Haa !h1y3 Hadilyaii d00 Bik’7daasti’ii: Naa !h1y3 N1 Hadilyaii d00 Bik’4 As7n7[1adoo7g77 Naa !h1y3 Nik’4sti’doo: 01/01/2018 – 12/31/2018

Donnelley Financial: Copay Value Haa 1h1y3 Ak’4sti’ii: T’11[ashdilt’4h4go d00 Ha’1[ch7n7 Bee Haa !h1y3 Hadilyaii: PPO

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Na’7d7kid danil7n7g77 N1t’33’ baa n1h1ne’7g77 Biniinaa 1k0t’4h7g77:

Deductible t’11 1t’4go d7kw7ish nijil44h?

Bi[ neilnishgo d00 doo bi[ neilnishdago: Ni t4iy1 $4,600; $9,200 ni d00 bi[ hin7n1anii, ni d00 1[ch7n7; $9,200 t’11[a’ dahaghan7g77 ah7idzogo

Azee’ yee 1k1 an7daalwo’ii haa oosb1n7g77 t’11 1t’4 bich’8’ nijil44h deductible 1n4elt’e’ b7ighahj8’ 47 bik’ij8’ d77 bee naa 1h1y3 hadilyaii, plan, bee n1 ni’iily4. ![ch7n7 d00 bi[ hin7n1anii bee naa 1h1y3 1lyaii, plan, 47 b7zhi’ dabik1ago 47 t’11 [1’7 n7z7n7go deductible b7ighahgo niidool44[ 47 t’11 a[tso ah7idzogo t’11 dahjookahgo 47 deductible h0l= 47 over all family deductible 1t’4.

Deductible t’1hdo a[tso nij7l4h4 nidi7sh h1k1 o’oolwod7g77 h1bik’4 ni’dooly44[?

Aoo’. Hait’477sh99 Ats’77s b22h dahwiidoo’aa[ bich’33h n1ho’di’n4l’88h adaat’4h7g77, copay nihaly4h7g77, azee’ nahaniih d00 y4ego 1jiit’88hgo h1k1 e’elwo’7g77 47 h1 bik’4 ni’iily4, deductible doo a[tso nazhn7l1ada nidi.

D77 bee naa 1h1y3 hadilyaii, plan, Hait’477sh99 h1k1 e’elwogo chodaoz’88d7g77 d00 na’azhnish7g77 yik’4 ni’dool44[ deductible doo b7ighahgo nizhn7l1ada nidi. !kondi copayment 47 doodago coinsurance t’47 [ahda t’11 nizhdool44[. Bee naa 1h1y3 hadilyaii, plan, 47 ats’77s b22h dahwiidoo’aa[ bich’33h n1ho’di’n4l’88h7g77 bik’4sti’ b33h azl99’7g77 doo a[ts’33 da’j7lk’iizda cost sharing yi[n7 d00 deductible t’1adoo b7ighahgo nij7l4h4 nidi. Ats’77s b22h dahwiidoo’aa[ bich’33h n1ho’di’n4l’88h7g77 47 kwe’4 dabik11’ https://www.healthcare.gov/coverage/preventive-care-benefits/.

N11n1 [a’ n1hodi’n4l’88h d00 1k1 e’awo’ daats’7 bi deductible a[’aan b1 dah0l=?

Dooda N1hodi’n4l’88h d00 h1 4’4l’88h7g77 doo [a’ t’11 sahdii 1t’4ego deductible b1 h0l=-da.

Out-of-pocket limit hab4eso nijiil4h7g77 47 haan4elt’e’ beehaz’3 d77 bee haa 1h1y3 hadilyaiij7, plan?

Bi[ neilnishgo d00 doo bi[ neilnishdago: $6,550 t’11[ashdilt’4h4/$13,100 hoghand0 t’11 1j7[tso

Out-of-pocket limit 47 n1hodi’n4l’88h d00 h1k1 an1’1lwo’ b33h azl’99’7g77 [ahd00 hab4eso t’11 1t’4 bik’4 nijiil4 n7n1hahgo 0oly4. Ha’1[ch7n7 d00 bi[ jiin1anii a[d0’ b7zhi’ daasdzoh7g77 a[d0’ Out-of-pocket limit b1 dah0l= 47 t’11[1’7 n7z7n7go b7ighah 1dayiil’88h t’11[a’ dahjookahgo out-of-pocket limit 1dajii[‘88hj8’.

Out-of-pocket limit 47 ha’1t’77 doo bi[ w0lta’da?

B4eso 1ch’33h naa’nil bik’4 nijiil4h7g77 Premiums, balanced-billed charges, d00 bik’ehgo naa 1h1y1n7g77 doo yik4 as[1h7g77.

