Upload
others
View
2
Download
0
Embed Size (px)
Citation preview
Summary of Benefits and Coverage: What this plan covers and What You Pay For Covered Services.Coverage for: Individual/FamilyPlan type: DHMOKaiser Permanente: DEDUCTIBLE PLANCoverage Period: 01/01/2019-12/31/2019
The S
umm
ary o
f Ben
efits
and
Cove
rage
(SBC
) doc
umen
t will
help
you
choo
se a
healt
h pl
an. T
he S
BC sh
ows y
ou h
ow yo
u an
d th
e plan
wou
ld
shar
e the
cost
for c
over
ed h
ealth
care
serv
ices.
NOTE
: Inf
orm
atio
n ab
out t
he co
st o
f thi
s plan
(call
ed th
e pre
miu
m) w
ill be
pro
vided
sepa
rate
ly.Th
is is
only
a sum
mar
y. Fo
r mor
e info
rmati
on ab
out y
our c
over
age,
or to
get a
copy
of th
e com
plete
terms
of co
vera
ge se
e www
.kp.or
g/plan
docu
ments
or ca
ll 1-
800-
278-
3296
(TTY
: 711
). Fo
r gen
eral
defin
itions
of co
mmon
term
s, su
ch as
allow
ed am
ount,
balan
ce bi
lling,
coins
uran
ce, c
opay
ment,
dedu
ctible
, pro
vider
, or
other
unde
rlined
term
s see
the G
lossa
ry. Y
ou ca
n view
the G
lossa
ry at
www.
Healt
hCar
e.gov
/sbc-g
lossa
ry or
call 1
-800
-278
-329
6 (TT
Y: 71
1) to
requ
est a
copy
.
Impo
rtant
Que
stio
nsAn
swer
sW
hy th
is Ma
tters
:
Wha
t is t
he o
vera
ll de
duct
ible?
$1,50
0 Ind
ividu
al / $
3,000
Fam
ily
Gene
rally
, you
mus
t pay
all o
f the c
osts
from
prov
iders
up to
the d
educ
tible
amou
nt be
fore t
his pl
an be
gins t
o pay
. If yo
u hav
e othe
r fam
ily m
embe
rs on
the
plan,
each
fami
ly me
mber
mus
t mee
t their
own i
ndivi
dual
dedu
ctible
until
the
total
amou
nt of
dedu
ctible
expe
nses
paid
by al
l fami
ly me
mber
s mee
ts the
ov
erall
fami
ly de
ducti
ble.
Are t
here
serv
ices
cove
red
befo
re yo
u m
eet
your
ded
uctib
le?Ye
s. Pr
even
tive c
are a
nd se
rvice
s ind
icated
in
char
t star
ting o
n pag
e 2.
This
plan c
over
s som
e item
s and
servi
ces e
ven i
f you
have
n’t ye
t met
the
dedu
ctible
amou
nt. B
ut a c
opay
ment
or co
insur
ance
may
apply
. For
exam
ple,
this p
lan co
vers
certa
in pr
even
tive s
ervic
es w
ithou
t cos
t sha
ring a
nd be
fore y
ou
meet
your
dedu
ctible
. See
a lis
t of c
over
ed pr
even
tive s
ervic
es at
htt
ps://w
ww.he
althc
are.g
ov/co
vera
ge/pr
even
tive-
care
-ben
efits/
. Ar
e the
re o
ther
de
duct
ibles
for s
pecif
ic se
rvice
s?No
.Yo
u don
’t hav
e to m
eet d
educ
tibles
for s
pecif
ic se
rvice
s.
Wha
t is t
he o
ut-o
f-poc
ket
limit
for t
his p
lan?
$4,00
0 Ind
ividu
al / $
8,000
Fam
ilyTh
e out-
of-po
cket
limit i
s the
mos
t you
could
pay i
n a ye
ar fo
r cov
ered
servi
ces.
If you
have
othe
r fam
ily m
embe
rs in
this p
lan, th
ey ha
ve to
mee
t their
own o
ut-of-
pock
et lim
its un
til the
over
all fa
mily
out-o
f-poc
ket li
mit h
as be
en m
et.
Wha
t is n
ot in
clude
d in
th
e out
-of-p
ocke
t lim
it?Pr
emium
s, he
alth c
are t
his pl
an do
esn't
cove
r, and
se
rvice
s ind
icated
in ch
art s
tartin
g on p
age 2
.Ev
en th
ough
you p
ay th
ese e
xpen
ses,
they d
on't c
ount
towar
d the
out-o
f-poc
ket
limit.
Will
you
pay l
ess i
f you
us
e a n
etwo
rk p
rovid
er?
Yes.
See w
ww.kp
.org o
r call
1-80
0-27
8-32
96 (T
TY:
711)
for a
list o
f netw
ork p
rovid
ers.
This
plan u
ses a
prov
ider n
etwor
k. Yo
u will
pay l
ess i
f you
use a
prov
ider in
the
plan’s
netw
ork.
You w
ill pa
y the
mos
t if yo
u use
an ou
t-of-n
etwor
k pro
vider
, and
yo
u migh
t rec
eive a
bill f
rom
a pro
vider
for t
he di
ffere
nce b
etwee
n the
prov
ider’s
ch
arge
and w
hat y
our p
lan pa
ys (b
alanc
e billi
ng).
Be aw
are,
your
netw
ork
prov
iders
migh
t use
an ou
t-of-n
etwor
k pro
vider
for s
ome s
ervic
es (s
uch a
s lab
wo
rk). C
heck
with
your
prov
ider b
efore
you g
et se
rvice
s.Do
you
need
a re
ferra
l to
see a
spec
ialist
?Ye
s, bu
t you
may
self-r
efer t
o cer
tain s
pecia
lists.
This
plan w
ill pa
y som
e or a
ll of th
e cos
ts to
see a
spec
ialist
for c
over
ed se
rvice
s bu
t only
if yo
u hav
e a re
ferra
l befo
re yo
u see
the s
pecia
list.
Sum
mar
y of B
enef
its an
d Co
vera
ge: W
hat th
is Pl
an C
over
s & W
hat Y
ou P
ay F
or C
over
ed S
ervic
esCo
vera
ge P
erio
d: 01
/01/20
19-1
2/31/2
019
: DED
UCTI
BLE
PLAN
Cove
rage
for:
Indi
vidua
l/Fam
ily | P
lan Ty
pe: D
HMO
AVNE
T, IN
C.PI
D:23
2743
CNT
R:1
EU:-1
Plan
ID:63
54 S
BC ID
:3274
28
1 of 8
https://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#premiumhttp://www.kp.org/plandocumentshttps://www.healthcare.gov/sbc-glossary/#allowed-amounthttps://www.healthcare.gov/sbc-glossary/#balance-billinghttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#copaymenthttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#providerhttps://www.HealthCare.gov/sbc-glossary/https://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#providerhttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#preventive-carehttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#copaymenthttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#preventive-carehttps://www.healthcare.gov/sbc-glossary/#cost-sharinghttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#preventive-carehttps://www.healthcare.gov/coverage/preventive-care-benefits/https://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#out-of-pocket-limithttps://www.healthcare.gov/sbc-glossary/#out-of-pocket-limithttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#out-of-pocket-limithttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#out-of-pocket-limithttps://www.healthcare.gov/sbc-glossary/#out-of-pocket-limithttps://www.healthcare.gov/sbc-glossary/#out-of-pocket-limithttps://www.healthcare.gov/sbc-glossary/#out-of-pocket-limithttps://www.healthcare.gov/sbc-glossary/#premiumhttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#out-of-pocket-limithttps://www.healthcare.gov/sbc-glossary/#out-of-pocket-limithttps://www.healthcare.gov/sbc-glossary/#network-providerhttp://www.kp.orghttps://www.healthcare.gov/sbc-glossary/#network-providerhttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#networkhttps://www.healthcare.gov/sbc-glossary/#providerhttps://www.healthcare.gov/sbc-glossary/#networkhttps://www.healthcare.gov/sbc-glossary/#out-of-network-providerhttps://www.healthcare.gov/sbc-glossary/#providerhttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#balance-billinghttps://www.healthcare.gov/sbc-glossary/#network-providerhttps://www.healthcare.gov/sbc-glossary/#network-providerhttps://www.healthcare.gov/sbc-glossary/#out-of-network-providerhttps://www.healthcare.gov/sbc-glossary/#providerhttps://www.healthcare.gov/sbc-glossary/#referralhttps://www.healthcare.gov/sbc-glossary/#specialisthttps://www.healthcare.gov/sbc-glossary/#specialisthttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#specialisthttps://www.healthcare.gov/sbc-glossary/#referralhttps://www.healthcare.gov/sbc-glossary/#specialist
All c
opay
ment
and c
oinsu
ranc
e cos
ts sh
own i
n this
char
t are
after
your
dedu
ctible
has b
een m
et, if
a ded
uctib
le ap
plies
.
