include bitewing X-rays) or a panorex are payable once in any five-year period. ⮚ Sealants are payable for first and second permanent molars for people age 18 and under. The surface must be free from decay and restorations. ⮚ Veneers are payable on incisors, cuspids, and bicuspids once per tooth per five-year period when necessary due to fracture or decay. ⮚ Composite resin (white) restorations are payable on posterior teeth. ⮚ Porcelain and resin facings on crowns are Covered Services 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. ⮚ People with special health care needs may be eligible for additional services including exams, hygiene visits, dental case management, and sedation/anesthesia. Special health care needs include any physical, developmental, mental, sensory, behavioral, cognitive, or emotional impairment or limiting condition that requires medical management, healthcare intervention, and/or use of specialized services or programs. The condition may be congenital, developmental, or acquired through disease, trauma, or environmental cause and may impose limitations in performing daily self-maintenance activities or substantial limitations in a major life activity. Having Delta Dental coverage makes it easy for you to get dental 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 schedule care. For more information, check our website or contact your benefits representative to get a copy of our Passport Dental information sheet. Maximum Payment – $1,500 per Member total per Benefit Year on all services except orthodontic services. $1,500 per Member 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 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 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 50% of the per month fee charged by your Dentist based upon the agreed upon payment plan provided by Delta Dental to your Dentist. Deductible – None.