Kaiser Permanente: KP Select CO Silver 2000/30
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: Beginning on or after 01/01/2017
Coverage for: Individual/Family | Plan Type: HMO
This is only
a summary.
If you
Kaiser Permanente:
KP Select
CO Silver 2000/30
want more detail about your coverage and costs, you can get the complete terms in the policy or plan
document at www.kp.org/plandocuments or by calling 1-855-249-5005.
Coverage Period: Beginning on or after 01/01/2017
Important Questions
Answers
$2,000 person/$4,000 family
Summary of Benefits and Coverage: What this plan covers and what it costs.
Coverage for: Individual/Family
Why this Matters:
You must pay all the costs up to the deductible amount before this plan begins
to pay for covered services you use. Check your policy or plan document to see
when the deductible starts over (usually, but not always, January 1st). See the
chart starting on page 2 for how much you pay for covered services after you
meet the deductible.
deductible?
Plan
type: HMO
What is the overall
Does not apply to Preventive services and
prescription drugs do not count toward the
deductible.
Are there other
deductibles for specific
services?
Yes. Prescription Drugs: $500 person in
network. Pediatric Dental: $50 person in
network. There are no other specific
deductibles.
You must pay all of the costs for these services up to the specific deductible
amount before this plan begins to pay for these services.
Is there an out–of–
pocket limit on my
expenses?
Yes. For Plan Provider $7,150 person /
$14,300 family
The out-of-pocket limit is the most you could pay during a coverage period
(usually one year) for your share of the cost of covered services. This limit helps
you plan for health care expenses.
What is not included in Premiums, balanced-billed charges and
the out–of–pocket
health care this plan doesn't cover.
limit?
Even though you pay these expenses, they don't count toward the out-of-pocket
limit.
Is there an overall
annual limit on what
the plan pays?
No.
The chart starting on page 2 describes any limits on what the plan will pay for
specific covered services, such as office visits.
Does this plan use a
network of providers?
Yes. For a list of preferred providers, see
www.kp.org or call 1-855-249-5005.
If you use an in-network doctor or other health care provider, this plan will pay
some or all of the costs of covered services. Be aware, your in-network doctor or
hospital may use an out-of-network provider for some services. Plans use the
term in-network, preferred, or participating for providers in their network. See
the chart starting on page 2 for how this plan pays different kinds of
providers.
Do I need a referral to
see a specialist?
No.
You can see the specialist you choose without permission from this plan.
Are there services this
plan doesn’t cover?
Yes.
Some of the services this plan doesn’t cover are listed on page 6. See your
policy or plan document for additional information about excluded services.
Questions: Call 1-855-249-5005 or Colorado Springs: 711 Denver/Boulder: 711 (TTY) or visit us at www.kp.org. If you aren’t
clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call
1-855-249-5005 or Colorado Springs: 711 Denver/Boulder: 711 (TTY) to request a copy.
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● Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
● Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if
the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if
you haven’t met your deductible.
● The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the
allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and
the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
● This plan may encourage you to use preferred providers by charging you lower deductibles, copayments and coinsurance amounts.
Common
Medical Event
cost if you use a Your cost if you use a
Services You May Need YourPlan
Provider
Non-Plan Provider
Visit 1 No Charge. Visit 2
thereafter $30 copay
Primary care visit to treat an and
per
visit.
(30% coinsurance Not Covered
injury or illness
for covered services
received during a visit)
If you visit a health
Specialist visit
care provider’s
office or clinic
If you have a test
$50 Copay (30%
coinsurance for covered
services received during a
visit.)
Limitations & Exceptions
Visit 1 (can be Primary Care, Mental Health
or Substance Abuse Disorder) not subject to
the deductible. Visit 2 and thereafter, copay
not subject to the deductible.
Not Covered
Copay not subject to the deductible.
Other practitioner office visit $30 Copay
Not Covered
Coverage is limited to 20 visits per year for
chiropractic care. Copay not subject to the
deductible.
