Common use of Language Access Services Clause in Contracts

Language Access Services. For assistance in a language below please call the number on the back of your BCBSM ID card. SPANISH (Español): Para ayuda en español, llame al número de servicio al cliente que se encuentra en este aviso ó en el reverso de su tarjeta de identificación. TAGALOG (Tagalog): Para sa tulong sa wikang Tagalog, mangyaring tumawag sa numero ng serbisyo sa mamimili na nakalagay sa likod ng iyong pagkakakilanlan kard o sa paunawang ito. CHINESE (中文): 要获取中文帮助，请致电您的身份识别卡背面或本通知提供的客户服务号码。 NAVAJO (Dine): Taa’dineji’keego shii’kaa’ahdool’wool ninizin’goo, beesh behane’e naal’tsoos bikii sin’dahiigii binii’deehgo eeh’doodago di’naaltsoo bikaiigii bichi’hoodillnii. ––––––––––––––––––––––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. Please note: Coverage examples are calculated based on individual coverage and calculations may not include a coinsurance maximum. ■ Amount owed to providers: $7,540 ■ Plan pays $6,620 ■ Patient pays $920 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 $250 Co-pays $0 Co-insurance $500 Limits or exclusions $170 ■ Amount owed to providers: $5,400 ■ Plan pays $2,000 ■ Patient pays $3,400 Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Deductibles $250 Co-pays $100 Co-insurance $120 Limits or exclusions $2,930 • 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, co-payments, and co-insurance 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.