Kaiser Permanente: KP DC STD Bronze 5000/50

Kaiser Permanente: KP DC STD Bronze 5000/50/Dental/PedDental Coverage Period: Beginning on or after 01/01/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: HMO

Kaiser Permanente:This is onlyKP DC aSTD summary. Bronze 5000/50/Dental/PedDental If you 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 800-777-7902. Coverage Period: Beginning on or after 01/01/2017 Important Questions Answers Why this Matters: Summary of Benefits and Coverage: What this plan covers and what it costs. $5,000 person/$10,000 family Coverage for: Individual/Family You must pay all the costs up to the deductible amount before this plan begins Does not apply to Outpatient Visits, to pay for covered services you use. Check your policy or plan document to see PlanWhat type: is theHMO overall Preventive Care, Prescription Drugs, Vision when the deductible starts over (usually, but not always, January 1st). See the deductible? or Dental Services. Copayments and the chart starting on page 2 for how much you pay for covered services after you Prescription Drug Deductible do not count meet the deductible. toward the deductible. Are there other Yes. Rx Deductible (Doesn't apply to deductibles for specific Generic): $300 person in network. There are You must pay all of the costs for these services up to the specific deductible services? no other specific deductibles. amount before this plan begins to pay for these services. Is there an out–of– The out-of-pocket limit is the most you could pay during a coverage period pocket limit on my Yes. For Plan Provider $7,150 person / (usually one year) for your share of the cost of covered services. This limit helps expenses? $14,300 family you plan for health care expenses. What is not included in Premiums, balance-billed charges (unless the out–of–pocket balance-billing is prohibited), and health care Even though you pay these expenses, they don't count toward the out-of-pocket limit? this plan does not cover. limit. Is there an overall annual limit on what No. The chart starting on page 2 describes any limits on what the plan will pay for the plan pays? specific covered services, such as office visits. 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 Does this plan use a Yes. For a list of preferred providers, see hospital may use an out-of-network provider for some services. Plans use the network of providers? www.kp.org or call 800-777-7902. 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. Yes. A written referral is required to see a Do I need a referral to Plan specialist. You may self refer to certain This plan will pay some or all of the costs to see a specialist for covered services see a specialist? specialists. but only if you have the plan’s permission before you see the specialist. Are there services this Some of the services this plan doesn’t cover are listed on page 5. See your plan doesn’t cover? Yes. policy or plan document for additional information about excluded services.

Questions: Call 800-777-7902 or 1-301-879-6380 or 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 800-777-7902 or 1-301-879-6380 or 711 (TTY) to request a copy.KAISER FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC., 2101 East Jefferson Street, Rockville, MD 20852 1 of 8 ● 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 Your cost if you use a Your cost if you use a Medical Event Services You May Need Plan Provider Non-Plan Provider Limitations & Exceptions Primary care visit to treat an injury or illness $50/visit Not Covered Deductible does not apply. Specialist visit $50/visit Not Covered Deductible does not apply. If you visit a health care provider’s Other practitioner office visit $50/visit after deductible Not Covered Spinal Manipulation limited to Members age office or clinic 12 and over. Cost-sharing will apply if non-preventive Preventive care/screening/ No Charge Not Covered services are provided during a scheduled immunization preventive visit. Deductible does not apply. Diagnostic test (x-ray, blood work) $50/visit after deductible Not Covered –––––––––––none––––––––––– If you have a test Imaging (CT/PET scans, MRIs) $500/test after deductible Not Covered –––––––––––none–––––––––––

2 of 8 Common Your cost if you use a Your cost if you use a Medical Event Services You May Need Plan Provider Non-Plan Provider Limitations & Exceptions Copay for up to 30-day supply. Up to 90-day supply for 2 copays. No charge for If you need drugs Generic drugs $25/prescription Not Covered preventive drugs, contraceptives or oral to treat your illness chemotherapy drugs. Rx Deductible does or condition not apply. Up to 30-day supply or 90-day supply. No More information Preferred brand drugs 50% Coinsurance after Rx Not Covered charge for preventive drugs, contraceptives about prescription deductible or oral chemotherapy drugs. drug coverage is available at 50% Coinsurance after Rx Up to 30-day supply or 90-day supply. No www.kp.org/ Non-preferred brand drugs deductible Not Covered charge for preventive drugs, contraceptives formulary . or oral chemotherapy drugs. 50% Coinsurance after Rx Up to 30-day supply or 90-day supply. No Specialty drugs deductible Not Covered charge for oral chemotherapy drugs.