D77 bik’4 ni’ay7n7la’ nidi out-of-pocket limitj7 doo bi[ 77d0oltahda.

T’11 daats’7 a’ohgo nidadoo[44[ azee’77[’7n7 bi[ nidaa[nish7g77 choo’98go?

Aoo’. Kwe’4 www.bcbsil.com 47 doodago koj8’ hod77lnih 1-888-895-6985 azee’77[‘7n7 network providers danil7n7g77 b7zhi’ dabik11’.

D77 bee naa 1h1y3 hadilyaii, plan, 47 azee’77’7n7 provider network danil7n7g77 yi[ naalnish. Provider 47 network atah danil7n7g77 47 doo [3 naa dayoo[b88hda doo. Azee’77[’7n7 out-of-network n7l98go 47 [3 neidoo[b88[. Provider binaanish ay0o 7[98go balance billing 77[‘98go yee yoosb1n7g77 t’11 1t’4 n7yokeedoo. Provider choin7[’88h7g77 out-of-network nil7n7g77 yi[ n7diilnishgo bik’4 ni’7ly4 t’11 nanit[’adoo. (Hadi[ haakaah d00 naalkaah7g77 1daat’47). Yi[ n7dadiilnish7g77 b7nab7zhd7[ki’ t’ahdo ho’din77shg0.

Ats’77s b22h dahaz’3 yeda’aniih7g77, specialist bich’8’ jidigh1ahgo daats7 naaltsoos 1l’88hgo t’47?

Dooda Specialist choin7[‘88hgo 47 naaltsoos, referral, t’11g44d nidi choid77[‘88[.

Naa !h1y3 d00 Nik’4sti’ii Baa Hane’ (SBC) binaaltsoos bee naa 1h1y3 hadilyaa7g77 47 bee b4eso 1ch’33h naa’nil d00 h0 bik’4 nizhdool44[7g77 a[ts’33’ aj7lk’iiz. BAA !KON&N&ZIN: Naa 1h1y3 bik’4 as7n7[1 (premium) 47 t’11 sahdii baa hodoonih.

D77 47 t’00 ch’7’7t’32go hane’ 1t’4. Bee haz’1anii binaaltsoos bik’ehgo haa 1h1y1n7g77, policy, 47 1h1n7go hon7’32go h1k1 an1’1lwo’ d00 nihely4h7g77 yaa halne’7g77 koj8’ b7na’7d7d77[ki[ 1-888-895-6985 47 doodago computer bee koj8’ na’7d7d77[ki[ www.bcbsil.com. Saad chodaa’7n7g77 allowed amount, balance billing, coinsurance copayment, deductible, provider, 47 doodago saad biyaag0naa da’7dzoo7g77 47 Glossary woly4h7g77 d7n77[‘88[. Saad 11h yi[n7g77 Glossary kwe’4 d7n77[’88[ https://www.cms.gov/CCIIO/Resources/Forms-Reports-and-Other-Resources/Downloads/UG-Glossary-508-MM.pdf koj8’ 1-888-895-6985 hw77n7lne’go y7d77ki[.

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* Beehaz’1anii biyi’di bik’ehgo 1k1 i’doolwo[ d00 bik’4 ni’dooly44[ baahane’7g77 47 naaltsoos n1 hadilyaa7g77 bik11’ 47 doodago kwe’4 d7n77[‘88[ http://www.cms.gov/CCIIO/Resources/Files/Downloads/sbc-uniform-glossary-navajo-2.pdf.

Na’7d7[kidgo k0j8’ hod77lnih:1-844-443-3726 47 doodago kwe’4 na’7d7d77[ki[ mybenefitsdfsco.com.

Copayment d00 coinsurance bee naa oob88h7g77 47 deductible n77n7l11d00 bik’ij8 nih7l4edoo, deductible nidooly4e[go.

Ats’77s baa 1h1y3

biniy4 choo’9

hajigh1h7g77

D77 47 ats’77s baa 1h1y3 biniy4 choo’9 hajigh1a [eh

D77 nid77l44[

H1 ni’iily4 1n4elt’e’j8’ d00 bee

nahaz’1anii h0l0n7g77 baa hane’

Azee’77['7 bi[ a[ha’deet’1n7g77

(A’ohgo nid77l44[)

Azee’77['7n7 doo bi[ a[ha’deet’1n7g77

({3 nid77l44[)

Provider bich’8’ nis7n7y1ago

Hatah doo hats’7idago, t7zhd7lyaago azee’77['7n7 baa jigh1ahgo.