Com
mon
Medi
cal E
vent
Serv
ices Y
ou M
ay
Need
Wha
t You
Will
Pay
Plan
Pro
vider
(You
will
pay t
he le
ast)
Wha
t You
Will
Pay
Non-
Plan
Pro
vider
(You
will
pay t
he m
ost)
Lim
itatio
ns, E
xcep
tions
& O
ther
Impo
rtant
In
form
atio
n
If yo
u vis
it a h
ealth
ca
re p
rovid
er's
offic
e or c
linic
Prim
ary c
are v
isit to
tre
at an
injur
y or
illnes
s$4
0 / vi
sit, d
educ
tible
does
not
apply
.No
t Cov
ered
None
Spec
ialist
visit
$40 /
visit
, ded
uctib
le do
es no
t ap
ply.
Not C
over
edNo
ne
Prev
entiv
e car
e/sc
reen
ing/
immu
nizati
onNo
Cha
rge,
dedu
ctible
does
not
apply
.No
t Cov
ered
You m
ay ha
ve to
pay f
or se
rvice
s tha
t are
n't
prev
entiv
e. As
k you
r pro
vider
if the
servi
ces y
ou
need
are p
reve
ntive
. The
n che
ck w
hat y
our
plan w
ill pa
y for.
If yo
u ha
ve a
test
Diag
nosti
c tes
t (x-
ray,
blood
wor
k)$1
0 / en
coun
terNo
t Cov
ered
None
Imag
ing (C
T/PE
T sc
ans,
MRI's
)30
% co
insur
ance
Not C
over
edNo
ne
If yo
u ne
ed d
rugs
to
treat
your
illne
ss o
r co
nditi
on
More
info
rmat
ion
abou
t pre
scrip
tion
drug
cove
rage
is
avail
able
at
www.
kp.o
rg/
form
ular
y.
Gene
ric dr
ugs
Retai
l: $10
/ pre
scrip
tion;
orde
r: $2
0 / pr
escri
ption
, de
ducti
ble do
es no
t app
ly.No
t Cov
ered
Up to
a 30
-day
supp
ly re
tail o
r 100
-day
supp
ly ma
il ord
er. S
ubjec
t to fo
rmula
ry gu
idelin
es. N
o Ch
arge
for C
ontra
cepti
ves,
dedu
ctible
does
not
apply
.
Prefe
rred b
rand
dr
ugs
Retai
l: $30
/ pre
scrip
tion;
orde
r: $6
0 / pr
escri
ption
, de
ducti
ble do
es no
t app
ly.No
t Cov
ered
Up to
a 30
-day
supp
ly re
tail o
r 100
-day
supp
ly ma
il ord
er. S
ubjec
t to fo
rmula
ry gu
idelin
es. N
o Ch
arge
for C
ontra
cepti
ves,
dedu
ctible
does
not
apply
.No
n-pr
eferre
d bra
nd
drug
sSa
me as
prefe
rred b
rand
drug
sNo
t Cov
ered
Same
as pr
eferre
d bra
nd dr
ugs w
hen a
ppro
ved
throu
gh ex
cepti
on pr
oces
s.
Spec
ialty
drug
s$3
0 / pr
escri
ption
, ded
uctib
le do
es no
t app
ly.No
t Cov
ered
Up to
a 30
-day
supp
ly re
tail. S
ubjec
t to
formu
lary g
uideli
nes.
2 of 8
https://www.healthcare.gov/sbc-glossary/#copaymenthttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#providerhttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#specialisthttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#preventive-carehttps://www.healthcare.gov/sbc-glossary/#screeninghttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#providerhttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#diagnostic-testhttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#prescription-drug-coveragehttps://www.healthcare.gov/sbc-glossary/#prescription-drug-coveragehttps://www.healthcare.gov/sbc-glossary/#prescription-drug-coveragehttp://www.kp.org/formularyhttp://www.kp.org/formularyhttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#formularyhttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#formularyhttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#specialty-drughttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#formulary
Com
mon
Medi
cal E
vent
Serv
ices Y
ou M
ay
Need
Wha
t You
Will
Pay
Plan
Pro
vider
(You
will
pay t
he le
ast)
Wha
t You
Will
Pay
Non-
Plan
Pro
vider
(You
will
pay t
he m
ost)
Lim
itatio
ns, E
xcep
tions
& O
ther
Impo
rtant
In
form
atio
n
If yo
u ha
ve
outp
atien
t sur
gery
Facil
ity fe
e (e.g
., am
bulat
ory s
urge
ry ce
nter)
30%
coins
uran
ceNo
t Cov
ered
None
Phys
ician
/surg
eon
fees
30%
coins
uran
ceNo
t Cov
ered
None
If yo
u ne
ed
imm
ediat
e med
ical
atte
ntio
n
Emer
genc
y roo
m ca
re30
% co
insur
ance
30%
coins
uran
ceNo
ne
Emer
genc
y med
ical
trans
porta
tion
$150
/ trip
$150
/ trip
None
Urge
nt ca
re$4
0 / vi
sit, d
educ
tible
does
not
apply
.$4
0 / vi
sit, d
educ
tible
does
not
apply
.No
n-Pl
an pr
ovide
rs co
vere
d whe
n tem
pora
rily
outsi
de th
e ser
vice a
rea.
If yo
u ha
ve a
hosp
ital s
tay
Facil
ity fe
e (e.g
., ho
spita
l room
)30
% co
insur
ance
Not C
over
edNo
ne
Phys
ician
/surg
eon
fee30
% co
insur
ance
Not C
over
edNo
ne
If yo
u ne
ed m
enta
l he
alth,
beh
avio
ral
healt
h, o
r sub
stan
ce
abus
e ser
vices
Outpa
tient
servi
ces
Menta
l / Be
havio
ral H
ealth
: $40
/ ind
ividu
al vis
it, de
ducti
ble do
es
not a
pply.
30%
coins
uran
ce fo
r oth
er ou
tpatie
nt se
rvice
s; Su
bstan
ce A
buse
: $40
/ ind
ividu
al vis
it, de
ducti
ble do
es
not a
pply.
30%
coins
uran
ce up
to
$5 / d
ay fo
r othe
r outp
atien
t se
rvice
s, de
ducti
ble do
es no
t ap
ply.
Not C
over
edMe
ntal /
Beha
viora
l Hea
lth: $
20 / g
roup
visit
, de
ducti
ble do
es no
t app
ly; S
ubsta
nce A
buse
: $5
/ gro
up vi
sit, d
educ
tible
does
not a
pply.
