SummaCare: SummaCare Bronze 6000-17 SConnect
Coverage Period: 01/01/2017-12/31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual, Spouse, Family | Plan Type: PPO
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan
document at www.summacare.com/coi or by calling 1-800-996-8701.
Important Questions
What is the overall
deductible?
Are there other
deductibles for
specific services?
Is there an out–of–
pocket limit on my
expenses?
Answers
In-Network $6,000 person /
$12,000 family
Out-of-Network $18,000 person /
$36,000 family
Doesn’t apply to preventive
care
Yes. $500 per person for
prescription drug coverage for
in-network pharmacies and
$1,500 per person for out-ofnetwork pharmacies
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.
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.
Yes. For In-Network providers
The out-of-pocket limit is the most you could pay during a coverage period (usually
$7,150 person / $14,300 family one year) for your share of the cost of covered services. This limit helps you plan for
For Out-of-Network providers
health care expenses.
$21,450 person / $42,900 family
What is not included in Premiums, balance-billed
the out–of–pocket
charges, and 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 In-Network
Providers, see
www.summacare.com or call
1-800-996-8701.
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.
Page 1 of 12
Questions: Call 1-800-996-8701 or visit us at www.summacare.com.
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.cciio.gov or call 1-800-996-8701 to request a copy.
SummaCare: SummaCare Bronze 6000-17 SConnect
Coverage Period: 01/01/2017-12/31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual, Spouse, Family | Plan Type: PPO
Important Questions
Do I need a referral to
see a specialist?
Answers
Why this Matters:
You can see the specialist you
choose without permission from
this plan.
Are there services this Some of the services this plan
plan doesn’t cover?
doesn't cover are listed in the
following pages.
•
•
•
•
You can see the specialist you choose without permission from this plan.
Some of the services this plan doesn’t cover are listed in the following pages. See your
policy or plan document for additional information about excluded services.
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 In-Network providers by charging you lower deductibles, copayments and coinsurance
amounts.
Common
Medical Event
If you visit a health
care provider’s
office or clinic
Services You May Need
Your Cost If You Use an
In-Network Provider
Your Cost If You Use an
Out-of-Network Provider
Limitations & Exceptions
Primary care visit to treat an
injury or illness
$30 copay
50%
Subject to deductible
Specialist visit
$60 copay
50%
Subject to deductible
Other practitioner office visit
$60 copay for chiropractor
50% for chiropractor
Chiropractor limited to 12 visits per
calendar year. Subject to
deductible.
Preventive
care/screening/immunization
No cost share
50%
Out-of-network subject to
deductible.
Page 2 of 12
Questions: Call 1-800-996-8701 or visit us at www.summacare.com.
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.cciio.gov or call 1-800-996-8701 to request a copy.
SummaCare: SummaCare Bronze 6000-17 SConnect
Coverage Period: 01/01/2017-12/31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual, Spouse, Family | Plan Type: PPO
Common
Medical Event
If you have a test
Services You May Need
Diagnostic test (x-ray, blood
work)
Your Cost If You Use an
Out-of-Network Provider
20%
50%
Imaging (CT/PET scans, MRIs) 20%
20%
Generic drugs
If you need drugs to
treat your illness or
condition
More information
about prescription
drug coverage is
available at
www.summacare.com/Li
braries/Formularies/201
7Formulary.sflb
Your Cost If You Use an
In-Network Provider
Preferred brand drugs
Non-preferred brand drugs
Limitations & Exceptions
Physician order required. Subject
to deductible.
Requires prior authorization.
Subject to deductible.
$15/$20 copay per
prescription for
$25 copay per prescription
preferred/non-preferred
for preferred generic drugs
generic drugs for up to a 30- for up to a 30-day supply
Some drugs require Prior
day supply retail at a
retail at a non-participating Authorization. Refer to our
formulary,www.summacare.com/Li
participating pharmacy;
pharmacy; $30 copay per
$30/$40 per prescription for prescription for non-preferred braries/Formularies/2017Formulary.
preferred/non-preferred
generic drugs for up to a 30- sflb. Subject to deductible.
generic drugs for up to a 90- day supply retail at a nonday supply through our mail participating pharmacy
order pharmacy
$35 copay per prescription
for preferred brand drugs for
$45 copay per prescription Some drugs require Prior
up to a 30-day supply retail
for preferred brand drugs for Authorization. Refer to our
at a participating pharmacy;
up to a 30-day supply retail formulary,www.summacare.com/Li
$87.50 per prescription for
braries/Formularies/2017Formulary.