$35 copay/n7j7d1ahgo; deductible 47 doo nidooly4e[da

D99y11l b7ighahgo 50% coinsurance

Adin

Azee’77['7n7 ats’77stahdi d00 22h dahaz’3 yeda’aniih7g77 baa jigh1ahgo.

$55 copay/n7j7d1ahgo; deductible 47 doo nidooly4e[da

D99y11l b7ighahgo 50% coinsurance

Adin

Ats’77s bich’33h na’anishgo n1hodi’n4l’88h d00 naa[niih bich’8’ haa an1’1tsih.

Doo b33h7l7n7da; deductible doo nid77l4e[da

D99y11l b7ighahgo 50% coinsurance

!k1 e’elyeed doo ats’77s bich’33h na’nish preventive-7g77 choo’88hgoda, 47 bik’4 ni’d77l44[. Ni provider nab7d7d77[ki[ choiidoo’99[7g77 daats’7 preventivej7 b7d47t’i’. !ko bee naa 1h1y3 hadilyaa7g77 plan d7n77[’88[, 47 ha’1t’77 yik’4 as[1adoo.

Ats’77s naalkaah n1 1lyaago

Iyisii nida’alkaah (agha’dildlaad, dił naalkaah)

T11’ doot[‘izh b7ghahgo 30% coinsurance

D99y11l b7ighahgo 50% coinsurance

Adin

Naalkid bee na’alkaah (CT/PET bee e’eln44h, MRI wolyehigii)

T11’ doot[‘izh b7ghahgo 30% coinsurance

D99y11l b7ighahgo 50% coinsurance

Adin

Nich’8’ an1h00t’i’ d00 1n7t’4h7g77 azee’ b22h 1lyaago t’47 y1’1t’44h doo Azee’ bik’4 azl1h7g77 prescription drug coverage kwe’4 baa hane’ mybenefitsdfsco.com

Azee’ doo b7zhi’ dahol0n7g77 Generic dei[n7n7g77.

T11’ doot[‘izh b7ghahgo 30% coinsurance

T11’ doot[‘izh b7ghahgo 30% coinsurance

Nahaniihgo: $10 d00, $45j8’ B7k1 e’4ln4ehgo: $25 d00, $115j8’

Azee’ b7zhi’ 1daalyaa, brand name dei[n77g77

D99’ doot[‘izh b7ghahgo 40% coinsurance

D99’ doot[‘izh b7ghahgo 40% coinsurance

Nahaniihgo: $40 d00, $100j8’ B7k1 e’4ln4ehgo: $100 d00, $250j8’

Azee’ doo ay0o choo’7n7g77, non-preferred dei[n7g77

D99y11l b7ighahgo 50% coinsurance

D99y11l b7ighahgo 50% coinsurance

Nahaniihgo: $75 d00, $150j8’ B7k1 e’4ln4ehgo: $185d00, $375j8’

Azee’ t’11 [1h1go haz’3 biniy4 1lyaa7g77, specialty drug dei[n7n7g77

$210 $210 Doo b7k1 1h1l’98da

T’11 [a’aj7 hats’77s nidoolgish t’47 biniiy4 jigh11h d00 ch’44j7d1ahgo.

Azee’1l’98di nida’algizh b1 haz’3 chojoos’88dgo bik’4 ni’jil44h7g77 (ats’77s naalgizh b1haz’1n7g0ne’)

T11’ doot[‘izh b7ghahgo 30% coinsurance

D99y11l b7ighahgo 50% coinsurance

Adin

Azee’77['7n7 / na’algizjh binahji’ aa’oozb3n77g77

T11’ doot[‘izh b7ghahgo 30% coinsurance

D99y11l b7ighahgo 50% coinsurance Adin

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* Beehaz’1anii biyi’di bik’ehgo 1k1 i’doolwo[ d00 bik’4 ni’dooly44[ baahane’7g77 47 naaltsoos n1 hadilyaa7g77 bik11’ 47 doodago kwe’4 d7n77[‘88[ http://www.cms.gov/CCIIO/Resources/Files/Downloads/sbc-uniform-glossary-navajo-2.pdf.

Na’7d7[kidgo k0j8’ hod77lnih:1-844-443-3726 47 doodago kwe’4 na’7d7d77[ki[ mybenefitsdfsco.com.