Inpati
ent s
ervic
es30
% co
insur
ance
/ ind
ividu
al vis
itNo
t Cov
ered
None
3 of 8
https://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#emergency-room-care-emergency-serviceshttps://www.healthcare.gov/sbc-glossary/#emergency-room-care-emergency-serviceshttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#emergency-medical-transportationhttps://www.healthcare.gov/sbc-glossary/#emergency-medical-transportationhttps://www.healthcare.gov/sbc-glossary/#urgent-carehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#providerhttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#coinsurance
Com
mon
Medi
cal E
vent
Serv
ices Y
ou M
ay
Need
Wha
t You
Will
Pay
Plan
Pro
vider
(You
will
pay t
he le
ast)
Wha
t You
Will
Pay
Non-
Plan
Pro
vider
(You
will
pay t
he m
ost)
Lim
itatio
ns, E
xcep
tions
& O
ther
Impo
rtant
In
form
atio
n
If yo
u ar
e pre
gnan
t
Offic
e visi
tsNo
Cha
rge,
dedu
ctible
does
not
apply
.No
t cov
ered
Depe
nding
on th
e typ
e of s
ervic
es, a
co
paym
ent, c
oinsu
ranc
e, or
dedu
ctible
may
ap
ply. M
atern
ity ca
re m
ay in
clude
tests
and
servi
ces d
escri
bed e
lsewh
ere i
n the
SBC
(i.e.
ultra
soun
d).
Child
birth/
deliv
ery
profe
ssion
al se
rvice
s30
% co
insur
ance
Not C
over
edNo
ne
Child
birth/
deliv
ery
facilit
y ser
vices
30%
coins
uran
ceNo
t Cov
ered
None
If yo
u ne
ed h
elp
reco
verin
g or
hav
e ot
her s
pecia
l hea
lth
need
s
Home
healt
h car
eNo
Cha
rge,
dedu
ctible
does
not
apply
.No
t Cov
ered
Up to
2 ho
urs m
axim
um / v
isit, u
p to 3
visit
s ma
ximum
/ day
, up t
o 100
visit
s max
imum
/ ye
ar.Re
habil
itatio
n se
rvice
sInp
atien
t: 30%
coins
uran
ce;
Outpa
tient:
$40 /
visit
Not C
over
edNo
ne
Habil
itatio
n ser
vices
$40 /
visit
Not C
over
edNo
neSk
illed n
ursin
g car
e30
% co
insur
ance
Not C
over
edUp
to 10
0 day
s max
imum
/ ben
efit p
eriod
.Du
rable
med
ical
equip
ment
20%
coins
uran
ce, d
educ
tible
does
not a
pply.
Not C
over
edSu
bject
to for
mular
y guid
eline
s. Re
quire
s prio
r au
thoriz
ation
.
Hosp
ice se
rvice
No C
harg
e, de
ducti
ble do
es no
t ap
ply.
Not C
over
edNo
ne
If yo
ur ch
ild n
eeds
de
ntal
or ey
e car
e
Child
ren's
eye e
xam
No C
harg
e, de
ducti
ble do
es no
t ap
ply.
Not C
over
edNo
ne
Child
ren's
glas
ses
Not C
over
edNo
t Cov
ered
None
Child
ren's
denta
l ch
eck-u
pNo
t Cov
ered
Not C
over
edNo
ne
4 of 8
https://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#copaymenthttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#home-health-carehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#rehabilitation-serviceshttps://www.healthcare.gov/sbc-glossary/#rehabilitation-serviceshttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#habilitation-serviceshttps://www.healthcare.gov/sbc-glossary/#skilled-nursing-carehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#durable-medical-equipmenthttps://www.healthcare.gov/sbc-glossary/#durable-medical-equipmenthttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#formularyhttps://www.healthcare.gov/sbc-glossary/#hospice-serviceshttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#deductible
Exclu
ded
Serv
ices &
Oth
er C
over
ed S
ervic
es:
Serv
ices Y
our P
lan G
ener
ally D
oes N
OT C
over
(Che
ck yo
ur p
olicy
or p
lan d
ocum
ent f
or m
ore i
nfor
mat
ion
and
a list
of a
ny o
ther
exclu
ded
serv
ices.)
●Ch
ildre
n's gl
asse
s●
Chiro
prac
tic ca
re●
Cosm
etic s
urge
ry●
Denta
l Car
e (Ad
ult &
Chil
d)
●He
aring
aids
●Lo
ng-te
rm ca
re●
Non-
emer
genc
y car
e whe
n tra
velin
g outs
ide
the U
.S.
●Pr
ivate-
duty
nursi
ng●
Routi
ne fo
ot ca
re●
Weig
ht los
s pro
gram
s
Othe
r Cov
ered
Ser
vices
(Lim
itatio
ns m
ay ap
ply t
o th
ese s
ervic
es. T
his i
sn’t
a com
plet
e list
. Plea
se se
e you
r plan
doc
umen
t.)●
Acup
unctu
re (p
lan pr
ovide
r refe
rred)
●Ba
riatric
surg
ery
●Inf
ertili
ty tre
atmen
t●
Routi
ne ey
e car
e (Ad
ult)
Your
Rig
hts t
o Co
ntin
ue C
over
age:
The
re ar
e age
ncies
that
can h
elp if
you w
ant to
conti
nue y
our c
over
age a
fter it
ends
. The
conta
ct inf
orma
tion f
or th
ose
agen
cies i
s sho
wn in
the c
hart
below
. Othe
r cov
erag
e opti
ons m
ay be
avail
able
to yo
u too
, inclu
ding b
uying
indiv
idual
insur
ance
cove
rage
thro
ugh t
he H
ealth
Ins
uran
ce M
arke
tplac
e. Fo
r mor
e info
rmati
on ab
out th
e Mar
ketpl
ace,
visit w
ww.H
ealth
Care
.gov o
r call
1-80
0-31
8-25
96.
Your
Grie
vanc
e and
App
eals
Righ
ts: T
here
are a
genc
ies th
at ca
n help
if yo
u hav
e a co
mplai
nt ag
ainst
your
plan
for a
denia
l of a
claim
. This
comp
laint
is ca
lled
a grie
vanc
e or a
ppea
l. For
mor
e info
rmati
on ab
out y
our r
ights,
look
at th
e exp
lanati
on of
bene
fits yo
u will
rece
ive fo
r tha
t med
ical c
laim.
You
r plan
docu
ments
also
pr
ovide
comp
lete i
nform
ation
to su
bmit a
claim
, app
eal, o
r a gr
ievan
ce fo
r any
reas
on to
your
plan
. For
mor
e info
rmati
on ab
out y
our r
ights,
this
notic
e, or
as
sistan
ce, c
ontac
t the a
genc
ies in
the c
hart
below
.Co
ntac
t Inf
orm
atio
n fo
r You
r Rig
hts t
o Co
ntin
ue C
over
age &
You
r Grie
vanc
e and
App
eals
Righ
ts:
Kaise
r Per
mane
nte M
embe
r Ser
vices
1-80
0-27
8-32
96 (T
TY: 7
11) o
r www
.kp.or
g/mem
berse
rvice
sDe
partm
ent o
f Lab
or’s
Emplo
yee B
enefi
ts Se
curity
Adm
inistr
ation
1-86
6-44
4-EB
SA (3
272)
or w
ww.do
l.gov
/ebsa
/healt
hrefo
rmDe
partm
ent o
f Hea
lth &
Hum
an S
ervic
es, C
enter
for C
onsu
mer I
nform
ation
& In
sura
nce O
versi
ght
1-87
7-26
7-23
23 x6
1565
or w
ww.cc
iio.cm
s.gov
Califo
rnia
Depa
rtmen
t of In
sura
nce
1-80
0-92
7-HE
LP (4
357)
or w
ww.in
sura
nce.c
a.gov
Califo
rnia
Depa
rtmen
t of M
anag
ed H
ealth
care
1-88
8-46
6-22
19 or
www
.healt
hhelp
.ca.go
v/
Does
this
plan
pro
vide M
inim
um E
ssen
tial C
over
age?