at a non-participating
preferred brand drugs for up
sflb. Subject to deductible.
pharmacy
to a 90-day supply through
our mail order pharmacy
$75 copay per prescription
for preferred brand drugs for
up to a 30-day supply retail $95 copay per prescription Some drugs require Prior
at a participating pharmacy; for preferred brand drugs for Authorization. Refer to our
$187.50 per prescription for up to a 30-day supply retail formulary,www.summacare.com/Li
braries/Formularies/2017Formulary.
preferred brand drugs for up at a non-participating
sflb. Subject to deductible.
pharmacy
to a 90-day supply through
our mail order pharmacy
Page 3 of 12
Questions: Call 1-800-996-8701 or visit us at www.summacare.com.
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.cciio.gov or call 1-800-996-8701 to request a copy.
SummaCare: SummaCare Bronze 6000-17 SConnect
Coverage Period: 01/01/2017-12/31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual, Spouse, Family | Plan Type: PPO
Common
Medical Event
Services You May Need
If you need
immediate medical
attention
Your Cost If You Use an
Out-of-Network Provider
Limitations & Exceptions
25% of the cost of the drug 45% of the cost of the drug
up to $300
Limited up to a 30-day supply
retail through our designated
Specialty Pharmacy; some drugs
require prior authorization. Refer
to our formulary,
www.summacare.com/Libraries/
Formularies/2017Formulary.sflb.
Subject to deductible.
Facility fee (e.g., ambulatory
surgery center)
20%
50%
Certain outpatient services require
prior authorization. Refer to prior
authorization list at
www.summacare.com. Subject to
deductible.
Physician/surgeon fees
20%
50%
Subject to deductible
Emergency room services
$350 copay
$350 copay
Copay waived if admitted. Subject
to deductible.
Emergency medical
transportation
20%
50%
Subject to deductible
Urgent care
$75 copay
50%
Subject to deductible
Facility fee (e.g., hospital
room)
20%
50%
If you have a hospital stay, it
requires prior authorization.
Subject to deductible.
Physician/surgeon fee
20%
50%
Subject to deductible
Specialty drugs
If you have
outpatient surgery
Your Cost If You Use an
In-Network Provider
If you have a
hospital stay
Page 4 of 12
Questions: Call 1-800-996-8701 or visit us at www.summacare.com.
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.cciio.gov or call 1-800-996-8701 to request a copy.
SummaCare: SummaCare Bronze 6000-17 SConnect
Coverage Period: 01/01/2017-12/31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual, Spouse, Family | Plan Type: PPO
Common
Medical Event
Services You May Need
Mental/Behavioral health
outpatient services
Mental/Behavioral health
If you have mental
inpatient services
health, behavioral
health, or substance Substance use disorder
abuse needs
outpatient services
Substance use disorder
inpatient services
If you are pregnant
Your Cost If You Use an
In-Network Provider
Your Cost If You Use an
Out-of-Network Provider
Limitations & Exceptions
$30 copay
50%
Subject to deductible
20%
50%
Requires prior authorization.
Subject to deductible.
$30 copay
50%
Subject to deductible
20%
50%
Requires prior authorization.
Subject to deductible.
Prenatal and postnatal care
$30 copay for initial visit;
then $0 copay
50%
Subject to deductible
Delivery and all inpatient
services
20%
50%
Subject to deductible
Page 5 of 12
Questions: Call 1-800-996-8701 or visit us at www.summacare.com.
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.cciio.gov or call 1-800-996-8701 to request a copy.
SummaCare: SummaCare Bronze 6000-17 SConnect
Coverage Period: 01/01/2017-12/31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual, Spouse, Family | Plan Type: PPO
Common
Medical Event
Services You May Need
Home health care
Your Cost If You Use an
In-Network Provider
20%
Your Cost If You Use an
Out-of-Network Provider
50%
Limited to 100 visits per calendar
year combined in and out-ofnetwork; Limits do not apply to IV
therapy and private duty nursing.
Subject to deductible.
50%
Limited to a combined 60 days per
Benefit Period maximum for both
Inpatient and outpatient day
rehabilitation therapy services.