Facility fee (e.g., ambulatory 20% Coinsurance after Not Covered –––––––––––none––––––––––– If you have surgery center) deductible outpatient surgery 20% Coinsurance after Physician/surgeon fees deductible Not Covered –––––––––––none––––––––––– 20% Coinsurance after 20% Coinsurance after Emergency room services deductible deductible –––––––––––none––––––––––– If you need immediate medical Emergency medical No Charge No Charge Non-licensed ambulance services not attention transportation covered. Deductible does not apply. Non-plan providers are covered only outside Urgent care $50/visit $50/visit the service area. Deductible does not apply.

Facility fee (e.g., hospital 20% Coinsurance after Not Covered –––––––––––none––––––––––– If you have a room) deductible hospital stay 20% Coinsurance after Physician/surgeon fee deductible Not Covered –––––––––––none–––––––––––

3 of 8 Common Your cost if you use a Your cost if you use a Medical Event Services You May Need Plan Provider Non-Plan Provider Limitations & Exceptions Group Therapy is $25/visit. All other Mental/Behavioral health $50/visit Not Covered Outpatient Services are 10% coinsurance. outpatient services Deductible does not apply. If you have mental Mental/Behavioral health 20% Coinsurance after health, behavioral inpatient services deductible Not Covered –––––––––––none––––––––––– health, or substance abuse Substance use disorder Group Therapy is $25/visit. All other needs $50/visit Not Covered Outpatient Services are 10% coinsurance. outpatient services Deductible does not apply. Substance use disorder 20% Coinsurance after inpatient services deductible Not Covered –––––––––––none––––––––––– Prenatal and postnatal care No Charge Not Covered Deductible does not apply. If you are pregnant Delivery and all inpatient 20% Coinsurance after services deductible Not Covered –––––––––––none––––––––––– Home health care No Charge after deductible Not Covered Limited to 90 visits per episode of care. Inpatient: 20% Coinsurance after Inpatient: None; Outpatient: Cardiac Rehab Rehabilitation services deductible; Outpatient: Not Covered limited to 90 consecutive days; Pulmonary $50/visit after deductible Rehab limited to 1 program per lifetime. If you need help recovering or have Habilitation services $50/visit after deductible Not Covered –––––––––––none––––––––––– other special 20% Coinsurance after health needs Skilled nursing care deductible Not Covered Limited to 60 days per year. 20% Coinsurance after Durable medical equipment deductible Not Covered –––––––––––none––––––––––– 20% Coinsurance after Hospice service deductible Not Covered Limited to 180 days per eligibility period.

4 of 8 Common Your cost if you use a Your cost if you use a Medical Event Services You May Need Plan Provider Non-Plan Provider Limitations & Exceptions One exam per year. Deductible does not Eye exam $50/visit Not Covered apply.; 1 pair glasses/yr (single OR bifocal lenses) No charge (Deductible OR 1st purchase of contact lenses/yr OR 2 If your child needs Glasses does not apply) Not Covered pair/eye/yr medically necessary contacts dental or eye care (select group of frames and contacts) Ages 6-18: 1 set of full mouth x-rays/ No charge (Deductible panoramic film covered every 5 years per Dental check-up does not apply) Not Covered patient. No more than 1 set of x-rays are covered per year.

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 ● Infertility Treatment ● Private-Duty Nursing ● Cosmetic Surgery ● Long-Term/Custodial Nursing Home Care ● Routine Foot Care ● Hearing Aids ● 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.) ● Bariatric Surgery ● Routine Eye Exam (Adult) ● Voluntary Termination of Pregnancy with ● Chiropractic Care with limits ● Routine Hearing Tests limits ● Routine Dental Services (Adult) with limits ● Weight Loss Programs with limits

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

5 of 8 For more information on your rights to continue coverage, contact the insurer at 800-777-7902. You may also contact your state insurance department at (202) 724-7491; ; .

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: 1-866-444-3272

Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coverage.

Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides.