Ats’77s baa 1h1y3

biniy4 choo’9

hajigh1h7g77

D77 47 ats’77s baa 1h1y3 biniy4 choo’9 hajigh1a [eh

D77 nid77l44[

H1 ni’iily4 1n4elt’e’j8’ d00 bee

nahaz’1anii h0l0n7g77 baa hane’

Azee’77['7 bi[ a[ha’deet’1n7g77

(A’ohgo nid77l44[)

Azee’77['7n7 doo bi[ a[ha’deet’1n7g77

({3 nid77l44[)

T’11 k’ad azee’77['7n7 sh7k1 adoolwo[ jin7zingo

Azee’ 1l’99g0ne’ y4ego ach’8’ hodiin1ahgo ts98[go 1k1 i’iilyeedg0ne’ hona’azhnishgo

$600 copay/n7j7d1ahgo; deductible d00 nij7l4eda d00 T11’ doot[‘izh b7ghahgo 30% coinsurance

$600 copay/n7j7d1ahgo; deductible d00 nij7l4eda d00 T11’ doot[‘izh b7ghahgo 30% coinsurance

Copay doo nij7l4eda yah aj77y1ago. Doo ach’8’ hodiis’n11’g00 Ts98[go 1k1 ada’iilyeedgi jigh1ahgo: In-Network nijil44h7g77 47 $600 copay, deductible 47 1din d00 In-Network coinsurance nijil44h. Out-of-Network nijil44h7g77 47 $600 copay, deductible 47 1din d00 Out-of-Network coinsurance nijil44h.

Y4ego 1j7t’4 jileehgo hach’8’ hodiin1ahgo bee azee’1l99g00 hodi’g44h7g77 choo’88hgo

T11’ doot[‘izh b7ghahgo 30% coinsurance

T11’ doot[‘izh b7ghahgo 30% coinsurance

Adin

T’1adoo hooy1n7 hach’8’ 1n1h00t’i haleehgo 1k1 i’iilyeed choo’88hgo

T11’ doot[‘izh b7ghahgo 30% coinsurance

D99y11l b7ighahgo 50% coinsurance

Adin

Azee’1l’99g0ne’ yah aj77y1ago

Azee’ 1l’98gii b1 hilinigii (azee’ il’i ̨i ̨ gone’ n1 haz’1n7g77)

T11’ doot[‘izh b7ghahgo 30% coinsurance

D99y11l b7ighahgo 50% coinsurance

Preauthorization 1[ts4 l3 aleeh – doo 1lyaag00 47 $500 hak’ij8 doodzo d00 nizhdool44[.

Azee’77['7n7 / naho’dishgizhgo haa’oozb1n7g77

T11’ doot[‘izh b7ghahgo 30% coinsurance

D99y11l b7ighahgo 50% coinsurance

Adin

N7ni’ haada yit’4ego, ha’1t’7ida nidiniiltsoodgo 47 doodago tsi’na’ii[1h1 bee nich’8 an1h00t’i’go

Azee’1l’98gi n7j7d1ahgo n1hodi’n4l’88h

T11’ doot[‘izh b7ghahgo 30% coinsurance

D99y11l b7ighahgo 50% coinsurance

$35 azee’77[‘7n7 copay bich’8’ nijil44h 47 h1n7 n1lzh--h biniy4 jin7y1h1gi t’47 binii y4.

Azee’1l’99g0ne’ jizhd1ago haa 1h1y3

T11’ doot[‘izh b7ghahgo 30% coinsurance

D99y11l b7ighahgo 50% coinsurance

Preauthorization 1[ts4 l3 aleeh – doo 1lyaag00 47 $500 hak’ij8 doodzo d00 nizhdool44[.

Y7n7lts32go

Azee’77[’7n7 n1hon4l’88h biniiy4 n7j7d11hgo.

$35 copay/n7j7d1ahgo; deductible doo nij7l4eda

D99y11l b7ighahgo 50% coinsurance

Preventive services choo’98hgo 47 cost sharing d00 1l’98da. Choo’oo’88h7g77 b0h0ln77h d77 binahji’copayment, d00 coinsurance, d00 deductible b7 daa d44t’i’do. Ach77h d00 bik’ij8’ haa 1h1y1n7g77 47 n1hodi’n4l’88h naa 1h1y3 binaaltsoos dabik11. (hak’i na’at’1 1daat’4h7g77)

Aw44 haleeh/aw44’ yich77go bina’anish7g77

T11’ doot[‘izh b7ghahgo 30% coinsurance

D99y11l b7ighahgo 50% coinsurance

Aw44’ yich77h/aw44 haleehgii, azee’1l’97gii bee nida’azhnish7g77

Taa’ doot[‘izh b7ghahgo 30% coinsurance

D99y11l b7ighahgo 50% coinsurance

Preauthorization 1[ts4 l3 aleeh – doo 1lyaag00 47 $500 hak’ij8 doodzo d00 nizhdoodl44[.