Yes
If you
don’t
have
Mini
mum
Esse
ntial
Cove
rage
for a
mon
th, yo
u’ll h
ave t
o mak
e a pa
ymen
t whe
n you
file y
our t
ax re
turn u
nless
you q
ualify
for a
n exe
mptio
n fro
m the
requ
ireme
nt tha
t you
have
healt
h cov
erag
e for
that
month
.
Does
this
plan
mee
t the
Min
imum
Valu
e Sta
ndar
ds?
Yes
If you
r plan
does
n’t m
eet th
e Mini
mum
Value
Stan
dard
s, yo
u may
be el
igible
for a
prem
ium ta
x cre
dit to
help
you p
ay fo
r a pl
an th
roug
h the
Mar
ketpl
ace.
5 of 8
https://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#excluded-serviceshttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#marketplacehttps://www.healthcare.gov/sbc-glossary/#marketplacehttps://www.healthcare.gov/https://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#claimhttps://www.healthcare.gov/sbc-glossary/#grievancehttps://www.healthcare.gov/sbc-glossary/#appealhttps://www.healthcare.gov/sbc-glossary/#claimhttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#claimhttps://www.healthcare.gov/sbc-glossary/#appealhttps://www.healthcare.gov/sbc-glossary/#grievancehttps://www.healthcare.gov/sbc-glossary/#planhttps://healthy.kaiserpermanente.org/health/care/consumer/locate-our-services/member-services?kp_shortcut_referrer=kp.org/memberserviceshttps://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisershttps://www.cms.gov/cciio/index.htmlhttp://www.insurance.ca.gov/http://www.healthhelp.ca.gov/https://www.healthcare.gov/sbc-glossary/#minimum-essential-coveragehttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#minimum-value-standardhttps://www.healthcare.gov/sbc-glossary/#premium-tax-creditshttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#marketplace
Lang
uage
Acc
ess S
ervic
es:
SPAN
ISH
(Esp
añol)
: Par
a obte
ner a
sisten
cia en
Esp
añol,
llame
al 1-
800-
788-
0616
(TTY
: 711
)TA
GALO
G (Ta
galog
): Ku
ng ka
ilang
an ni
nyo a
ng tu
long s
a Tag
alog t
umaw
ag sa
1-80
0-27
8-32
96 (T
TY: 7
11)
CHIN
ESE
(中文
): 如果需要中
文的帮助,请拨打这个号码
1-80
0-75
7-75
85 (T
TY: 7
11)
NAVA
JO (D
ine):
Dine
k'ehg
o shik
a at'o
hwol
ninisi
ngo,
kwiiji
go ho
lne' 1
-800
-278
-329
6 (TT
Y: 71
1)––
––––
––––
––––
––––
––––
To se
e ex
ample
s of h
ow th
is pla
n m
ight c
over
costs
for a
sam
ple m
edica
l situ
ation
, see
the
next
secti
on.––
––––
––––
––––
––––
––––
6 of 8
Abou
t the
se C
over
age E
xam
ples
:Th
is is
not a
cost
estim
ator
. Tre
atmen
ts sh
own a
re ju
st ex
ample
s of h
ow th
is pla
n migh
t cov
er m
edica
l car
e. Yo
ur ac
tual c
osts
will b
e diffe
rent
depe
nding
on th
e actu
al ca
re yo
u rec
eive,
the pr
ices y
our p
rovid
ers c
harg
e, an
d man
y othe
r fac
tors.
Focu
s on t
he co
st sh
aring
amou
nts (d
educ
tibles
, co
paym
ents
and c
oinsu
ranc
e) an
d exc
luded
servi
ces u
nder
the p
lan. U
se th
is inf
orma
tion t
o com
pare
the p
ortio
n of c
osts
you m
ight p
ay un
der d
iffere
nt he
alth p
lans.
Plea
se no
te the
se co
vera
ge ex
ample
s are
base
d on s
elf-o
nly co
vera
ge.
Peg
is Ha
ving
a Bab
y(9
mon
ths of
in-n
etwor
k pre
-nata
l car
e and
a ho
spita
l de
liver
y)
The p
lan's
over
all d
educ
tible
Spec
ialist
copa
ymen
t Ho
spita
l (fa
cility
) coi
nsur
ance
Ot
her (
bloo
d wo
rk) c
opay
men
t
$1,50
0$4
030
% $10
Th
is EX
AMPL
E ev
ent i
nclu
des s
ervic
es lik
e:Sp
ecial
ist of
fice v
isits
(pre
nata
l car
e)Ch
ildbir
th/De
liver
y Pro
fessio
nal S
ervic
esCh
ildbir
th/De
liver
y Fac
ility S
ervic
esDi
agno
stic t
ests
(ultr
asou
nds a
nd b
lood
work
)Sp
ecial
ist vi
sit (a
nesth
esia)
To
tal E
xam
ple C
ost
$12,8
00In
this e
xamp
le, P
eg w
ould
pay:
Cost
Sha
ring
Dedu
ctible
s$1
,500
Copa
ys$0
Coins
uran
ce$2
,500
Wha
t isn
't cov
ered
Limits
or ex
clusio
ns$6
0Th
e tot
al Pe
g wo
uld
pay i
s$4
,060
Mana
ging
Joe's
type
2 Di
abet
es(a
year
of ro
utine
in-n
etwor
k car
e of a
well
-contr
olled
co
nditio
n)
The p
lan's
over
all d
educ
tible
Spec
ialist
copa
ymen
t Ho
spita
l (fa
cility
) coi
nsur
ance
Ot
her (
bloo
d wo
rk) c
opay
men
t
$1,50
0$4
030
% $10
Th
is EX
AMPL
E ev
ent i
nclu
des s
ervic
es lik
e:Pr
imar
y car
e phy
sician
offic
e visi
ts (in
cludin
g dis
ease
edu
catio
n)Di
agno
stic t
ests
(bloo
d wo
rk)
Pres
cripti
on dr
ugs
Dura
ble m
edica
l equ
ipmen
t (glu
cose
met
er)
To
tal E
xam
ple C
ost
$7,40
0In
this e
xamp
le, Jo
e wou
ld pa
y:Co
st S
harin
gDe
ducti
bles
$100
Copa
ys$1
,200
Coins
uran
ce$2
00W
hat i
sn't c
over
edLim
its or
exclu
sions
$50
The t
otal
Joe w
ould
pay
is$1
,550
Mia's
Sim
ple F
ract
ure
(in-n
etwor
k eme
rgen
cy ro
om vi
sit an
d foll
ow up
care
)
The p
lan's
over
all d
educ
tible
Spec
ialist
copa
ymen
t Ho
spita
l (fa
cility
) coi
nsur
ance
Ot
her (
x-ra
y) co
paym
ent
$1,50
0$4
030
% $10
Th
is EX
AMPL
E ev
ent i
nclu
des s
ervic
es lik
e:Em
erge
ncy r
oom
care
(inclu
ding
med
ical s
uppli
es)
Dura
ble m
edica
l equ
ipmen
t (cr
utch
es)
Diag
nosti
c tes
t (x-
ray)
Reha
bilita
tion s
ervic
es (p
hysic
al th
erap
y)
To
tal E
xam
ple C
ost
$1,90
0In
this e
xamp
le, M
ia wo
uld pa
y:Co
st S
harin
gDe
ducti
bles
$1,50
0Co
pays
$200
Coins
uran
ce$1
0W
hat i
sn't c
over
edLim
its or
exclu
sions
$0Th
e tot
al Mi
a wou
ld p
ay is
$1,71
0Th
e plan
wou
ld be
resp
onsib
le for
the o
ther c
osts
of the
se E
XAMP
LE co
vere
d ser
vices
.