Language Access Services: SPANISH (Español): Para obtener asistencia en Español, llame al 800-777-7902 or TTY/TDD 1-301-879-6380 or 711. TAGALOG (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 800-777-7902 or TTY/TDD 1-301-879-6380 or 711. CHINESE (中文): 如果需要中文的帮助，请拨打这个号码 800-777-7902 or TTY/TDD 1-301-879-6380 or 711. NAVAJO (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 800-777-7902 or TTY/TDD 1-301-879-6380 or 711. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––

6 of 8 About these Coverage Having a baby Managing type 2 diabetes (normal delivery) (routine maintenance of a well-controlled Examples: condition)

These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial Amount owed to providers: $7,540 Amount owed to providers: $5,400 protection a sample patient might get if they are Plan pays $2,820 Plan pays $2,420 covered under different plans. Patient pays $4,720 Patient pays $2,980

This is not a Sample care costs: Sample care costs: cost Hospital charges (mother) $2,700 Prescriptions $2,900 estimator. Routine obstetric care $2,100 Medical Equipment and Supplies $1,300 Hospital charges (baby) $900 Office Visits and Procedures $700 Don’t use these examples to Anesthesia $900 Education $300 estimate your actual costs Laboratory tests $500 Laboratory tests $100 under this plan. The actual care you receive will be different Prescriptions $200 Vaccines, other preventive $100 from these examples, and the Radiology $200 Total $5,400 cost of that care will also be Vaccines, other preventive $40 different. Total $7,540 Patient Pays: Deductibles $1400 See the next page for important information about Patient Pays: Copays $1500 these examples. Deductibles $4500 Coinsurance $0 Copays $20 Limits or exclusions $80 Coinsurance $0 Total $2,980 Limits or exclusions $200 Note: These numbers assume the patient is Total $4,720 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 800-777-7902, TTY/TDD 1-301-879-6380 or 711.

7 of 8 Questions and answers about the Coverage Examples:

What are some of the What does a Coverage Example Can I use Coverage Examples to assumptions behind the show? compare plans? Coverage Examples? For each treatment situation, the Coverage Yes. When you look at the Summary of ● Costs don’t include premiums. Example helps you see how deductibles, Benefits and Coverage for other plans, you’ll ● Sample care costs are based on national copayments, and coinsurance can add up. It also find the same Coverage Examples. When you averages supplied by the U.S. helps you see what expenses might be left up to compare plans, check the “Patient Pays” box Department of Health and Human you to pay because the service or treatment isn’t in each example. The smaller that number, Services, and aren’t specific to a covered or payment is limited. the more coverage the plan provides. particular geographic area or health plan. ● The patient’s condition was not an Does the Coverage Example Are there other costs I should excluded or preexisting condition. predict my own care needs? consider when comparing plans? ● All services and treatments started and ended in the same coverage period. No. Treatments shown are just examples. ● There are no other medical expenses for Yes. An important cost is the premium you The care you would receive for this condition pay. Generally, the lower your premium, the any member covered under this plan. could be different based on your doctor’s ● Out-of-pocket expenses are based only more you’ll pay in out-of-pocket costs, such advice, your age, how serious your condition as copayments, deductibles, and on treating the condition in the is, and many other factors. example. coinsurance. You should also consider ● The patient received all care from in- contributions to accounts such as health network providers. If the patient had Does the Coverage Example savings accounts (HSAs), flexible spending received care from out-of-network arrangements (FSAs) or health providers, costs would have been predict my future expenses? reimbursement accounts (HRAs) that help higher. you pay out-of-pocket 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.

Questions: Call 800-777-7902 or 1-301-879-6380 or 711 (TTY), or visit us at www.kp.org. If you aren’t clear about any of the Questions: Call 800-777-7902 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 800-777-7902 or (TTY) to request a copy. 800-777-7902 or 1-301-879-6380 or 711 (TTY) to request a copy.KAISER FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC., 2101 East Jefferson Street, Rockville, MD 20852 8 of 8 KAISER FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC., 2101 East Jefferson Street, Rockville, MD 20852 of Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (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. District of Columbia 1-800-777-7902 Maryland 1-800-777-7902 Virginia 1-800-777-7902 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, 2101 East Jefferson Street, Rockville, MD 20852, telephone number: 1-800-777-7902. 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.