Outpatient: Limited to 20 visits
Occupational Therapy; 20 visits
Physical Therapy; 20 visits
Speech Therapy; 36 visits Cardiac
Rehabilitation; 20 visits
Pulmonary. Visit limits per
calendar year combined in and
out-of-network when rendered at
an outpatient rehab facility.
Subject to deductible.
If you need help
recovering or have
other special health
needs
Rehabilitation services
$60 copay
Limitations & Exceptions
Page 6 of 12
Questions: Call 1-800-996-8701 or visit us at www.summacare.com.
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.cciio.gov or call 1-800-996-8701 to request a copy.
SummaCare: SummaCare Bronze 6000-17 SConnect
Coverage Period: 01/01/2017-12/31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual, Spouse, Family | Plan Type: PPO
Common
Medical Event
Services You May Need
Habilitative services
Your Cost If You Use an
In-Network Provider
Your Cost If You Use an
Out-of-Network Provider
$60 copay for rehabilitation; 50%
$30 for mental health
Limitations & Exceptions
Habilitative services are included
in the Mental Health and
Rehabilitative Service Benefit.
Habilitative services for children up
to the age of 21 with a medical
diagnosis of Autism Spectrum
disorder also included. Services
include Outpatient Physical
Rehab, including Speech and
Language Therapy and
Occupational Therapy, limited to
20 visits per service. Clinical
Therapeutic Intervention provided
by an appropriate agency of this
state limited to 20 hours per week.
Mental/Behavioral Health
Outpatient Services performed by
a licensed psychologist,
psychiatrist, or physician limited to
30 visits per calendar year
combined in and out-of-network.
Subject to deductible.
Page 7 of 12
Questions: Call 1-800-996-8701 or visit us at www.summacare.com.
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.cciio.gov or call 1-800-996-8701 to request a copy.
SummaCare: SummaCare Bronze 6000-17 SConnect
Coverage Period: 01/01/2017-12/31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual, Spouse, Family | Plan Type: PPO
Common
Medical Event
Services You May Need
Your Cost If You Use an
In-Network Provider
Your Cost If You Use an
Out-of-Network Provider
Limitations & Exceptions
Skilled nursing care
20%
50%
Limited to 90 days per calendar
year combined in and out-ofnetwork. Subject to deductible.
Durable medical equipment
20%
50%
Subject to deductible
Hospice service
20%
50%
Subject to deductible
50%
One routine exam per calendar
year. Limited to age 19 and
under. Out-of-network subject to
deductible.
Eye exam
0%
If your child needs
dental or eye care
Glasses
0%
50%
One frame/set of lenses per
calendar year (pediatric). Limited
to age 19 and under. Out-ofnetwork subject to deductible.
Dental check-up
Not covered
Not covered
Limited to age 19 and under.
Refer to stand alone dental
benefit.
Page 8 of 12
Questions: Call 1-800-996-8701 or visit us at www.summacare.com.
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.cciio.gov or call 1-800-996-8701 to request a copy.
SummaCare: SummaCare Bronze 6000-17 SConnect
Coverage Period: 01/01/2017-12/31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual, Spouse, Family | Plan Type: PPO
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
•
Bariatric surgery
•
Cosmetic surgery
•
Dental care
•
Hearing Aids
•
Infertility treatment.
•
Long-Term Care
•
•
Routine foot care
•
Weight loss programs
Non-emergency care when traveling outside
the U.S.
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.)
•
Routine eye care
•
Chiropractic services
•
Adult Vision Discount
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 1-800-996-8701. You may also contact your state
insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or
www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov
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 SummaCare at 1-800-996-8701 or contact us via our website at
Page 9 of 12
Questions: Call 1-800-996-8701 or visit us at www.summacare.com.
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.cciio.gov or call 1-800-996-8701 to request a copy.
SummaCare: SummaCare Bronze 6000-17 SConnect
Coverage Period: 01/01/2017-12/31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual, Spouse, Family | Plan Type: PPO
www.summacare.com. You may also contact the Ohio Department of Insurance at www.insurance.ohio.gov, 1-800-686-1526 or the Department of
Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.
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
minimum value standard 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.
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––
Page 10 of 12
Questions: Call 1-800-996-8701 or visit us at www.summacare.com.
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.cciio.gov or call 1-800-996-8701 to request a copy.