7 of 8
AVNET, INC.PID:232743CNTR:1EU:-1Plan ID:6354SBC ID:327428
https://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#providerhttps://www.healthcare.gov/sbc-glossary/#cost-sharinghttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#copaymenthttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#excluded-serviceshttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#specialisthttps://www.healthcare.gov/sbc-glossary/#copaymenthttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#copaymenthttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#specialisthttps://www.healthcare.gov/sbc-glossary/#copaymenthttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#copaymenthttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#specialisthttps://www.healthcare.gov/sbc-glossary/#copaymenthttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#copaymenthttps://www.healthcare.gov/sbc-glossary/#plan
This
pag
e is
inte
ntio
nally
left
blan
k.
Non
disc
rimin
atio
n N
otic
e
Kais
er P
erm
anen
te d
oes
not d
iscr
imin
ate
on th
e ba
sis
of a
ge, r
ace,
eth
nici
ty, c
olor
, nat
iona
l orig
in, c
ultu
ral b
ackg
roun
d, a
nces
try, r
elig
ion,
sex
, gen
der
iden
tity,
gen
der e
xpre
ssio
n, s
exua
l orie
ntat
ion,
mar
ital s
tatu
s, p
hysi
cal o
r men
tal d
isab
ility,
sou
rce
of p
aym
ent,
gene
tic in
form
atio
n, c
itize
nshi
p, p
rimar
y la
ngua
ge, o
r im
mig
ratio
n st
atus
.
Lang
uage
ass
ista
nce
serv
ices
are
ava
ilabl
e fro
m o
ur M
embe
r Ser
vice
s C
onta
ct C
ente
r 24
hour
s a
day,
sev
en d
ays
a w
eek
(exc
ept c
lose
d ho
liday
s).
Inte
rpre
ter s
ervi
ces,
incl
udin
g si
gn la
ngua
ge, a
re a
vaila
ble
at n
o co
st to
you
dur
ing
all h
ours
of o
pera
tion.
We
can
also
pro
vide
you
, you
r fam
ily, a
nd fr
iend
s w
ith a
ny s
peci
al a
ssis
tanc
e ne
eded
to a
cces
s ou
r fac
ilitie
s an
d se
rvic
es. I
n ad
ditio
n, y
ou m
ay re
ques
t hea
lth p
lan
mat
eria
ls tr
ansl
ated
in y
our l
angu
age,
and
m
ay a
lso
requ
est t
hese
mat
eria
ls in
larg
e te
xt o
r in
othe
r for
mat
s to
acc
omm
odat
e yo
ur n
eeds
. For
mor
e in
form
atio
n, c
all 1
-800
-464
-400
0 (T
TY u
sers
cal
l 71
1).
A gr
ieva
nce
is a
ny e
xpre
ssio
n of
dis
satis
fact
ion
expr
esse
d by
you
or y
our a
utho
rized
repr
esen
tativ
e th
roug
h th
e gr
ieva
nce
proc
ess.
For
exa
mpl
e, if
you
be
lieve
that
we
have
dis
crim
inat
ed a
gain
st y
ou, y
ou c
an fi
le a
grie
vanc
e. P
leas
e re
fer t
o yo
ur E
viden
ce o
f Cov
erag
e or
Cer
tifica
te o
f Ins
uran
ce, o
r spe
ak w
ith
a M
embe
r Ser
vice
s re
pres
enta
tive
for t
he d
ispu
te-re
solu
tion
optio
ns th
at a
pply
to y
ou. T
his
is e
spec
ially
impo
rtant
if y
ou a
re a
Med
icar
e, M
ediC
al, M
RM
IP,
Med
iCal
Acc
ess,
FEH
BP, o
r Cal
PER
S m
embe
r bec
ause
you
hav
e di
ffere
nt d
ispu
te-re
solu
tion
optio
ns a
vaila
ble.
You
may
sub
mit
a gr
ieva
nce
in th
e fo
llow
ing
way
s:
●By
com
plet
ing
a C
ompl
aint
or B
enef
it C
laim
/Req
uest
form
at a
Mem
ber S
ervi
ces
offic
e lo
cate
d at
a P
lan
Faci
lity
(ple
ase
refe
r to
Your
Gui
debo
ok fo
r ad
dres
ses)
●By
mai
ling
your
writ
ten
grie
vanc
e to
a M
embe
r Ser
vice
s of
fice
at a
Pla
n Fa
cilit
y (p
leas
e re
fer t
o Yo
ur G
uide
book
for a
ddre
sses
)
●By
cal
ling
our M
embe
r Ser
vice
Con
tact
Cen
ter t
oll f
ree
at 1
-800
-464
-400
0 (T
TY u
sers
cal
l 711
)
●By
com
plet
ing
the
grie
vanc
e fo
rm o
n ou
r web
site
at k
p.or
g
Plea
se c
all o
ur M
embe
r Ser
vice
Con
tact
Cen
ter i
f you
nee
d he
lp s
ubm
ittin
g a
grie
vanc
e.
The
Kais
er P
erm
anen
te C
ivil
Rig
hts
Coo
rdin
ator
will
be n
otifi
ed o
f all
grie
vanc
es re
late
d to
dis
crim
inat
ion
on th
e ba
sis
of ra
ce, c
olor
, nat
iona
l orig
in, s
ex, a
ge,
or d
isab
ility.
You
may
als
o co
ntac
t the
Kai
ser P
erm
anen
te C
ivil
Rig
hts
Coo
rdin
ator
dire
ctly
at O
ne K
aise
r Pla
za, 1
2th
Floo
r, Su
ite 1
223,
Oak
land
, CA
9461
2.
You
can
also
file
a c
ivil
right
s co
mpl
aint
with
the
U.S
. Dep
artm
ent o
f Hea
lth a
nd H
uman
Ser
vice
s, O
ffice
for C
ivil
Rig
hts
elec
troni
cally
thro
ugh
the
Offi
ce fo
r C
ivil
Rig
hts
Com
plai
nt P
orta
l, av
aila
ble
at o
crpo
rtal.h
hs.g
ov/o
cr/p
orta
l/lobb
y.jsf
, or b
y m
ail o
r pho
ne a
t: U
.S. D
epar
tmen
t of H
ealth
and
Hum
an S
ervi
ces,
200
In
depe
nden
ce A
venu
e SW
, Roo
m 5
09F,
HH
H B
uild
ing,
Was
hing
ton,
D.C
. 202
01, 1
-800
-368
-101
9, 1
-800
-537
-769
7 (T
DD
). C
ompl
aint
form
s ar
e av
aila
ble
at
www.
hhs.
gov/
ocr/o
ffice
/file
/inde
x.ht
ml.
https://ocrportal.hhs.gov/ocr/portal/lobby.jsfhttp://www.hhs.gov/ocr/office/file/index.html
Avis
o de
no
disc
rimin
ació
n
Kais
er P
erm
anen
te n
o di
scrim
ina
a ni
ngun
a pe
rson
a po
r su
edad
, raz
a, e
tnia
, col
or, p
aís
de o
rigen
, ant
eced
ente
s cu
ltura
les,
asc
ende
ncia
, rel
igió
n, s
exo,
id
entid
ad d
e gé
nero
, exp
resi
ón d
e gé
nero
, orie
ntac
ión
sexu
al, e
stad
o ci
vil,
disc
apac
idad
físi
ca o
men
tal,
fuen
te d
e pa
go, i
nfor
mac
ión
gené
tica,
ciu
dada
nía,
le
ngua
mat
erna
o e
stad
o m
igra
torio
.