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* Beehaz’1anii biyi’di bik’ehgo 1k1 i’doolwo[ d00 bik’4 ni’dooly44[ baahane’7g77 47 naaltsoos n1 hadilyaa7g77 bik11’ 47 doodago kwe’4 d7n77[‘88[ http://www.cms.gov/CCIIO/Resources/Files/Downloads/sbc-uniform-glossary-navajo-2.pdf.

Na’7d7[kidgo k0j8’ hod77lnih:1-844-443-3726 47 doodago kwe’4 na’7d7d77[ki[ mybenefitsdfsco.com.

Ats’77s baa 1h1y3

biniy4 choo’9

hajigh1h7g77

D77 47 ats’77s baa 1h1y3 biniy4 choo’9 hajigh1a [eh

D77 nid77l44[

H1 ni’iily4 1n4elt’e’j8’ d00 bee

nahaz’1anii h0l0n7g77 baa hane’

Azee’77['7 bi[ a[ha’deet’1n7g77

(A’ohgo nid77l44[)

Azee’77['7n7 doo bi[ a[ha’deet’1n7g77

({3 nid77l44[)

Y1’1t’44h n7d77dlee[ biniy4 naa 1h1y1n7g77 n7n7zingo 47 doodago [ahgo nich’8’ an1h00t’i’go 1k1 e’elyeed n7n7zingo

Home health care haghandi haa 1h1y3

T11’ doot[‘izh b7ghahgo 30% coinsurance

D99y11l b7ighahgo 50% coinsurance

N11haiji’ azee’77[’7n7 d00 hats’77s ch’iiy11n doo hazho’0 choyoo[’9 bik’i ad44st’99’7g77 PDK, ah7idzogo, Neezn1diin d00 bi’aan naadiin b7neel’33ji’ haa’dood11[.

Rehabilitation services hadziil n7j7dleeh biniy4 haa 1h1y3

T11’ doot[‘izh b7ghahgo 30% coinsurance

D99y11l b7ighahgo 50% coinsurance N1h1st’4diindi n7zhdood11[ t11[a’77

n11haiji’, 47 naanish b7n1hoo’aah, y1ti’ b7n1hoo’aah, d00 hats’77s dilz4eh d00 bidziil 1n1ln44h.

Habilitation services t’11doole’4 1j7l’9 b7n1hojii[’aah

T11’ doot[‘izh b7ghahgo 30% coinsurance

D99y11l b7ighahgo 50% coinsurance

Skilled nursing care Azee’ neikk1h7 44h0sin7g77 bee aa’1h1y3.

T11’ doot[‘izh b7ghahgo 30% coinsurance

D99y11l b7ighahgo 50% coinsurance

Hwe’oonish7g77binahji’ n1h1st’47diin j9 b77ghah. Preauthorization 1[ts4 l3 aleeh – doo 1lyaag00 47 $500 hak’ij8 doodzo d00 nizhdool44[.

Durable medical equipment ats’77s y7k1 an1lwo’ii bee na’ad1 d00 bee na’ii’n1 bee 1k1 an1’1lwo’

T11’ doot[‘izh b7ghahgo 30% coinsurance

D99y11l b7ighahgo 50% coinsurance

Bee h1k1 i’doolwo[7g77 47 bee y1’1t’44h jidoolee[ii t’4iy1 1l’9. Ats’77s y7k1 an1lwo’ii i[ naalb22s7da, bee 1k1’ e’elwo’7g77 DME benefits 47 nahidoonih 47 doodago ha’doo’ni[ go choo’9 (b33h7l7n7g77 b7ighahj8’).

Hospice services Iin1 nih0d7n0ol 22[g77 haa’1h1y3.

T11’ doot[‘izh b7ghahgo 30% coinsurance

D99y11l b7ighahgo 50% coinsurance

Preauthorization 1[ts4 l3 aleeh – doo 1lyaag00 47 $500 hak’ij8 doodzo d00 nizhdool44[.

Na’1[ch7n7 biwoo’da bin11’da baa 1h1y3.

![ch7n7 bin11’ n7l’9, naalkaah Doo bi[ wolta’da. Doo bi[ wolta’da. Adin !’ch7n7 bin11k’ee sinil7 Doo bi[ wolta’da. Doo bi[ wolta’da. Adin A[ch7n7 biwoo’ b1 n1n4l’88h. Doo bi[ wolta’da. Doo bi[ wolta’da. Adin

!k1 an1’1lwo’ d00 haa 1h1y3 doo h1 bik’4 ni’iily4h7g77 kwe’4 bik11’ (Doo t’11 a[tso bik1a’da. Naaltsoos bik’ehgo naa 1h1y1n7g77, policy 47 doodago plan biyi’di, excluded services, h1d7d77’88[.)

