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. Does this Coverage Provide Minimum Essential Coverage? 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. Does this Coverage Meet the Minimum Value Standard? 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. Language Access Services: 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.–––––––––––––––––––––– 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. 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. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $7,490 Patient pays $50 Sample care costs: 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 Total $7,540 Patient pays: Deductibles $0 Copays $20 Coinsurance $0 Limits or exclusions $30 Total $50 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount o...
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 Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. 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. 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. 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- contro...
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 toappealor file agrievance. For questions about your rights, this notice, or assistance, you can contact: [insert applicable contact information from instructions]. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– About these Coverage Examples: 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. 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) Amount owed to providers: $7,540 Plan pays $4,935 Patient pays $2,605 Sample care costs: 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 Total $7,540 Patient pays: Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $3,545 Patient pays $1,855 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits andProcedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Deductibles $1,000 Copays $775 Coinsurance $80 Limits or exclusions $0 Total $1,855 Patient pays: Deductibles $1,900 Copays $45 Coinsurance $660 Limits or exclusions $0 Total $2,605 Note: These numbers assume the patient is filling scriptsat a participating pharmacy. Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? 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 What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles,copayments, and coinsuranc...
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: Paramount Insurance Co., Member Service Department at: (000) 000-0000, Toll Free: 1-800-462-3589, or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx Does this plan provide Minimum Essential Coverage? Yes If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet the Minimum Value Standard? 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. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.–––––––––––––––––––––– Paramount Insurance Co. : Ottawa Hills Board of Education HSA Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage for: Single/Family | Plan Type: HMO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered heath care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, contact Paramount at 0-000-000-0000 or xxx.xxxxxxxxxxxxxxxxxxx.xxx/xxxxxx-xxxxxxxxx. For general definitions of common terms such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxxxxxxxxxxxxxxxxx.xxx or call 0-000-000-0000 to request a copy.
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: Human Resources, 00000 Xxxxx Xxxxx Xxxx, Xxxxxxx Xxxxxxxx, XX 00000, 1-586- 723-8072 or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx. Does this Coverage Provide Minimum Essential Coverage? 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. Does this Coverage Meet the Minimum Value Standard? 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.
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: Paramount Insurance Co., Member Service Department at: (000) 000-0000, Toll Free: 1-800-462-3589, or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx Does this plan provide Minimum Essential Coverage? Yes If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet the Minimum Value Standard? 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. Notice of Nondiscrimination and Accessibility: Discrimination is Against the Law Paramount Insurance Company complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Paramount Insurance Company does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Paramount Insurance Company provides: • Free aids and services to people with disabilities to communicate effectively with us, such as: ○ Qualified sign language interpreters ○ Written information in other formats (large print, audio, accessible electronic formats, other formats) • Free language services to people whose primary language is not English, such as: ○ Qualified interpreters ○ Information written in other languages If you need these services, contact Member Services at 1-800-462-3589. If you believe that Paramount Insurance Company has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance. You can file a grievance in person or by mail, fax, or email. Member Services 0000 Xxxxxx Xxxx Xxxxxx, Xxxxxx XX 00000 Phone: 000-000-0000 Toll Free: 1-800-462-3589 TTY: 0-000-000-0000 Fax: 000-000-0000 Email: X...
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 Cigna Customer service at 1-800-Cigna24. You may also contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx. Does this Coverage Provide Minimum Essential Coverage? 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. Does this Coverage Meet the Minimum Value Standard? 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. 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 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...
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 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 Coverage Provide Minimum Essential Coverage? 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. Does this Coverage Meet the Minimum Value Standard? 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. 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 page.–––––––––––––––––––––– Amount owed to providers: $7,540 Plan pays $3,340 Patient pays $4,200 Sample care costs: Patient pays: About these Coverage Examples: 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. 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 Total $7,540 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 provid...
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 Blue Cross®and Blue Shield®of Michigan by calling the number on the back of your BCBSM ID card. Or, you can contact Michigan Office of Financial and Insurance Regulation at xxx.xxxxxxxx.xxx/xxxx or 1-000-000-0000. For group health coverage subject to ERISA, you may also contact Employee Benefits Security Administration at 1-866-444-EBSA (3272). Does this Coverage Provide Minimum Essential Coverage? 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. Does this Coverage Meet the Minimum Value Standard? 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. (IMPORTANT: Blue Cross Blue Shield of Michigan is assuming that your coverage provides for all Essential Health Benefit (EHB) categories as defined by the State of Michigan. The minimum value of your plan may be affected if your plan does not cover certain EHB categories, such as prescription drugs, or if your plan provides coverage of specific EHB categories, for example prescription drugs, through another carrier.)
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: AultCare Customer Service Center at 330-363-6360 or 0-000-000-0000, or send your appeal or grievance in writing to our Grievance and Appeal Coordinator at X.X. Xxx 0000, Xxxxxx, Xxxx 00000-0000, the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx.