La C
entra
l de
Llam
adas
de
Serv
icio
a lo
s M
iem
bros
brin
da s
ervi
cios
de
asis
tenc
ia c
on e
l idi
oma
las
24 h
oras
del
día
, los
sie
te d
ías
de la
sem
ana
(exc
epto
lo
s dí
as fe
stiv
os).
Se o
frece
n se
rvic
ios
de in
terp
reta
ción
sin
cos
to a
lgun
o pa
ra u
sted
dur
ante
el h
orar
io d
e at
enci
ón, i
nclu
ido
el le
ngua
je d
e se
ñas.
Tam
bién
po
dem
os o
frece
rle a
ust
ed, a
sus
fam
iliare
s y
amig
os c
ualq
uier
ayu
da e
spec
ial q
ue n
eces
iten
para
acc
eder
a n
uest
ros
cent
ros
de a
tenc
ión
y se
rvic
ios.
Ad
emás
, pue
de s
olic
itar l
os m
ater
iale
s de
l pla
n de
sal
ud tr
aduc
idos
a s
u id
iom
a, y
tam
bién
los
pued
e so
licita
r con
letra
gra
nde
o en
otro
s fo
rmat
os q
ue s
e ad
apte
n a
sus
nece
sida
des.
Par
a ob
tene
r más
info
rmac
ión,
llam
e al
1-8
00-7
88-0
616
(los
usua
rios
de la
líne
a TT
Y de
ben
llam
ar a
l 711
).
Una
que
ja e
s un
a ex
pres
ión
de in
conf
orm
idad
que
man
ifies
ta u
sted
o s
u re
pres
enta
nte
auto
rizad
o a
travé
s de
l pro
ceso
de
quej
as. P
or e
jem
plo,
si u
sted
cre
e qu
e ha
suf
rido
disc
rimin
ació
n de
nue
stra
par
te, p
uede
pre
sent
ar u
na q
ueja
. Con
sulte
su
Evid
encia
de
Cobe
rtura
(Evid
ence
of C
over
age)
o C
ertif
icado
de
Segu
ro (C
ertif
icate
of I
nsur
ance
), o
com
uníq
uese
con
un
repr
esen
tant
e de
Ser
vici
o a
los
Mie
mbr
os p
ara
cono
cer l
as o
pcio
nes
de re
solu
ción
de
disp
utas
que
le
cor
resp
onde
n. E
sto
tiene
esp
ecia
l im
porta
ncia
si e
s m
iem
bro
de M
edic
are,
Med
i-Cal
, el P
rogr
ama
de S
egur
o M
édic
o pa
ra R
iesg
os M
ayor
es (M
ajor
Ris
k M
edic
al In
sura
nce
Prog
ram
MR
MIP
), M
edi-C
al A
cces
s, e
l Pro
gram
a de
Ben
efic
ios
Méd
icos
par
a lo
s Em
plea
dos
Fede
rale
s (F
eder
al E
mpl
oyee
s H
ealth
Be
nefit
s Pr
ogra
m, F
EHBP
) o C
alPE
RS,
ya
que
disp
one
de o
tras
opci
ones
par
a re
solv
er d
ispu
tas.
Pued
e pr
esen
tar u
na q
ueja
de
las
sigu
ient
es m
aner
as:
●co
mpl
etan
do u
n fo
rmul
ario
de
quej
a o
de re
clam
ació
n/so
licitu
d de
ben
efic
ios
en u
na o
ficin
a de
Ser
vici
o a
los
Mie
mbr
os u
bica
da e
n un
cen
tro d
el p
lan
(con
sulte
las
dire
ccio
nes
en S
u G
uía)
●en
vian
do p
or c
orre
o su
que
ja p
or e
scrit
o a
una
ofic
ina
de S
ervi
cio
a lo
s M
iem
bros
en
un c
entro
del
pla
n (c
onsu
lte la
s di
recc
ione
s en
Su
Guí
a)
●lla
man
do a
la lí
nea
tele
fóni
ca g
ratu
ita d
e la
Cen
tral d
e Ll
amad
as d
e Se
rvic
io a
los
Mie
mbr
os a
l 1-8
00-7
88-0
616
(los
usua
rios
de la
líne
a TT
Y de
ben
llam
ar a
l 711
)
●co
mpl
etan
do e
l for
mul
ario
de
quej
a en
nue
stro
siti
o w
eb e
n kp
.org
Llam
e a
nues
tra C
entra
l de
Llam
adas
de
Serv
icio
a lo
s M
iem
bros
si n
eces
ita a
yuda
par
a pr
esen
tar u
na q
ueja
.
Se le
info
rmar
á al
coo
rdin
ador
de
dere
chos
civ
iles
de K
aise
r Per
man
ente
(Civ
il R
ight
s C
oord
inat
or) d
e to
das
las
quej
as re
laci
onad
as c
on la
dis
crim
inac
ión
por m
otiv
os d
e ra
za, c
olor
, paí
s de
orig
en, g
éner
o, e
dad
o di
scap
acid
ad. T
ambi
én p
uede
com
unic
arse
dire
ctam
ente
con
el c
oord
inad
or d
e de
rech
os c
ivile
s de
Kai
ser P
erm
anen
te e
n O
ne K
aise
r Pla
za, 1
2th
Floo
r, Su
ite 1
223,
Oak
land
, CA
9461
2.
Tam
bién
pue
de p
rese
ntar
una
que
ja fo
rmal
de
dere
chos
civ
iles
de fo
rma
elec
tróni
ca a
nte
la O
ficin
a de
Der
echo
s C
ivile
s (O
ffice
for C
ivil
Rig
hts)
en
el
Dep
arta
men
to d
e Sa
lud
y Se
rvic
ios
Hum
anos
de
los
Esta
dos
Uni
dos
(U.S
. Dep
artm
ent o
f Hea
lth a
nd H
uman
Ser
vice
s) m
edia
nte
el p
orta
l de
quej
as fo
rmal
es
de la
Ofic
ina
de D
erec
hos
Civ
il es
(Offi
ce fo
r Civ
il R
ight
s C
ompl
aint
Por
tal),
en
ocrp
orta
l.hhs
.gov
/ocr
/por
tal/lo
bby.
jfs (e
n in
glés
) o p
or c
orre
o po
stal
o p
or
telé
fono
a: U
.S. D
epar
tmen
t of H
ealth
and
Hum
an S
ervi
ces,
200
Inde
pend
ence
Ave
nue
SW, R
oom
509
F, H
HH
Bui
ldin
g, W
ashi
ngto
n, D
.C. 2
0201
, 1-
800-
368-
1019
, 1-8
00-5
37-7
697
(líne
a TD
D).