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Kaiser Permanente for Individuals and Families

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 if this is a notice that 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 Ɓǎsɔ́ ɔ̀ Wùɖù (Bassa): Ɔ mɔ̀ nì kpé ɓɛ́ m̀ ke gbo- California...... 1-800-464-4000 መብት አለዎት። ስለ ማመልከቻዎ ወይም ከኬሰር ፐርማነንቴ kpá-kpá edy ɖe nì mìɔùn nììn ɓiɖí -ẃ uɖu mú pidyi.́ Kaiser Permanente ስለሚያገኙት ሽፋን ማንኛውም ጥያቄዎች Ɔ jǔ ek m dyi dyi-diè-ɖɛ ɓě eɓ ɖe ɓá ni céè-ɖɛ m ̀ ̀ ̀ ̀ ̀ Colorado...... 1-800-632-9700 ካሉዎት፣ ወይም ይህ ማሳወቂያ በግልፅ በተጠቀሰ ቀን ማድረግ tò ɓó ɖɛ zɔ̀ jè dyíɛ ní, mɔɔ jǔ ɓá ̀ ni kũun kpɔ ̃ je dyi ́ ያለብዎ ነገር እንዳለ የሚያስገድድዎ ከሆነ፣ በተጠቀሰው የስልክ ቁጥር dyiì ǹ ɖe Kaiser Permanente muɛ ní, mɔɔ ɔ dyi bɔ̌ ̃ District of Columbia. . . 1-800-777-7902 ለስቴትዎ ወይም ለክልልዎ ደውለው ከአስተርጓሚ ጋር ይነጋገሩ። ɖò jǔ ɓɛ́ m̀ ké ɖɛ ɖo nyu ɓó wé jɛ́ɛ́ ɖò kɔ ̃ ni,̀ niì ,́ ɖá Georgia...... 1-888-865-5813 nɔ̀ ɓà ɓɛ́ wa toà oɓ ni ̀ ɓóɖóɔ̀ mɔɔ ni ̀ gbɛ̌ ɛ̀ɔ̀ bììɛ, ke العربية )Arabic(: لك الحق في الحصول على المساعدة بلغتك دون nì mu nyɔ-wuɖuún-zà-nyɔ̀ ɖo gbo wuɖuùn. Hawaii...... 1-800-966-5955 تحمل أي تكاليف. إذا كانت لديك استفسارات بشأن طلبك أو تغطيتك বাংলা (Bengali): বিনা খরচে আপনার নিজের ভাষায় সাহায㖯 পাওয়ার অধিকার Maryland...... 1-800-777-7902 التي تقدمها Kaiser، Permanente أو إذا كان هذا اإلشعار الذي আপনার আছে। আপনার যদি আপনার আবেদন বা Kaiser Permanente-এর يتطلب منك اتخاذ إجراء خالل تاريخ محدد، ُيرجى االتصال بالرقم মাধ㖯মে পাওয়া কভারেজ নিয়ে ক�োন�ো প্রশ্নকে থা বা এ綿 যদি ক�োন�ো ন�ো綿স হয় যার Oregon...... 1-800-813-2000 المخصص لواليتك أو منطقتك للتحدث إلى مترجم فوري. ফলে আপনার এক綿 নিরধার্ ত দিনের মধ্য ক�োন�ো পদক�প গ্রহণ করারয়�োজ প্র ন হয়, Virginia...... 1-800-777-7902 Հայերեն (Armenian): Դուք ունեք Ձեր լեզվով তাহলে দ�োভাষীর সাথে কথা বলতে আপনার রাজ㖯 বা অঞ্চলের জন㖯 প্রদত্ত নম্বর綿তে անվճար օգնություն ստանալու իրավունք: ফ�োন করুন। Washington ...... 1-800-813-2000 Եթե Դուք հարցեր ունեք Ձեր դիմումի կամ Kaiser Permanente-ի միջոցով Ձեր ծածկույթի Cebuano (Bisaya): Anaa moy katungod nga վերաբերյալ, կամ եթե սա ծանուցում է, որը mangayo og tabang sa inyo pinulongan ug kini TTY...... 711 պարտադրում է Ձեզ, որպեսզի գործուղություններ walay bayad. Kung naa mo pangutana bahin sa ձեռնարկեք մինչև որոշակի ամսաթիվ, ապա inyo aplikasyon o coverage sa Kaiser Permanente, զանգահարե՛ք Ձեր նահանգի կամ շրջանի o kung kaning pahibalo nanginahanglan sa inyo համար տրամադրված հեռախոսահամարով` paglihok sa dili pa usa ka piho nga petsa, palihug թարգմանչի հետ խոսելու համար: lang pagtawag sa mga numero sa telepono nga gihatag sa imong estado (“state”) o rehiyon (“region”) para makigstorya sa usa ka interpreter.

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

Have questions? Call us at 1-800-494-5314. • Go to buykp.org/apply. • Or contact your agent or broker.