Preventive care/screening/
immunization
No Charge
Not Covered
Not subject to the deductible.
Diagnostic test (x-ray, blood
work)
30% Coinsurance
Not Covered
–––––––––––none–––––––––––
Imaging (CT/PET scans,
MRIs)
30% Coinsurance
Not Covered
–––––––––––none–––––––––––
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Common
Medical Event
cost if you use a
Services You May Need YourPlan
Provider
If you need drugs
to treat your illness Generic drugs
or condition
More information
about prescription
drug coverage is
available at
www.kp.org/
formulary .
Preferred brand drugs
Retail: $55 Copay; Mail
Order: $110 Copay
Not Covered
Subject to formulary guidelines.
Non-preferred brand drugs
30% Coinsurance
Not Covered
Must be authorized through the nonpreferred drug process.
Specialty drugs
30% Coinsurance
Not Covered
Not subject to the "overall" deductible.
Subject to formulary guidelines.
30% Coinsurance
Not Covered
–––––––––––none–––––––––––
30% Coinsurance
Not Covered
–––––––––––none–––––––––––
30% Coinsurance
30% Coinsurance
–––––––––––none–––––––––––
30% Coinsurance
30% Coinsurance
–––––––––––none–––––––––––
$75 Copay (30%
coinsurance for covered
services received during a
visit.)
$75 Copay (30%
coinsurance for covered
services received during a
visit.)
Non-Plan Providers: only covered if you are
out of the service area. Copay not subject to
the deductible.
Facility fee (e.g., hospital
room)
30% Coinsurance
Not Covered
–––––––––––none–––––––––––
Physician/surgeon fee
30% Coinsurance
Not Covered
–––––––––––none–––––––––––
Facility fee (e.g., ambulatory
If you have
surgery center)
outpatient surgery
Physician/surgeon fees
Emergency room services
Emergency medical
If you need
transportation
immediate medical
attention
Urgent care
If you have a
hospital stay
Retail: $15 Copay; Mail
Order: $30 Copay
Your cost if you use a Limitations & Exceptions
Non-Plan Provider
Subject to formulary guidelines. Federally
mandated over the counter items are
covered with a prescription when filled at a
Kaiser Permanente pharmacy. For Southern
Colorado members: Prescriptions for second
Not Covered
and on-going maintenance medications must
be filled at a Pharmacy in a Kaiser
Permanente medical office or through
Kaiser Permanente mail order. Not subject
to pharmacy deductible.
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Common
Medical Event
cost if you use a Your cost if you use a
Services You May Need YourPlan
Provider
Non-Plan Provider
Visit 1 No Charge. Visit 2
and thereafter $30 per visit.
Mental/Behavioral health
(30% coinsurance for
Not Covered
outpatient services
covered services received
during a visit)
If you have mental Mental/Behavioral health
health, behavioral inpatient services
health, or
substance abuse
needs
Substance use disorder
outpatient services
30% Coinsurance
Not Covered
Limitations & Exceptions
Visit 1 (can be Primary Care, Mental Health
or Substance Abuse Disorder) not subject to
the deductible. Visit 2 and thereafter, copay
not subject to the deductible. Group visit
50% of individual visit copay.
–––––––––––none–––––––––––
Visit 1 No Charge. Visit 2
and thereafter $30 per visit.
(30% coinsurance for
Not Covered
covered services received
during a visit)
Visit 1 (can be Primary Care, Mental Health
or Substance Abuse Disorder) not subject to
the deductible. Visit 2 and thereafter, copay
not subject to the deductible. Group visit
50% of individual visit copay
Substance use disorder
inpatient services
30% Coinsurance
Not Covered
–––––––––––none–––––––––––
Prenatal and postnatal care
30% Coinsurance
Not Covered
After confirmation of pregnancy, for the
normal series of regularly scheduled routine
visits.