Tsah bee ats’77s hasht’e n1l’9, Acupuncture.

!zhnoolnin biniy4 na’algizh, cosmetic surgery.

Awoo’ bina’anish,Dental care (T’11

h0y1anii).

N7zaadg00 haa 1h1y3

United States bits’32di, t['0o’di ch’aa joog1a[go, doo t’11’77yis7 t7zhdiit’88hg0 azee’77['7n7 choo’88h7g77.

Hakee’ n1n4l’88hgo baa 1h1y32go, Routine foot care (1kondi ats’77s ch’iy11n doo hazh0’0 choyoo['98da, diabetes, bee h22h dahaz’32go 47 dooda).

!zhn7[d77l d00 dahizhd4dlo’ t’33’ n7doolki[ biniy4 atah jidoog11[, Weight loss program.

5 of 8

!k1 an1’1lwo’ d00 haa 1h1y3 doo h1 bik’4 ni’iily4h7g77 Excluded Services d00 t’11 h1 bik’4 ni’iily4h7g77:

N11n1 [a’1k1 an1’1lwo’ d00 haa 1h1y3n7g77 (Doo t’11 a[tso bik1a’da. Naaltsoos bik’ehgo naa 1h1y1n7g77 [a nidaheezt’i’j8’ daasdzoh plan biyi’di, h1d7d77’88[.)

Hats32di naalgizhgo bee 1zhn7ld77l7g77 t’33’ 1n1l’88h, Bariatric surgery.

Chiropractic care hw77shgh11n d00 hats’in hasht’e’ nin1halkeed. (naadiin b77ghahji’ jigh11h)

Jeeh n1t’1ahgo bee azhdiits’a’7g77, Hearing aids.

Doo i'izhniilts22dago biniy4 h22h 4’4l’7n7g77, Infertility treatment (biniinaa1g77 d00 be oonish t’47)

Azee’ neik1hi hak’id44z’99’(Azee’ 1l’98gii jizd1ago [a’ hak’i d44z’98’go 47 nidaga’)

An11’naagh11j7 bik’i ad44st’97’ (T’11 h0y1anii b1)

Ats’77s baa 1h1y3 n1 had7t’4ego 1lyaa7g77 n11sg00 bee n1 haz’3: Naat’1anii bi[ nidahaz’3 47 h1k1 iijah bee haa 1h1y3 hadil’88h7g77 niit’ihgo. Kwe’4 bich’8’ hojilnih:b4eso 1ch’33h naa’nil bee haa 1h1y3 plan

1-888-895-6985, U.S. Department of Labor’s Employee Benefits Security Administration kwe’4 1-866-444-EBSA (3272) 47 doodago

www.dol.gov/ebsa/healthreform, 47 doodago Department of Health and Human Services, Center for Consumer Information and Insurance Oversight,

kwe’4 1-877-267-2323 x61565 47 doodago www.cciio.cms.gov. !1d00 n11n1 [ahgo 1t’1o haa 1h1y3 dah0l=, t’11 sahdii b4eso 1ch’33h naa’nil

dah0l0n7g77 nijii[nih 47 Health Insurance Marketplace h1k1 iijah. Marketplace, kwe’4 b7na’7zhd7[ki’ www.HealthCare.gov koj8’ b44sh bee hojilnih

1-800-318-2596.

Ha’1t’7ida baa saad haleehgo N7d7n0ol’88[ d00 Baa N1hwiid7n0ot’88[: N1 ni’dooly44[ d00 n1 l3 adoolee[ claim n7t’66’ doo l3 azl99’dago denial 47

da’7n7ishgo nahaz’3 47 [a’ bee haa 1h1y1n7g77 hadilyaa, plan bich’8’ saad hoji[44hgo h1 yinidaalnish. Baa saad haleeh7g77 47 n1n4l’88h, grievance, 47

doodago baa n1hwiid7n0ot’88[, woly4. K0t’4ego bee n1 ah00t’i’7g77 47 claim hach’8’ doo l3 azl98’da bee ho[ hane’go naaltsoos hach’8’ 1l’88h7g77 bik11’

baa saad hoji[eehgo 11l’88[7g77. Bee Naa !h1y3 Naaltsoos hadilyaa7g7, plan, 47 a[d0’ bik11’ h1 ni’7ly4da bee ni’j7[ts0osgo, claim d00 doo l3 azl99’g00

baa n1hwiid7n0ot’88[, appeal d00 n7d7n0l’88[, grievance bee haa 1h1y3 hadilyaii, plan bich’8’ saad hoji[eehgo bik’ehgo binizhdoolnish7g77. K0t’4ego bee n1 ah00t’i’7g77, d77 naaltsoos, 47 doodago h1k1’ i’doowo[7g77 baa hane’ kwe’4: Blue Cross and Blue Shield of Illinois kwe’4 1-888-895-6985 47

doodago kwe’4 na’7d7d77[ki[ www.bcbsil.com, 47 doodago U.S. Department of Labor's Employee Benefits Security Administration kwe’4

