Common use of Language Access Services Clause in Contracts

Language Access Services. Spanish (Español): Para obtener asistencia en Español, llame al ▇-▇▇▇-▇▇▇-▇▇▇▇. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa ▇-▇▇▇-▇▇▇-▇▇▇▇. Chinese (中文): 如果需要中文的帮助，请拨打这个号码 ▇-▇▇▇-▇▇▇-▇▇▇▇. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' ▇-▇▇▇-▇▇▇-▇▇▇▇. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– Blue Cross Blue Shield Michigan: Division 0048 Coverage Period: 01/01/2016 – 12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Covered Individuals | Plan Type: PPO 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 $6,550  Patient pays $1,845 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  Amount owed to providers: $5,400  Plan pays $3,945  Patient pays $1,455 Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Deductibles $500 Copays $775 Coinsurance $180 Limits or exclusions $0 Note: These numbers assume the patient is filling scripts at a participating pharmacy. Deductibles $1,000 Copays $45 Coinsurance $800 Limits or exclusions $0 Blue Cross Blue Shield Michigan: Division 0048 Coverage Period: 01/01/2016 – 12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Covered Individuals | 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- 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.

Language Access Services. Spanish (Español): Para obtener asistencia en Español, llame al ▇-▇▇▇-▇▇▇-▇▇▇▇. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa ▇-▇▇▇-▇▇▇-▇▇▇▇. Chinese (中文): 如果需要中文的帮助，请拨打这个号码 ▇-▇▇▇-▇▇▇-▇▇▇▇. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' ▇-▇▇▇-▇▇▇-▇▇▇▇. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– Blue Cross Blue Shield Michigan: Division 0048 0050 Coverage Period: 01/01/2016 – 12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Covered Individuals | Plan Type: PPO 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 $6,550 6,374  Patient pays $1,845 1,166 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  Amount owed to providers: $5,400  Plan pays $3,945 4,300  Patient pays $1,455 1,100 Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Deductibles $500 250 Copays $775 735 Coinsurance $180 115 Limits or exclusions $0 Note: These numbers assume the patient is filling scripts at a participating pharmacy. Deductibles $1,000 500 Copays $45 21 Coinsurance $800 645 Limits or exclusions $0 Blue Cross Blue Shield Michigan: Division 0048 0050 Coverage Period: 01/01/2016 – 12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Covered Individuals | 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- 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.

Language Access Services. Spanish (Español): Para obtener asistencia en Español, llame al ▇-▇▇▇-▇▇▇-▇▇▇▇. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa ▇-▇▇▇-▇▇▇-▇▇▇▇. Chinese (中文): 如果需要中文的帮助，请拨打这个号码 ▇-▇▇▇-▇▇▇-▇▇▇▇. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' ▇-▇▇▇-▇▇▇-▇▇▇▇. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– Blue Cross Blue Shield Michigan: Division 0048 0049 Coverage Period: 01/01/2016 – 12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Covered Individuals | Plan Type: PPO 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 $6,550  4,935 ■ Patient pays $1,845 2,605 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  ■ Amount owed to providers: $5,400  ■ Plan pays $3,945  3,545 ■ Patient pays $1,455 1,855 Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Deductibles $500 1,000 Copays $775 Coinsurance $180 80 Limits or exclusions $0 Note: These numbers assume the patient is filling scripts at a participating pharmacy. Deductibles $1,000 1,900 Copays $45 Coinsurance $800 660 Limits or exclusions $0 Blue Cross Blue Shield Michigan: Division 0048 0049 Coverage Period: 01/01/2016 – 12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Covered Individuals | 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- 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.