60436922 National 2016 Option 2

Kaiser Permanente for Individuals and Families

中文 (Chinese): 您有權免費以您的語言獲得幫助。 Hmoob (Hmong): Koj muaj cai kom tau txais kev pab ગજરાતીુ (Gujarati): તમને કોઇ પણ ખર㚚 વગર 如果您對您的申請或承保有任 uas hais koj hom lus yam tsis tau them nqi. Yog koj muaj Kaiser Permanente તમારી ભાષામાં મદદ મેળવવાનો અધિકાર છે. જો lus nug txog koj daim ntawv thov los yog cov kev pab 何疑問，或者如果本通知要求您在具體日期之前採 તમને Kaiser Permanente મારફતે તમારી અર狀 them nyiaj tim Kaiser Permanente, los yog tias daim 取措施，請致電您所在的州或地區的電話，與口譯 અથવા કવરેજ વિશે પ્ર�ન હોય, અથવા જો આ નોટિસ ntawv no yog ib tsab ntawv ceebtoom uas yuav kom 員進行溝通。 હોય 狇મા તમને કોઈચોક્કસ તારીખથી પગલાં koj ua ib yam dabtsi raws li hnub tau teev tseg, hu rau લેવાની જ싂ર હોય, તો દુ ભાષિયા સાથે વાત કરવા tus nab npawb xovtooj uas tau muab rau koj lub xeev Chuuk (Chukese): Mei wor omw pwuung omw તમારા સ્ટે અથવા રી狀યન માટે પરાૂ પાડવામાં lossis cheeb tsam kom tau tham nrog tus kws txhais lus. kopwe angei aninis non foosun fonuomw આવેલ નંબર પર ફોન કરો. (Chuukese), ese kamo. Ika mei wor omw kapas eis usun omw apilikeison me/ika policy fan Kreyòl Ayisyen (Haitian Creole): Ou gen dwa Igbo (Igbo): Ị nwere ikike ịnweta enyemaka n’asụsụ nemenien Kaiser Permanente, are ika ei esinesin pou jwenn èd nan lang ou gratis. Si ou gen gị na akwụghị ụgwọ ọ bụla. Ọ bụrụ na ị nwere ajụjụ a erenuk pwe kopwe fori pwan ekoch fofor, ka nenpòt kesyon sou aplikasyon ou an oswa gbasara akwụkwọ anamachọihe gị ma ọ bụ mkpuchi tongeni omw kopwe kori ewe nampa mei kawor asirans ou ak Kaiser Permanente, oswa si nan avi si na Kaiser Permanente, ma ọ bụ ọ bụrụ na nke faniten omw state ika fonu (asan) iwe eman chon sa a gen bagay ou sipoze fè sa a avan yon sèten bụ ọkwa a chọrọ ka ị mee ihe tupu otu ụbọchị, kpọọ chiakku epwe anisuk non kapasen fonuomw. dat, rele nimewo nou mete pou Eta oswa rejyon nọmba enyere maka steeti ma ọ bụ mpaghara gị iji ou a pou w ka pale ak yon entèprèt. kwukọrịta okwu n’etiti onye ọkọwa okwu. Français (French): Une assistance gratuite dans votre langue est à votre disposition. Si ʻōlelo Hawaiʻi (Hawaiian): He pono a ua loaʻa no Iloko (Ilocano): Adda ti karbenganyo a vous avez des questions à propos de votre kekahi kōkua me kāu ʻōlelo inā makemake a he dumawat iti tulong iti pagsasaoyo nga awan ti demande d’inscription ou de la couverture par manuahi no hoʻi. Inā he mau nīnau kāu e pili ana i bayadanyo. No addaankayo kadagiti saludsod Kaiser Permanente, ou si cet avis vous demande kāu palapala noi ʻinikua ola kino a i ʻole i kōkua maʻō maipanggep ti aplikasionyo wenno coverage de prendre des mesures à une date précise, ka polokalamu kōkua ola kino Kaiser Permanente, a babaen ti Kaiser Permanente, wenno no appelez le numéro indiqué pour votre Etat ou i ʻole inā ke haʻi nei paha kēia leka nei iāʻoe e hana daytoy ket maysa a pakdaar a kalikagumanna votre région pour parler à un interprète. koke aku i kēia ma mua o kekahi lā i waiho ʻia, e a rumbeng nga aramidenyo ti addang iti kelepona aku i ka helu i loaʻa ma kēia leka nei no espesipiko a petsa, tawagan ti numero nga Deutsch (German): Sie haben das Recht, kāu mokuʻāina a i ʻole panaʻāina no ka walaʻau ʻana inpaay para ti estado wenno rehion tapno kostenlose Hilfe in Ihrer Sprache zu erhalten. me kekahi kanaka unuhi ʻōlelo. makipatang ti maysa mangipatarus iti pagsasao. Falls Sie Fragen bezüglich Ihres Antrags Italiano (Italian): Hai il diritto di ricevere assistenza oder Ihres Krankenversicherungsschutzes हिन्饀 (Hindi): आपको बिना किसी कीमत चुकाए आपकी nella tua lingua gratuitamente. In caso di domande durch Kaiser Permanente haben oder falls भाषा मᴂ सहायता पाने का अधिकार है। यदि आप आपके riguardanti la tua richiesta o la copertura attraverso Sie aufgrund dieser Benachrichtigung bis आवेदन पत्र केवि षय मᴂ या Kaiser Permanente के Kaiser Permanente, o se occorre intervenire entro zu bestimmten Stichtagen handeln müssen, कवरेज के विषय मᴂ कुछ पूछना चाहते हℂ या यदि यह एक una data specifica secondo quanto indicato in questa rufen Sie die für Ihren Bundesstaat oder Ihre नोटिस है जिसके कारण आपको किसी विशेष तिथि तक comunicazione, chiama il numero fornito per il tuo Region aufgeführte Nummer an, um mit einem कारवाई करनी पड़ेगी तो आपके राज् या 啍त्रष केल िए stato o la tua regione per parlare con un interprete. Dolmetscher zu sprechen. दिए गए नंबर पर फोन करके किसी दभाु षिये से बात करᴂ।