Delivery and all inpatient
services
30% Coinsurance
Not Covered
–––––––––––none–––––––––––
If you are pregnant
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Common
Medical Event
cost if you use a
Services You May Need YourPlan
Provider
Home health care
Rehabilitation services
If you need help
recovering or have
other special
Habilitation services
health needs
Skilled nursing care
30% Coinsurance
Your cost if you use a Limitations & Exceptions
Non-Plan Provider
Limited to less than 8 hours per day and 28
Not Covered
hours per week.
Not Covered
Inpatient: Multi-disciplinary facility limited
to 60 days per condition per year ;
Outpatient: Outpatient visits limited to 20
visits per therapy per year (autism spectrum
disorders are not subject to the visit limit);
copay not subject to the deductible.
$30 Copay
Not Covered
Outpatient visits limited to 20 visits per
therapy per year (autism spectrum disorders
are not subject to the visit limit); copay not
subject to the deductible.
30% Coinsurance
Not Covered
Limited to 100 days per year.
Inpatient: 30%
Coinsurance; Outpatient:
$30 Copay
Durable medical equipment
30% Coinsurance
Not Covered
Prosthetic arms and legs at 20%
coinsurance; not subject to the deductible.
Coverage is limited to items on our DME
formulary.
Hospice service
No Charge
Not Covered
Not subject to deductible
Eye exam
$30 Copay (30%
coinsurance for covered
services received during a
visit.)
Not Covered
Limited to members up to the end of the
month the member turns 19. Copay not
subject to the deductible. For services with
an ophthalmologist see "Specialist visit".
Not Covered
1 pair of glasses & lenses every 2 years or 2
year supply of contact lenses; not subject to
the deductible. Limited to members up to
the end of the month in which the member
turns 19.
If your child needs Glasses
dental or eye care
Dental check-up
50% Coinsurance
No Charge for preventive/
diagnostic services. 50%
Not Covered
coinsurance for basic/
major services.
Limited to members up to the end of the
month the member turns 19; limited
coverage for diagnostic and preventive
services, minor restorative (fillings), simple
extractions and crowns.
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Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
● Acupuncture
● Cosmetic Surgery
● Long-Term/Custodial Nursing Home Care
● Non-Emergency Care when Traveling
Outside the U.S.
● Routine Dental Services (Adult)
● Routine Eye Exam (Adult)
● Routine Foot Care
● Weight Loss Programs
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these
services.)
● Bariatric Surgery
● Chiropractic Care
● Hearing Aids with limits
● Infertility Treatment
● Private-Duty Nursing
● Routine Hearing Tests
● Voluntary Termination of Pregnancy
Your Rights to Continue Coverage:
Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are
exceptions, however, such as if:
● You commit fraud
● The insurer stops offering services in the State
● You move outside the coverage area
For more information on your rights to continue coverage, contact the insurer at 1-855-249-5005. You may also contact your state insurance department at
303-894-7490 (in-state, toll-free: 1-800-930-3745.
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: 1-855-249-5005
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.
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Language Access Services:
SPANISH (Español): Para obtener asistencia en Español, llame al 1-855-249-5005 or TTY/TDD Colorado Springs: 711 Denver/Boulder: 711.
TAGALOG (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-855-249-5005 or TTY/TDD Colorado Springs: 711 Denver/Boulder:
711.
CHINESE (中文): 如果需要中文的帮助，请拨打这个号码 1-855-249-5005 or TTY/TDD Colorado Springs: 711 Denver/Boulder: 711.
NAVAJO (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-855-249-5005 or TTY/TDD Colorado Springs: 711 Denver/Boulder: 711.
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––
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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
Managing type 2 diabetes
(normal delivery)
(routine maintenance of a well-controlled
condition)
Amount owed to providers: $7,540
Plan pays $3,720
Patient pays $3,820
Amount owed to providers: $5,400
Plan pays $4,060
Patient pays $1,340
Sample care costs:
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive
Total
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
Patient Pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$2000
$20
$1600
$200
$3,820
Sample care costs:
Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
Total
$2,900
$1,300
$700
$300
$100
$100
$5,400
Patient Pays:
Deductibles
$100
Copays
$900
Coinsurance
$300
Limits or exclusions
$40
Total
$1,340
Note: These numbers assume the patient is
participating in our diabetes wellness program. If
you have diabetes and do not participate in the
wellness program, your costs may be higher. For
more information about the diabetes wellness
program, please contact 1-855-249-5005,
TTY/TDD Colorado Springs: 711 Denver/
Boulder: 711.
