Common use of Language Access Services Clause in Contracts

Language Access Services. Spanish (Español): Para obtener asistencia en Español, llame al 330-363-6360 /▇-▇▇▇-▇▇▇-▇▇▇▇. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 330-363-6360 /▇-▇▇▇-▇▇▇-▇▇▇▇. Chinese (中文): 如果需要中文的帮助，请拨打这个号码 330-363-6360 / ▇-▇▇▇-▇▇▇-▇▇▇▇. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 330-363-6360 / ▇-▇▇▇-▇▇▇-▇▇▇▇. This is only a summary. It in no way modifies your benefits as described in your plan documents. Please refer to your plan documents provided by your employer for complete terms of this plan. City of Canton (Police, CPPA, FOP & Fire) Coverage Period: Beginning on or after 01/01/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family| Plan Type: PPO ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– City of Canton (Police, CPPA, FOP & Fire) Coverage Period: Beginning on or after 01/01/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family| 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 $5,870  Patient pays $1,670 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 $4,470  Patient pays $930 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 $200 Co-insurance $480 Limits or exclusions $0 Deductibles $500 Co-pays $40 Co-insurance $1,130 Limits or exclusions $0 City of Canton (Police, CPPA, FOP & Fire) Coverage Period: Beginning on or after 01/01/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family| Plan Type: PPO • Costs don’t include premiums. • Costs are based on individual coverage benefit levels. • 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. • Prescription drug costs (Prescriptions) shown in the Coverage Examples reflect information provided by the Plan’s Prescription Benefits Manager. 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.

Language Access Services. Spanish (Español): Para obtener asistencia en Español, llame al 330▇▇▇-363▇▇▇-6360 ▇▇▇▇ /▇-▇▇▇-▇▇▇-▇▇▇▇. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 330▇▇▇-363▇▇▇-6360 ▇▇▇▇ /▇-▇▇▇-▇▇▇-▇▇▇▇. Chinese (中文): 如果需要中文的帮助，请拨打这个号码 330▇▇▇-363▇▇▇-6360 ▇▇▇▇ / ▇-▇▇▇-▇▇▇-▇▇▇▇. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 330▇▇▇-363▇▇▇-6360 ▇▇▇▇ / ▇-▇▇▇-▇▇▇-▇▇▇▇. This is only a summary. It in no way modifies your benefits as described in your plan documents. Please refer to your plan documents provided by your employer for complete terms of this plan. City of Canton (Police, CPPA, FOP & Fire) Coverage Period: Beginning on or after 01/01/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family| Plan Type: PPO ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– City of Canton (Police, CPPA, FOP & Fire) Coverage Period: Beginning on or after 01/01/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family| 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 $5,870  ◼ Patient pays $1,670 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 $4,470  ◼ Patient pays $930 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 $200 Co-insurance $480 Limits or exclusions $0 Deductibles $500 Co-pays $40 Co-insurance $1,130 Limits or exclusions $0 City of Canton (Police, CPPA, FOP & Fire) Coverage Period: Beginning on or after 01/01/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family| Plan Type: PPO • Costs don’t include premiums. • Costs are based on individual coverage benefit levels. • 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. • Prescription drug costs (Prescriptions) shown in the Coverage Examples reflect information provided by the Plan’s Prescription Benefits Manager. 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.