SummaCare: SummaCare Bronze 6000-17 SCConnect
Coverage Period: 01/01/2017-12/31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual, Spouse, Family | Plan Type: PPO
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
Managing type 2 diabetes
(normal delivery)
(routine maintenance of
a well-controlled condition)
 Amount owed to providers: $7,540
 Plan pays $1,120
 Patient pays $6,420
 Amount owed to providers: $5,400
 Plan pays $50
 Patient pays $5,350
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
$6,000
$20
$250
$150
$6,420
Sample care costs:
Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
$2,900
$1,300
$700
$300
$100
$100
$5,400
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$5,270
$0
$0
$80
$5,350
Page 11 of 12
Questions: Call 1-800-996-8701 or visit us at www.summacare.com.
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.cciio.gov or call 1-800-996-8701 to request a copy.
SummaCare: SummaCare Bronze 6000-17 SCConnect
Coverage Period: 01/01/2017-12/31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual, Spouse, Family | Plan Type: PPO
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-ofpocket 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.
Page 12 of 12
Questions: Call 1-800-996-8701 or visit us at www.summacare.com.
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.cciio.gov or call 1-800-996-8701 to request a copy.
Important Information
SummaCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age,
disability, religion, gender identity or sex.
SummaCare does not exclude people or treat them differently because of race, color, national origin, age, disability, religion, gender identity or
sex.
SummaCare:
•
Provides free 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 (large print, audio, accessible electronic formats, other formats)
•
Provides free 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, contact Customer Service.
If you believe that SummaCare has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age,
disability, religion, gender identity or sex, you can file a grievance through Customer Service:
Civil Rights Coordinator
PO Box 1107
Akron, OH 44309-1107
Toll-free: 800-996-8701
TTY: 800-750-0750
Fax: 330-996-8545
Email: [email protected]
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, a Customer Service Representative 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, 1-800-368-1019, 800-537-7697 (TDD).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Important Information
Language Access Services:
Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de SummaCare, tiene derecho a obtener ayuda e información en su
idioma sin costo alguno. Para hablar con un intérprete, llame al 1-800-996-8701.
Este Aviso contiene información importante. Este aviso contiene información importante acerca de su solicitud o cobertura a través de
SummaCare. Preste atención a las fechas clave que contiene este aviso. Es posible que deba tomar alguna medida antes de determinadas fechas
para mantener su cobertura médica o ayuda con los costos. Usted tiene derecho a recibir esta información y ayuda en su idioma sin costo alguno.
Llame al 1-800-996-8701.
如果您，或是您正在協助的對象，有關於 插入 SBM 項目的名稱 SummaCare 方面的問題，您有權利免費以您的母語得到幫助和訊息。洽詢一位翻譯
員，請撥電話 在此插入數字1-800-996-8701。
本通知有重要的訊息。本通知有關於您透過 插入SBM 項目的名稱 SummaCare 提交的申請或保險的重要訊息。請留意本通知內的重要日期。您可能
需要在截止日期之前採取行動，以保留您的健康保險或者費用補貼。您有權利免費以您的母語得到本訊息和幫助。請撥電話 在此插入數字1-800-9968701。
Falls Sie oder jemand, dem Sie helfen, Fragen zum SummaCare haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache
zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 1-800-996-8701 an.
Diese Benachrichtigung enthält wichtige Informationen. Diese Benachrichtigung enthält wichtige Informationen bezüglich Ihres Antrags auf
Krankenversicherungsschutz durch SummaCare. Suchen Sie nach wichtigen Terminen in dieser Benachrichtigung. Sie könnten bis zu bestimmten
Stichtagen handeln müssen, um Ihren Krankenversicherungsschutz oder Hilfe mit den Kosten zu behalten. Sie haben das Recht, kostenlose Hilfe
und Informationen in Ihrer Sprache zu erhalten. Rufen Sie an unter 1-800-996-8701.
‫ فلديك الحق في الحصول على المساعدة والمعلومات‬، SummaCare ‫ إن كان لديك أو لدى شخص تساعده أسئلة بخصوص‬1-800996-8701. ‫ للتحدث مع مترجم اتصل ب‬.‫الضرورية بلغتك من دون اية تكلفة‬
‫ ابحث عن التواريخ الهامة في هذا‬SummaCare. ‫ يحوي هذا الاشعار معلومات مهمة بخصوص طلبك للحصول على التغطية من خلال‬.‫دفع يحوي هذا الاشعار معلومات هامة‬
‫ قد تحتاج لاتخاذ اجراء في تواريخ معينة للحفاظ على تغطيتك الصحية او للمساعدة في‬.‫الاشعار‬
1-800-996-8701. ‫ اتصل ب‬.‫ لك الحق في الحصور على المعلومات والمساعدة بلغتك من دون أي تكلفة‬.‫التكاليف‬
Important Information (continued)
Wann du hoscht en Froog, odder ebber, wu du helfscht, hot en Froog baut SummaCare, hoscht du es Recht fer Hilf un Information in deinre eegne
Schprooch griege, un die Hilf koschtet nix. Wann du mit me Interpreter schwetze witt, kannscht du 1-800-996-8701 uffrufe.