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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
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 innetwork providers. If the patient had
received care from out-of-network
providers, costs would have been
higher.
What does a Coverage Example
show?
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.
Does the Coverage Example
predict my own care needs?
No. Treatments shown are just examples.
The care you would receive for this condition
could be different based on your doctor’s
advice, your age, how serious your condition
is, and many other factors.
Does the Coverage Example
predict my future expenses?
No. Coverage Examples are not cost
estimators. You can’t use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your own
costs will be different depending on the care
you receive, the prices your providers charge,
and the reimbursement your health plan
allows.
Can I use Coverage Examples to
compare plans?
Yes. When you look at the Summary of
Benefits and Coverage for other plans, you’ll
find the same Coverage Examples. When you
compare plans, check the “Patient Pays” box
in each example. The smaller that number,
the more coverage the plan provides.
Are there other costs I should
consider when comparing plans?
Yes. An important cost is the premium you
pay. Generally, the lower your premium, the
more you’ll pay in out-of-pocket costs, such
as copayments, deductibles, and
coinsurance. You should also consider
contributions to accounts such as health
savings accounts (HSAs), flexible spending
arrangements (FSAs) or health
reimbursement accounts (HRAs) that help
you pay out-of-pocket expenses.
Questions: Call 1-855-249-5005 or Colorado Springs: 711 Denver/Boulder: 711 (TTY), or visit us at www.kp.org. If you aren’t clear about any of the
Questions: Call 1-855-249-5005 or (TTY) or visit us at www.kp.org. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can
underlined terms used in this form, see the Glossary. You can view the Glossary at www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call
view the Glossary
at www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf,
or call
1-855-249-5005 or (TTY) to request a copy.
1-855-249-5005
or Colorado
Springs: 711 Denver/Boulder: 711 (TTY) to request
a copy.
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of
Colorado Supplement to the Summary of Benefits and Coverage Form
Kaiser Foundation Health Plan of Colorado
Name of Carrier
KP Select CO Silver 2000/30
Name of Plan
Individual Policy
Policy Type
TYPE OF COVERAGE
1. Type of plan. ₁
Health maintenance organization (HMO)
2. Out-of-network care covered?
Only for emergency care
3. Areas of Colorado where plan is
available.
Plan is available only in the following counties as determined by zip code:
1. For Denver/Boulder service area: Adams, Arapahoe, Boulder, Broomfield, Clear Creek, Denver, Douglas, Elbert,
Gilpin, Jefferson, Larimer, Park and Weld;
2. For Southern Colorado: Crowley, Custer, Douglas, El Paso, Elbert, Fremont, Huerfano, Las Animas, Lincoln, Otero,
Park, Pueblo and Teller;
3. For Southern Colorado KP Select Plan: Douglas, El Paso, Elbert, Fremont, Lincoln, Park, Pueblo and Teller;
4. For Northern Colorado: Adams, Larimer, Morgan, and Weld;
5. For Mountain Colorado: Eagle, Summit, Garfield, Grand and Routt.
SUPPLEMENTAL INFORMATION REGARDING BENEFITS
Important Note: The contents of this form are subject to the provisions of the policy, which contains all terms, covenants and conditions of coverage. It provides
additional information meant to supplement the Summary of Benefits of Coverage you have received for this plan. This plan may exclude coverage for certain
treatments, diagnoses, or services not specifically noted. Consult the actual policy to determine the exact terms and conditions of coverage.
Description
What this means.
4. Deductible Period
5. Annual Deductible Type
6. What cancer screenings are
covered?
Calendar year
Calendar year deductibles restart each January 1.