1-866-444-EBSA (3272) 47 doodago kwe’4 na’7d7d77[ki[ www.dol.gov/ebsa/healthreform. N11n1 baa saad h0l0n7g77 baa n1hwiid7n0ot’88[, appeal kwe’4 h1k1 iijahgo bee ni’ji[tsos Illinois Department of Health Insurance (877) 527-9431 d00 http://insurance.illinois.gov.

Da’ d77sh Minimum Essential Coverage h0l=? Aoo’ B4eso 1ch’33 naanil bee ats’77s baa 1h1y3 Minimum Essential Coverage t’11[a’77 nideezid nee 1ding0 47, income tax 1n7daalne’go b4eso haash99

n4elt’e’ y7dayiizoh, 1kondi t’1 doolz88[7g77 binahji’ exemption h0l=-go 47 doo nik’ij8’ w0lta’da do.

Da’ d77sh Minimum Value Standards bik’ehgo 1lyaa? Aoo’

Bee naa 1h1y32go hadilyaa7g77 plan doo Minimum Value Standards, bik’ehgo 1lyaag0 47 premium tax credit binahji’ n1 l3 1t’4ego, Marketplace d66’

plan bik’4 azl1 yee nik1 adoolwo[.

Language Access Services:

Spanish (Español): Para obtener asistencia en Español, llame al 1-888-895-6985.

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-888-895-6985.

Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-888-895-6985.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-888-895-6985.

–––––––––––––––––– Bee haa 1h1y3 hadil’88hgo, plan bee h1k1 i’doolwo[ t’00 baa hane’go 1lyaa7g77 n11n1 n11sdi bik11’ –––––––––––––––––

6 of 8

Bee Naa !h1y1ni Hadilyaa7g77, Plan 47 haa oozb1n7g77 kwe’4 HANE’ bik11’7g77 doo baa h00ne’7g77 a[d0 [a’ t’11 yik’4 as[1a doo.

Peg aw44 bee haleeh

(N1h1st’47 n7deezid t’0 oolts22d0 in-network

n1hodi’n4l’88h d00 azee’ 1l’98di ach77h)

Mia bits’in yisk’is

(in-network di ts98[go 1k1 i’iilyeedi n7y1 d00

n1d11h bik44’d44’ be’oonish) bik44’d44’

be’oonish

Joe Diabetes 27g77 b22h dahas’3

(n11haij8’ in-network d0 bik’i ad4est’99’)

Plan deductible t’11 1t’4 yeehas’1n7g77 $4,600

Specialist copayment bich’8’ niily1 $55

Azee’1l’8 chooz’88dgi coinsurance 30%

Coinsurance n11n1 [a’ 30%

BEE HANE’II: k0hoot’4ego

Specialist bi[ yah an1’1d11h (oots32go)

Aw44’ haleehgi 1k1’ e’elwo’7g77

Aw44 haleehgo azee’ 1l’9 chooz’88d Diagnostic tests (hak11’ na’at’1 d00 di[ nil9)

Specialist visit (hwi’iilwosh)

T’00 bee hane’go b33 adoolee[7g77 $12,800

T’00 baa hane’go Peg k0n4elt’e’ nay7l4:

Hab4eso $4’zhdii’ni[

Deductibles ![ts4 nihely4h7g77 $4,600

Copayments n7j7d1ahgo nin1j7dl44h $40

Coinsurance $4’zh dii’ni[7g77 $1,900

Doo bik’4 azl1ada

Doo bik’4 azl1ada $60

K0n4elt’e’ Peg niidool44[ $6,600

Plan deductible t’11 1t’4 yeehas’1n7g77 $4,600

Specialist copayment bich’8’ niily1 $55

Azee’1l’8 chooz’88dgi coinsurance 30%

Coinsurance n11n1 [a’ 30%

BEE HANE’II k0hoot’4ego:

Azee’77[‘7n7 bi[ yahan7j7d11h (naa[niih baa

hane’)

Hats’77s naalkaah (Hadi[ naalkaah)

Azee’ nidahaniih7g77

Naaly4h4 bee ats’77s baa 1h1y1n7g77 (di[ be 1sh88h [ikanii nei[kaah4)