Die Bekanntmaching gebt wichdichi Auskunft. Die Bekanntmaching gebt wichdichi Auskunft baut dei Application oder Coverage mit
SummaCare. Geb Acht fer wichdiche Daadem in die Bekanntmachung. Es iss meeglich, ass du ebbes duh muscht, an beschtimmde Deadlines, so
ass du dei Health Coverage bhalde kannscht, odder bezaahle helfe kannscht. Du hoscht es Recht fer die Information un Hilf in deinre eegne
Schprooch griege, un die Hilf koschtet nix.
Если у вас или лица, которому вы помогаете, имеются вопросы по поводу SummaCare, то вы имеете право на бесплатное получение
помощи и информации на вашем языке. Для разговора с переводчиком позвоните по телефону 1-800-996-8701.
Настоящее уведомление содержит важную информацию. Это уведомление содержит важную информацию о вашем заявлении или
страховом покрытии через SummaCare. Посмотрите на ключевые даты в настоящем уведомлении. Вам, возможно, потребуется принять
меры к определенным предельным срокам для сохранения страхового покрытия или помощи с расходами. Вы имеете право на
бесплатное получение этой информации и помощь на вашем языке. Звоните по телефону 1-800-996-8701.
Si vous, ou quelqu'un que vous êtes en train d’aider, a des questions à propos de SummaCare, vous avez le droit d'obtenir de l'aide et l'information
dans votre langue à aucun coût. Pour parler à un interprète, appelez 1-800-996-8701.
Cet avis a d'importantes informations. Cet avis a d'importantes informations sur votre demande ou la couverture par l'intermédiaire de SummaCare.
Rechercher les dates clés dans le présent avis. Vous devrez peut-être prendre des mesures par certains délais pour maintenir votre couverture de
santé ou d'aide avec les coûts. Vous avez le droit d'obtenir cette information et de l’aide dans votre langue à aucun coût. Appelez 1-800-996-8701.
Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về SummaCare, quý vị sẽ có quyền được giúp và có thêm thông tin bằng ngôn ngữ của
mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 1-800-996-8701.
Thông báo này cung cấp thông tin quan trọng. Thông báo này có thông tin quan trọng bàn về đơn nộp hoặc hợp đồng bảo hiểm qua chương trình
SummaCare. Xin xem ngày then chốt trong thông báo này. Quý vị có thể phải thực hiện theo thông báo đúng trong thời hạn để duy trì bảo hiểm
sức khỏe hoặc được trợ trúp thêm về chi phí. Quý vị có quyền được biết thông tin này và được trợ giúp bằng ngôn ngữ của mình miễn phí. Xin gọi
số 1-800-996-8701.
Important Information (continued)
Isin yookan namni biraa isin deeggartan SummaCare irratti gaaffii yo qabaattan, kaffaltii irraa bilisa haala ta’een afaan keessaniin odeeffannoo
argachuu fi deeggarsa argachuuf mirga ni qabdu. Nama isiniif ibsu argachuuf, lakkoofsa bilbilaa 1-800-996-8701 tiin bilbilaa.
Beeksisni kun odeeffannoo barbaachisaa qaba. Beeksisti kun sagantaa yookan karaa SummaCare tiin tajaajila keessan ilaalchisee odeeffannoo
barbaachisaa qaba. Guyyaawwan murteessaa ta’an beeksisa kana keessatti ilaalaa. Tarii kaffaltiidhaan deeggaramuuf yookan tajaajila fayyaa
keessaniif guyyaa dhumaa irratti wanti raawwattan jiraachuu danda’a. Kaffaltii irraa bilisa haala ta’een afaan keessaniin odeeffannoo argachuu fi
deeggarsa argachuuf mirga ni qabaattu. Lakkoofsa bilbilaa 1-800-996-8701 tii bilbilaa.