Single Coverage /
Non-single Coverage
“Single” means the deductible amount you will have to pay for allowable covered expenses when you
are the only individual covered by the plan. “Non-single” is the deductible amount that must be met by
one or more family members before any covered expenses are paid. It may be an aggregated amount
(e.g., “$3,000 per family”) or specified as the number of individual deductibles that must be met (e.g., “3
deductibles per family”).
Breast Cancer (clinical breast exam, mammogram, genetic testing for inherited susceptibility for breast cancer); Colon and
Rectal Cancer (fecal occult blood test (FIT), flexible sigmoidoscopy, barium enema, colonoscopy); Cervical Cancer (pap test);
Prostate Cancer (digital rectal exam, serum prostatic specific antigen (PSA)
LIMITATIONS AND EXCLUSIONS
7. Period during which pre-existing
conditions are not covered for covered
persons age 19 and older. ₂
8. How does the policy define a “preexisting condition”?
Not applicable; plan does not impose limitation periods for pre-existing conditions.
Not applicable. Plan does not exclude coverage for pre-existing conditions.
9. Exclusionary Riders. Can an individual’s
specific, pre-existing condition be entirely
excluded from the policy?
No
USING THE PLAN
IN-NETWORK
OUT-OF-NETWORK
No
Yes, members are responsible for any amounts over usual,
reasonable and customary charges when receiving Emergency
Services and Non-Emergency, Non-Routine Care.
10. If the provider charges more for a covered service than the plan
normally pays, does the enrollee have to pay the difference?
11. Does the plan have a binding arbitration clause?
Yes
Asistencia en español
Para obtener esta información escrita en español o para servicios de interpretación, llame al 1-855-249-5005; para TTY/TDD Colorado Springs: 711; Denver/Boulder:
1- 303-338-3820 or 711
Questions: Call 1-855-249-5005 (TTY 711) or visit us at www.kp.org.
If you are not satisfied with the resolution of your complaint or grievance, contact:
Colorado Division of Insurance
Consumer Affairs Section
1560 Broadway, Suite 850, Denver, CO 80202
Call: 303-894-7490 (in-state, toll-free: 800-930-3745)
Email: [email protected]
Endnotes
1. “Network” refers to a specified group of physicians, hospitals, medical clinics and other health care providers that this pla n may require you to use in order for
you to get any coverage at all under the plan, or that the plan may encourage you to use because it may pay more of your bill if you use their network
providers (i.e., go in-network) than if you don’t (i.e., go out-of-network).
2. Waiver of pre-existing condition exclusions. State law requires carriers to waive some or all of the pre-existing condition exclusion period based on other
coverage you recently may have had. Ask your carrier or plan sponsor (e.g., employer) for details.
Kaiser Foundation Health Plan of Colorado (Kaiser Health Plan) complies with applicable federal civil rights laws and does not discriminate on the
basis of race, color, national origin, age, disability, or sex. Kaiser Health Plan does not exclude people or treat them differently because of race,
color, national origin, age, disability, or sex. We also:
x Provide no cost aids and services to people with disabilities to communicate effectively with us, such as:
o Qualified sign language interpreters
o Written information in other formats, such as large print, audio, and accessible electronic formats
x Provide no cost language services to people whose primary language is not English, such as:
o Qualified interpreters
o Information written in other languages
If you need these services, call the number provided below.
Colorado
1-800-632-9700
TTY
711
If you believe that Kaiser Health Plan 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 with the Kaiser Civil Rights Coordinator, 2500 South Havana, Aurora, CO 80014, telephone
number: 1-800-632-9700. You can file a grievance by mail or phone. If you need help filing a grievance, the Kaiser Civil Rights Coordinator is
available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights
electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201,
1-800-68-1019, 1-800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Help in your Language
English: You have the right to get help in your language at no cost. If you have questions about your application or coverage through
Kaiser Permanente, or this notice requires you to take action by a specific date, call the number provided for your state or region to talk
to an interpreter.