Los
form
ular
ios
de q
ueja
form
al e
stán
dis
poni
bles
en
hhs.
gov/
ocr/o
ffice
/file
/inde
x.ht
ml (
en in
glés
).
https://ocrportal.hhs.gov/ocr/portal/lobby.jfshttp://www.hhs.gov/ocr/office/file/index.html
無歧
視公
告
Kais
er P
erm
anen
te禁
止以
年齡
、人
種、
族裔
、膚
色、
原國
籍、
文化
背景
、血
統、
宗教
、性
別、
性別
認同
、性
別表
達、
性取
向、
婚姻
狀況
、生
理或
心理
殘障
、付
款來
源、
遺傳
資訊
、公
民身
份、
主要
語言
或移
民身
份為
由而
歧視
任何
人。
會員
服務
聯絡
中心
每週
七天
24小
時提
供語
言協
助服
務(
節假
日除
外)
。本
機構
在全
部營
業時
間內
免費
為您
提供
口譯
,包
括手
語服
務。
我們
還可
為您
和您
的親
友提
供使
用本
機構
設施
與服
務所
需要
的任
何特
別協
助。
此外
,您
還可
索取
翻譯
成您
的語
言的
健康
保險
計劃
資料
,以
及採
用大
號字
體或
其他
格式
的版
本來
滿足
您的
需求
。若
需更
多資
訊,
請致
電1-
800-
757-
7585
(TT
Y專
線使
用者
請撥
711)
。
投訴
指任
何您
或您
的授
權代
表透
過流
程來
表達
不滿
的做
法。
例如
,如
果您
認為
自己
受到
歧視
,即
可提
出投
訴。
若需
瞭解
適用
於自
己的
爭議
解決
選項
,請
參閱
《承
保範
圍說
明書
》(
Evi
denc
e of
Cov
erag
e)或
《保
險證
明書
》(
Cer
tific
ate
of In
sura
nce)
,或
咨詢
會員
服務
代表
。如
果您
是 M
edic
are、
Med
iCal
、M
RM
IP
(M
ajor
Ris
k M
edic
al In
sura
nce
Prog
ram
,高風
險醫
療保
險計
劃 )
、M
ediC
al A
cces
s、FE
HBP
(Fe
dera
l Em
ploy
ees
Hea
lth B
enef
its P
rogr
am, 聯
邦僱
員健
康保
險計
劃)
或C
alPE
RS
會員
,向
會員
服務
代表
咨詢
尤其
重要
,因
為您
可能
會有
不同
的爭
議解
決方
式選
擇。
您可
透過
以下
途徑
投訴
:
●在
健康
保險
計劃
服務
設施
的會
員服
務處
填寫
《投
訴或
福利
索賠
/申請
表》
,地
址見
《健
康服
務指
南》
(You
r Gui
debo
ok)。
●將
書面
投訴
信郵
寄到
健康
保險
計劃
計劃
服務
設施
的會
員服
務處
(地
址見
《健
康服
務指
南》
(You
r Gui
debo
ok)。
●給
我們
的會
員服
務聯
絡中
心打
免費
電話
,電
話號
碼是
1-80
0-75
7-75
85(
TTY
專線
使用
者請
撥71
1)。
●在
我們
的網
站上
填寫
投訴
表,
網址
是kp
.org
如果
您在
投訴
時需
要協
助,
請致
電我
們的
會員
服務
聯絡
中心
。
涉及
人種
、膚
色、
原國
籍、
性別
、年
齡或
殘障
歧視
的一
切申
訴都
將通
知 K
aise
r Per
man
ente
的 民
權事
務協
調員
(C
ivil
Rig
hts
Coo
rdin
ator
)。
您也
可與
Kais
er
Perm
anen
te的
民權
事務
協調
員 直
接聯
絡,
地址
:O
ne K
aise
r Pla
za, 1
2th
Floo
r, Su
ite 1
223,
Oak
land
, CA
9461
2。
您還
可以
電子
方式
透過
民權
辦公
室的
投訴
入口
網站
向美
國健
康與
公共
服務
部民
權辦
公室
(U
.S. D
epar
tmen
t of H
ealth
and
Hum
an S
ervi
ces,
Offi
ce fo
r Civ
il R
ight
s)提
出民
權投
訴,
網址
是 o
crpo
rtal.h
hs.g
ov/o
cr/p
orta
l/lob
by.js
f 或者
按照
如下
資訊
採用
郵寄
或電
話方
式聯
絡:
U.S
. Dep
artm
ent o
f Hea
lth a
nd H
uman
Se
rvic
es, 2
00 In
depe
nden
ce A
venu
e SW
, Roo
m 5
09F,
HH
H B
uild
ing,
Was
hing
ton,
D.C
. 202
01, 1
-800
-368
-101
9, 1
-800
-537
-769
7(TD
D專
線)
。投
訴表
可從
網站
hhs
.gov
/ocr
/offi
ce/fi
le/in
dex.
htm
l下載
。
https://ocrportal.hhs.gov/ocr/portal/lobby.jsfhttps://hhs.gov/ocr/office/file/index.html
NO
TIC
E O
F LA
NG
UA
GE
ASS
ISTA
NC
E
Engl
ish:
Thi
s is
impo
rtant
info
rmat
ion
from
Kai
ser P
erm
anen
te. I
f you
nee
d he
lp
unde
rsta
ndin
g th
is in
form
atio
n, p
leas
e ca
ll 1-
800-
464-
4000
and
ask
for l
angu
age
assi
stan
ce. H
elp
is a
vaila
ble
24 h
ours
a d
ay, 7
day
s a
wee
k, e
xclu
ding
hol
iday
s.A
rabi
c :
ويحتت
هذه
يقةلوثا
لىع
تومامعل
مةمه
من
Kais
er P
erm
anen
te.
إذاتكن
جةحاب
عدةساللم
في
همف
هذه
ت،ومامعلال
جىير
الصلاتا
لىع
رقمال
1-
800-
464-
4000
بطلو
عدةسام
ويةلغ
.عدةساالم
رةوفمت
لىع
ارمد
عةساال
يلةط
يامأ
ع،سبو
الأ
ناءستثبا
يامأ
تطلا
الع
ميةرسال
.
Arm
enia
n: Ս
ա կ
արև
որ տ
եղեկ
ությ
ուն
է «K
aise
r Per
man
ente
»-ից
: Եթե
այս
տեղ
եկու
թյու
նը հ
ասկ
անա
լու հ
ամա
ր Ձե
զ օգ
նութ
յուն
է հ
արկ
ավո
ր, խ
նդրո
ւմ
ենք
զանգ
ահա
րել 1
-800
-464
-400
0 հե
ռախ
ոսա
համա
րով
և օժ
անդ
ակո
ւթյո
ւն ս
տա
նալ լ
եզվի
հա
րցու
մ: Զ
անգ
ահա
րեք
օրը
24 ժ
ամ,
շա
բաթը
7 օ
ր` բ
ացի
տոն
օր
երից
:
Chi
nese
: 這是
來自
Kais
er P
erm
anen
te的
重要
資訊
。如
果您
需要
協助
瞭解
此資
訊,
請致
電1-
800-
757-
7585
尋求
語言
協助
。我
們每
週7
天,
每天
24小
時皆
提供
協助
(節
假日
休息
)。
Fars
i :
ينا
تعاطلا
ا
میمه
از
ویس
Ka
iser
Per
man
ente
می
شدبا
.گرا
در
دنهميف
ينا
تعاطلا
ا به
ککم
ازني
يد،ارد
ً طفال
با رهشما
1-
800-
464-
4000
ستما
فتهگر
و ایبر
دادام
نیزبا
تاسخودر
نيدک
.ککم
و
يینماراه
در
24 تاعس
وزنرشبا
7 و وزر
ه،هفت
ملشا
ایزهرو
يلعطت
ودوجم
تاس
.
Hin
di: य
ह Ka
iser
Per
man
ente क
ी ओर से
महत्वपरू
्ण सचून
ा है। य
दि आपक
ो इस
सचूना क
ो समझ
ने के
लिए मि
ि की
जरूरत है,
तो कृ
पया 1
-800
-464
-400
0 पर
फोन
करें औ
र भाषा
सहायता के
लिए पछू
ें। सह
ायता छु
ट्टियों क
ो छोड़क
र, सप्ताह के
सातों दि
न, दि
न के
24 घंिे,
उपिब्ध है।
Hm
ong:
Qho
v xo
v xw
m n
o ts
eem
cee
b lo
s nt
awm
Kai
ser P
erm
anen
te. Y
og k
oj x
av ta
u ke
v pa
b ko
m n
kag
siab
cov
xov
xw
m n
o, th
ov h
u ra
u 1-
800-
464-
4000
th
iab
thov
kev
pab
txha
is lu
s. M
uaj k
ev p
ab 2
4 te
ev ib
hnu
b tw
g, 7
hnu
b ib
lim
tiam
twg,
tsis
xam
cov
hnu
b ca
iv.