만약 귀하 또는 귀하가 돕고 있는 어떤 사람이SummaCare 에 관해서 질문이 있다면 귀하는 그러한 도움과 정보를 귀하의 언어로 비용 부담없이 얻을
수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는 1-800-996-8701로 전화하십시오.
본 통지서에는 중요한 정보가 들어 있습니다. 즉 이 통지서는 귀하의 신청에 관하여 그리고SummaCare을 통한 커버리지 에 관한 정보를 포함하고
있습니다. 본 통지서에서 핵심이 되는 날짜들을 찾으십시오. 귀하는 귀하의 건강 커버리지를 계속 유지하거나 비용을 절감하기 위해서 일정한
마감일까지 조치를 취해야 할 필요가 있을 수 있습니다. 귀하는 이러한 정보와 도움을 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 1800-996-8701 로 전화하십시오.
Se tu o qualcuno che stai aiutando avete domande su SummaCare, hai il diritto di ottenere aiuto e informazioni nella tua lingua gratuitamente. Per
parlare con un interprete, puoi chiamare 1-800-996-8701.
Questo avviso contiene informazioni importanti sulla tua domanda o copertura attraverso SummaCare. Cerca le date chiave in questo avviso.
Potrebbe essere necessario un tuo intervento entro una scadenza determinata per consentirti di mantenere la tua copertura o sovvenzione. Hai il
diritto di ottenere queste informazioni e assistenza nella tua lingua gratuitamente. Chiama 1-800-996-8701.
ご本人様、またはお客様の身の回りの方でも、SummaCareについてご質問がございましたら、ご希望の言語でサポートを受けたり、情報を入手
したりすることができます。料金はかかりません。通訳とお話される場合、1-800-996-8701までお電話ください。
この通知には重要な情報が含まれています。この通知には、SummaCareの申請または補償範囲に関する重要な情報が含まれています。この通知
に記載されている重要な日付をご確認ください。健康保険や有料サポートを維持するには、特定の期日までに行動を取らなければならない場合が
あります。ご希望の言語による情報とサポートが無料で提供されます。1-800-996-8701までお電話ください。
Important Information (continued)
Als u, of iemand die u helpt, vragen heeft over SummaCare, heeft u het recht om hulp en informatie te krijgen in uw taal zonder kosten. Om te
praten met een tolk, bel 1-800-996-8701.
Deze mededeling heeft belangrijke informatie. Deze mededeling heeft belangrijke informatie over uw aanvraag of dekking via SummaCare. Kijk
naar belangrijke datums in deze mededeling. Het kan nodig zijn om actie te ondernemen binnen bepaalde termijnen om uw zorgverzekering te
behouden of hulp met kosten te krijgen. U heeft het recht op deze informatie en hulp in uw taal zonder kosten. Bel 1-800-996-8701.
Якщо у Вас чи у когось, хто отримує Вашу допомогу, виникають питання про SummaCare, у Вас є право отримати безкоштовну допомогу та
інформацію на Вашій рідній мові. Щоб зв’язатись з перекладачем, задзвоніть на 1-800-996-8701.
Це повідомлення містить важливу інформацію. Це повідомлення містить важливу інформацію про Ваше звернення щодо страхувального
покриття через SummaCare. Зверніть увагу на ключові дати, вказані у цьому повідомленні. Існує імовірність того, що Вам треба буде
здійснити певні кроки у конкретні кінцеві строки для того, щоб зберегти Ваше медичне страхування або отримати фінансову допомогу. У
Вас є право на отримання цієї інформації та допомоги безкоштовно на Вашій рідній мові. Дзвоніть за номером телефону 1-800-996-8701.
Dacă dumneavoastră sau persoana pe care o asistați aveți întrebări privind SummaCare, aveți dreptul de a obține gratuit ajutor și informații în limba
dumneavoastră. Pentru a vorbi cu un interpret, sunați la 1-800-996-8701.
Prezenta notificare conține informații importante. Această notificare conține informații importante privind cererea sau acoperirea asigurării
dumneavoastre de sănătate prin SummaCare. Căutați datele cheie din această notificare. Este posibil să fie nevoie să acționați până la anumite
termene limită pentru a vă menține acoperirea asigurării de sănătate sau asistența privitoare la costuri. Aveți dreptul de a obține gratuit aceste
informații și ajutor în limba dumneavoastră. Sunați la 1-800-996-8701.