አማርኛ (Amharic): ያለምንም ክፍያ በራስዎ ቋንቋ እገዛ የማግኘት
መብት አለዎት። ስለ ማመልከቻዎ ወይም ከኬሰር ፐርማነንቴ
Kaiser Permanente ስለሚያገኙት ሽፋን ማንኛውም ጥያቄዎች
ካሉዎት፣ ወይም ይህ ማሳወቂያ በግልፅ በተጠቀሰ ቀን ማድረግ
ያለብዎ ነገር እንዳለ የሚያስገድድዎ ከሆነ፣ በተጠቀሰው የስልክ ቁጥር
ለስቴትዎ ወይም ለክልልዎ ደውለው ከአስተርጓሚ ጋር ይነጋገሩ።
Colorado 1-800-632-9700 (TTY 711)
‫ لك الحق في الحصول على المساعدة بلغتك‬:)Arabic( ‫العربية‬
‫ إذا كانت لديك استفسارات بشأن طلبك أو‬.‫دون تحمل أي تكاليف‬
‫ أو يتطلب هذا‬،Kaiser Permanente ‫تغطيتك التي تقدمها‬
‫ يُرجى االتصال بالرقم‬،‫اإلشعار منك اتخاذ إجراء خالل تاريخ محدد‬
.‫المخصص لواليتك أو منطقتك للتحدث إلى مترجم فوري‬
Colorado 1-800-632-9700 (TTY 711)
Ɓǎsɔ́ɔ̀ Wùɖù (Bassa): M̀ ɓéɖé dyi-́ ɓɛ̀ɖɛ̀in
̀ -ɖɛ̀ɔ̀ ɓɛ́
m̀ ké gbo-kpá-kpá dyé ɖé m̀ ɓiɖ
i
wùɖùǔn
ɓó pid
́ ́
́ yi.
Ɔ jǔ ké m̀ dyi dyi-dieǹ-ɖɛ̀ ɓě ɓéɖé ɓá nì ɖɛ-mɔ́ɖif̀ èɖèɔ̀ dyi,́ mɔɔ ɓá nì kũùn kpɔ̃ jè dyí dyiì n
̀ ɖé
Kaiser Permanente mú, mɔɔ ɔ jǔ ké bɔ̌ i-po-po
nià
̃
̀
kɛ dyi nií ń m̀ mɛ nyùin
ɖɛ
ɖò
wé
jɛ
ɛ
ɖò
kɔ
ɛ
ni
,
ni
̀
́ ́
̃ ̀ ì ,́
ɖá nɔ̀ɓà ɓɛ́ wa tòà ɓó nì gbɛ̌ɛ̀ vɛ̀nɛ̀ mɔɔ nì gbɛ̌ɛ̀
dyùɔ̀ jèɛ ɓɛ́ m̀ ké wuɖu-ziì ̃ n
̀ -nyɔ̀ ɖò gbo wùɖù.
Colorado 1-800-632-9700 (TTY 711)
中文 (Chinese): 您有權免費以您的語言獲得幫助。
如果您對您的Kaiser Permanente申請或承保有
任何疑問，或者本通知要求您在具體日期之前採
取措施，請致電您所在的州或地區的電話，與口
譯員進行溝通。
Colorado 1-800-632-9700 (TTY 711)
Français (French): Une assistance gratuite dans
votre langue est à votre disposition. Si vous
avez des questions à propos de votre demande
d’inscription ou de la couverture par
Kaiser Permanente, ou si cet avis vous demande
de prendre des mesures à une date précise,
appelez le numéro indiqué pour votre Etat ou
votre région pour parler à un interprète.
Colorado 1-800-632-9700 (TTY 711)
Deutsch (German): Sie haben das Recht,
kostenlose Hilfe in Ihrer Sprache zu erhalten.