Japa
nese
: Kai
ser P
erm
anen
teから重要なお知らせがあります。この情報を理解するためにヘルプが必要
な場合は、 1-
800-
464-
4000
に電話して、言語サー
ビス
を依頼してください。このサービスは年中無休(祝祭日を除く)でご利用いただけます。
Khm
er:នេ
ះគឺជាព័ត
៌មាេស
ំខាេ់ មក
ពី Ka
iser
Per
man
ente។ នបសសនេ្ន
កករតវការជំំេយយ
ឲ្យបា
េយល់ដឹង
ព័ត៌មាេនេះ
សូមទ
ូជស័ព្ទនៅនល
ខ 1-
800-
464-
4000
េនងនសកសសំំំំេ
យយខាង
ភាសា
។ ំំេ
យយគឺមា
េ 24
នមា្ងម
យយ្ងៃងៃ 7 ្ងៃងៃមយយ
អាទនត
្យ ជយមទាំង្ងៃងៃប
ំណ្យផង។
Kor
ean:
본 정
보는
Kai
ser P
erm
anen
te 에
서 전
하는
중요
한 메
시지
입니
다. 본
정보
를 이
해하
는 데
도움
이 필
요하
시면
, 1-
800-
464-
4000
번으
로 전
화해
언어
지원
서비
스를
요청
하십
시오
. 요
일 및
시간
에 관
계없
이 언
제든
지 도
움을
제공
해 드
립니
다(공
휴일
제외
).
Laot
ian:
ນີແ້ມ
ນ່ຂໍມ້ນູ
ສຳໍຄນັ
ຈຳກ
Kais
er P
erm
anen
te. ຖ
ຳ້ວຳ່ ທຳ່
ນຕອ້ງ
ກຳນຄ
ວຳມຊ
ວ່ຍເຫືຼອໃນກ
ຳນຊວ່
ຍໃຫເ້ຂ້ົຳໃຈຂ ໍມ້
ນູນີ,້ ກ
ະຣນຸຳໂທ
ຣ 1-
800-
464-
4000
ແລະ
ຂ ໍເອົຳກຳນ
ຊວ່ຍເຫືຼອ
ດຳ້ນພ
ຳສຳ.
ກຳນຊ
ວ່ຍເຫືຼອມ
ໃີຫຕ້ະ
ຫຼອດ
24 ຊ
ົ່ ວໂມງ
, 7 ວນັຕ່ໍ
ອຳທິດ
, ບ່ໍລວ
ມວນັພ
ກັຕຳ່ງໆ.
Nav
ajo:
D77
47 h
ane’
b7h
0ln7
ihii
1t’4
ego
Kais
er P
erm
anen
te y
ee n
ihal
ne’.
D77
hane
’7g77
doo
hazh
0’0
bik’
i’diit
88hg0
0 t’1
1 sh
--d7
koj
i’ ho
d77ln
ih 1
-800
-464
-400
0 1k
o sa
ad
bee
1k1
i’iily
eed
y7d7
7ki[.
Kw
e’4
1k1
an1’
1lw
o’ t’
11 1
[ahj
8’ na
adiin
d99’
ah44
’7lki
dg00
d00
tsos
ts’id
j9 2
2’1t
’4. D
ahod
7lzin
g0ne
’ 47 d
1’de
elka
al.
Punj
abi: ਇਹ
Kai
ser P
erm
anen
te ਵਲੋਂ ਜ਼ਰੂਰੀ
ਜਾਣਕਾਰੀ
ਹੈ। ਜੇ ਤੁਹਾਨੰੂ ਇਸ
ਜਾਣਕਾਰੀ
ਨੰੂ ਸਮਝਣ ਲਈ
ਮਦਦ
ਦੀ ਲੋੜ ਹੈ,
ਤਾਂ ਕਕ
ਰਪਾ ਕਰਕੇ 1
-800
-464
-400
0 'ਤੇ ਫ਼ੋਨ ਕਰੋ ਅਤੇ ਭਾਸ਼ਾ
ਸਹਾਇਤਾ
ਲਈ ਪੁੱਛੋ। ਮਦਦ
, ਛੁੱਟੀਆਂ ਨੰੂ
ਛੱਡ ਕੇ,
ਹਫ਼ਤੇ ਦੇ 7
ਕਦਨ,
ਅਤੇ ਕਦਨ ਦੇ
24 ਘੰਟੇ ਮੌਜੂਦ ਹੈ।
Rus
sian
: Это
важ
ная
инф
орм
ация
от
Kais
er P
erm
anen
te. Е
сли
Вам
тре
бует
ся п
омощ
ь, ч
тобы
пон
ять
эту
инф
орм
ацию
, поз
вони
те п
о но
мер
у 1-
800-
464-
4000
и п
опро
сите
пре
дост
авит
ь Ва
м у
слуг
и пе
рево
дчик
а. П
омощ
ь до
ступ
на 2
4 ча
са в
сут
ки, 7
дне
й в
неде
лю, к
ром
е пр
аздн
ичны
х дн
ей.
Span
ish:
La
pres
ente
incl
uye
info
rmac
ión
impo
rtant
e de
Kai
ser P
erm
anen
te. S
i nec
esita
ayu
da p
ara
ente
nder
est
a in
form
ació
n, ll
ame
al 1
-800
-788
-061
6 y
pida
ayu
da li
nguí
stic
a. H
ay a
yuda
dis
poni
ble
24 h
oras
al d
ía, s
iete
día
s a
la s
eman
a, e
xclu
idos
los
días
fest
ivos
.
Taga
log:
Ito
ay im
porta
nten
g im
porm
asyo
n m
ula
sa K
aise
r Per
man
ente
. Kun
g ka
ilang
an n
inyo
ng
tulo
ng p
ara
mau
naw
an a
ng im
porm
asyo
ng it
o, m
angy
arin
g tu
maw
ag s
a 1-
800-
464-
4000
at h
umin
gi n
g tu
long
kau
gnay
sa
leng
guw
ahe.
May
mak
ukuh
ang
tulo
ng 2
4 na
ora
s ba
wat
ara
w, 7
ara
w b
awat
ling
go, m
alib
an
sa m
ga a
raw
na
pist
a op
isya
l.
Thai
: นีเ่ป็นขอ้มลูสําคญัจาก
Kais
er P
erm
anen
te หากคณุ
ตอ้งการความชว่ยเหลอืในการทําความเขา้ใจขอ้มลูนี ้กรณุาโทรไปยงัหมายเลข
1-80
0-46
4-40
00 เพือ่ขอความชว่ย
เหลอืดา้นภาษา สามารถโทรตดิตอ่ไดต้ลอด
24 ชั ว่โมงทกุวนั
ยกเวน้วนัหยดุเทศกาล.
Viet
nam
ese:
Đây
là th
ông
tin q
uan
trọng
từ K
aise
r Per
man
ente
. Nếu
quý
vị c
ần đ
ược
giúp
đỡ
để h
iểu
rõ th
ông
tin n
ày, v
ui lò
ng g
ọi s
ố 1-
800-
464-
4000
và
yêu
cầu
được
cấp
dịc
h vụ
về
ngôn
ngữ
. Quý
vị s
ẽ đư
ợc g
iúp
đỡ 2
4 gi
ờ tro
ng n
gày,
7 n
gày
trong
tuần
, trừ
ngà
y lễ
.
This
pag
e is
inte
ntio
nally
left
blan
k.
Recipient 5 SBC_GRP_6550846_5Summary of Benefits and Coverage Letter in English1557 Notice of Non-Discrimination