T’00 bee hane’go b33 adoolee[7g77 $7,400

T’00 baa hane’go Joe k0n4elt’e’ nay7l4:

Hab4eso $4’zhdii’ni[

Deductibles ![ts4 nihely4h7g77 $4,600

Copayments n7j7d1ahgo nin1j7dl44h $400

Coinsurance $4’zh dii’ni[7g77 $600

Doo bik’4 azl1ada

Doo bik’4 azl1ada $60

K0n4elt’e’ Joe niidool44[ $5,120

Plan deductible t’11 1t’4 yeehas’1n7g77 $4,600

Specialist copayment bich’8’ niily1 $55

Azee’1l’8 chooz’88dgi coinsurance 30%

Coinsurance n11n1 [a’ 30%

BEE HANE’II k0hoot’4ego:

Tsx98[go Hodi’n4l’88h (azee’ 77[’98gii

choo’88h7g77) Hats’77s naalkaah (Agh1’d7ldlaad)

H44[ bee cho’joo[’7n7g77 (gish) Hats’77s bidziil 1n1ln44h (Hats’77s n1lz44h)

T’00 bee hane’go b33

adoolee[7g77 $1,900

T’00 baa hane’go Peg k0n4elt’e’ nay7l4:

Hab4eso $4’zhdii’ni[

Deductibles ![ts4 nihely4h7g77 $1,400

Copayments n7j7d1ahgo

nin1j7dl44h $400

Coinsurance $4’zh dii’ni[7g77 $0

Doo bik’4 azl1ada

Doo bik’4 azl1ada $0

K0n4elt’e’ Mia niidool44[ $1,800

Bee Haa !h1y3 Hadilyaago Hak’4sti’ Baa Hane’

D77 nidahaly4 dabik117g77 47 t’00 bee hane’ 1t’4. H22h 4’4lyaa yaahalne’7g77 47 t’00 bee hane’ 1daat’4. $7 bee haa 1h1y32

hadil’88h7g77, plan, ak’7daasti’7g77 bee baa 1kohwiinidzin. Naa n7’7ib88h7g77 47 azee’77[‘7n7 n1 7’iilaa7g77 d00 b33hda’7l7n7g77 bik’ehgo [ahgo 1t’4edoo. Bik’4 ni’iily4h7g77 ah44da’zhdii’ni[, cost sharing, 1dan4elt’e’7g77 hazh0’0 n7n7[‘98doo (deductibles,

copayments and coinsurance baa hane’go) d00 1k1 an1’1lwo’ doo h1 bik’4 ni’iily4h7g77 excluded services haa 1h1y3

hadilyaii, plan, bee hane’7g77. D77 bik’ehgo a[ch’8’ naninildoo. T’11[a’ jiz7n7go 1t’4edoo7g77 47 baahane’.

Ats’77s Baa !h1y3 h1 had7t’4ego 47 bee hasihgo na’ad1.

Baa 1dahwiily1n7g77 [a’ biy1ti’, adiits’a’ gi, saad doo y44 h0sinii b7k1 an7deijahgo bee bi[ hane’7g77 yik’i’diit88h. Doo h1ida nahj8’ k0day7n7ilzinda n11n1 [a’ dine’4 n7l7n7g77 b33, bik1g7 1noolnin7g77 b22, n11n1 [a’ k4yahd66’ naagh1, asd1n7

nil7n7g77, hast88/asdz1n7 nil7n7g77 h17sh99 yee 1d44h0lzin7g77, bin11ha7g77 e7 doodago b22h dahaz’1n7g77 biniinaa.

N11n1 [a’ saad bee sh7k1 i’doolwo[ jin7zingo koj8’ t’11j77k’e hojilnih 855-710-6984.

Doo hazh0’0 1da’iilyaadago 47 doodago t’11 ha’1t’7ida nits’22 k0olzingoda 47 nihich’8’ hod77lnihgo ni’d77[tsos:

Office of Civil Rights Coordinator Phone: 855-664-7270 (voicemail) 300 E. Randolph St. TTY/TDD: 855-661-6965 35th Floor Fax: 855-661-6960 Chicago, Illinois 60601 Email: CivilRightsCoordinator@hcsc.net

Saad hos7n7[98’g77 Civil Rights binahji’ koj7 baahon7t’i’ U.S. Department of Health and Human Services, Office for Civil Rights, kwe’4:

U.S. Dept. of Health & Human Services Phone: 800-368-1019 200 Independence Avenue SW TTY/TDD: 800-537-7697 Room 509F, HHH Building 1019 Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Washington, DC 20201 Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html