Falls Sie Fragen bezüglich Ihres Antrags
oder Ihres Krankenversicherungsschutzes
durch Kaiser Permanente haben oder falls
Sie aufgrund dieser Benachrichtigung bis
zu bestimmten Stichtagen handeln müssen,
rufen Sie die für Ihren Bundesstaat oder Ihre
Region aufgeführte Nummer an, um mit einem
Dolmetscher zu sprechen.
Colorado 1-800-632-9700 (TTY 711)
Kaiser Foundation Health Plan, Inc., in Northern and Southern California and Hawaii • Kaiser Foundation Health Plan of Colorado • Kaiser Foundation Health Plan
of Georgia, Inc., Nine Piedmont Center, 3495 Piedmont Road NE, Atlanta, GA 30305, 404-364-7000 • Kaiser Foundation Health Plan of the Mid-Atlantic States,
Inc., in Maryland, Virginia, and Washington, D.C., 2101 E. Jefferson St., Rockville, MD 20852 • Kaiser Foundation Health Plan of the Northwest, 500 NE Multnomah St.,
Suite 100, Portland, OR 97232
60436922 National 2016
Igbo (Igbo): Ị nwere ikike ịnweta enyemaka
n’asụsụ gị na akwụghị ụgwọ ọ bụla. Ọ bụrụ na ị
nwere ajụjụ gbasara akwụkwọ anamachọihe gị ma
ọ bụ mkpuchi si na Kaiser Permanente, ma ọ bụ na
ọkwa a chọrọ ka ị mee ihe tupu otu ụbọchị, kpọọ
nọmba enyere maka steeti ma ọ bụ mpaghara gị iji
kwukọrịta okwu n’etiti onye ọkọwa okwu.
Colorado 1-800-632-9700 (TTY 711)
日本語 (Japanese): あなたは、費用負担なしで
ご使用の言語で支援を受ける権利を保持してい
ます。お申し込みまたはKaiser Permanenteの
担保範囲に関してご質問があるか、または本通
知により、あなたが特定の日付までに行動を起
こすよう依頼されている場合、お住まいの州ま
たは地域に対して提供された電話番号に電話し
て、通訳と,お話ください。
Colorado 1-800-632-9700 (TTY 711)
한국어 (Korean): 귀하에게는 한국어 통역서비스를
무료로 받으실 수 있는 권리가 있습니다.
Kaiser Permanente를 통한 귀하의 보험 신청서나
보험 보장 범위에 관해 질문이 있을 경우 또는
이 통지서의 요구대로 일정 날짜까지 조취를
취해야 하는 경우, 귀하의 주 및 지역의 제공된
전화번호로 연락해 통역사와 통화하십시오.
Colorado 1-800-632-9700 (TTY 711)
Naabeehó (Navajo): T’11 ni nizaad bee n7k1
i’doolwo[ doo bik’4 as7n7[11g00 47 bee n1haz’3.
Kaiser Permanente 1k1 an1’1lwo’ n1 bik’4
azl1adoo y7n7keedgo naaltsoos hadinilaa, 47
b7na’7d7[kid doogo, 47 doodago d77 naaltsoos haa’7da
yoo[k1a[go hait’1oda 7’d77l77[ ni[n7igo 47 nitsaa
hahoodzoj7 47 doodago t’11 aadi nahós’a’di ata’
dahalne’7g77 bich’8’ h0lne’go bee bi[ ahi[ hod77lnih.
Colorado 1-800-632-9700 (TTY 711)
नेपाली (Nepali): तपाईंसगं कुनै शुल्क नदिइ आफ्नो
भाषामा सहायता पाउने अधिकार छ । तपाईँसंग
आफ्नो आवेदन बारे वा Kaiser Permanente मार्फत
कवरे ज बारे मा कुनै प्रश्नहरू भए, वा यो नोटिस
अनुसार तपाईँले कुनै निर्धारित मितिमा कुनै कार्यवाही
गर्नुपरे मा, दोभाषेसंग कुराकानी गर्न तपाईँको राज्य वा
क्षेत्रका लागि दिइएको नम्वरमा कल गर्नुहोस ् ।
Colorado 1-800-632-9700 (TTY 711)
Afaan Oromoo (Oromo): Baasii malee afaan
keetiin gargaarsa argachuudhaaf mirga qabda.
Waa’ee iyyata keetii yookaan tajaajila
Kaiser Permanente hammatu ilaalchisee gaaffii
yoo qabaatte, yookaan beeksisi Kun guyyaa
murtaa’e irratti tarkaanfii akka ati fudhattu
kan gaafatu yoo ta’e, lakkoofsa bilbilaa
naannoo yookaan goodina keetiif kenname
bibiluudhaan turjumaana haasofisiisi.
Colorado 1-800-632-9700 (TTY 711)
‫ شما حق دارید که بدون هیچ هزینه ای به‬:)Persian( ‫فارسی‬
‫ اگر درباره درخواست یا پوشش‬.‫زبان خود کمک دریافت کنید‬
‫ سؤالی داشته یا بر اساس این‬Kaiser Permanente ‫خود در‬
‫ برای صحبت‬،‫اعالمیه باید تا تاریخ مشخصی اقدامی بعمل آورید‬
‫با یک مترجم شفاهی با شماره تلفن ارائه شده برای ایالت یا منطقه‬
.‫خود تماس بگیرید‬
Colorado 1-800-632-9700 (TTY 711)
Pусский (Russian): У вас есть право получить
бесплатную помощь на своем языке. Если у
вас имеются вопросы относительно вашего
заявления или медицинского страхования в
Kaiser Permanente, либо данное уведомление
требует от вас каких-либо действий к
определенной дате, позвоните по номеру
телефона для своего штата или региона,
чтобы поговорить с переводчиком.
Colorado 1-800-632-9700 (TTY 711)
Tiếng Việt (Vietnamese): Quý vị có quyền
được nhận trợ giúp miễn phí bằng ngôn ngữ
của mình. Nếu quý vị có các câu hỏi về mẫu
đơn hoặc mức bảo hiểm của mình thông qua
Kaiser Permanente, hoặc thông báo này yêu
cầu quý vị thực hiện vào một ngày cụ thể, hãy
gọi đến số điện thoại được cung cấp cho bang
hoặc khu vực của quý vị để trò chuyện với
phiên dịch viên.
Colorado 1-800-632-9700 (TTY 711)
Español (Spanish): Usted tiene derecho a
obtener ayuda en su idioma sin costo alguno.
Si tiene preguntas acerca de su solicitud o
cobertura a través de Kaiser Permanente, o este
aviso requiere que usted tome alguna medida
antes de una fecha determinada, llame al
número de teléfono que se proporciona para su
estado o región para hablar con un intérprete.
Colorado 1-800-632-9700 (TTY 711)
Yorùbá (Yoruba): O ní ẹ̀tọ́ láti rí ìrànlọ́wọ́ gbà
nípa èdè rẹ láìsan owó. Bí o bá ní ìbéèrè nípa
ìṣàfilọ́lẹ̀ tàbí ìṣedéédé nípaṣẹ̀ Kaiser Permanente,
tàbí ìfitọnilétí yìí fẹ́ kí gbé ìgbésẹ̀ kan ní ọjọ́ kan
patọ́, pé nọ́mbà tí a pèsè fún ìpínlẹ̀ tàbí agbègbè
rẹ láti bá òǹgbifọ̀ kan sọ̀rọ̀.
Colorado 1-800-632-9700 (TTY 711)
Tagalog (Tagalog): Mayroon kang
karapatan na kumuha ng tulong sa iyong
wika nang walang bayad. Kung mayroon
kang mga katanungan tungkol sa iyong
aplikasyon o coverage sa pamamagitan ng
Kaiser Permanente, o ang abisong ito ay
nangangailangan ng iyong aksyon sa tiyak na
petsa, tumawag sa numerong ibinigay para
sa iyong estado o rehiyon para makipag-usap
usap sa tagapagsalin.
Colorado 1-800-632-9700 (TTY 711)
60436922 National 2016