Have questions? Call us at 1-800-494-5314. • Go to buykp.org/apply. • Or contact your agent or broker.

60436922 National 2016 Kaiser Permanente for Individuals and Families

فارسی )Persian(: شما حق دارید که بدون هیچ هزینه ای به 日本語 (Japanese): あなたは、費用負担なしでご Kajin Majōḷ (Marshallese): Ewōr jimwe eo aṃ زبان خود کمک دریافت کنید. اگر درباره درخواست یا پوشش 使用の言語で支援を受ける権利を保持していま in bōk jipañ ilo kajin eo aṃ ejjeḷọk wōṇāān. Ñe خود در Kaiser Permanente سؤالی داشته یا بر اساس این す。お申し込みまたはKaiser Permanenteの担保 ewōr aṃ kajjitōk kōn peba in aplaiki eo aṃ ak اعالمیه باید تا تاریخ مشخصی اقدامی بعمل آورید، برای صحبت 範囲に関してご質問があるか、または本通知に insurance eo aṃ jān Kaiser Permanente, ak ñe با یک مترجم شفاهی با شماره تلفن ارائه شده برای ایالت یا より、あなたが特定の日付までに行動を起こす enaan in kōjeḷā in ej aikuj bwe kwōn ṃakūtkūt منطقه خود تماس بگیرید. よう依頼されている場合、お住まいの州または ṃokta jān juon raan eo eṃōj an kallikkar, kaḷọk 地域に対して提供された電話番号に電話して、 nōṃba eo ej leḷọk ñan state eo aṃ ak jikūṃ bwe 通訳とお話ください。 kwōn maroñ kōnono ippān juon ri-ukōt. lokaiahn Pohnpei (Pohnpeian): Komw anehki pwung en rapahki sounkawehwe en omw Naabeehó (Navajo): T’11 ni nizaad bee n7k1 palien lokaia ni sohte isaihs. Ma mie iren owmi ខ្揂រ (Khmer): អ䮓ក掶នសទ្ទទួល厶នជនួយᾶ徶羶រំ ិ ធ i’doolwo[ doo bik’4 as7n7[11g00 47 bee n1haz’3. kalelapak ohng aplikeisin de iren audepe kan បស់អ䮓កដោយឥតគតថ្濃។ ប�សនអ䮓ក掶នសំណួរ㮶 ិ ើ ិ Kaiser Permanente 1k1 an1’1lwo’ n1 bik’4 ohng Kaiser Permanente, de ma pakair wet azl1adoo y7n7keedgo naaltsoos hadinilaa, 47 me anahne komwi en mwekid ohng rahn me មួយអំពី家ក䮙ស្នើសុំ ឬζរ䮶侶រ➶ប់រង㾶មរយៈ Kaiser Permanente b7na’7d7[kid doogo, 47 doodago d77 naaltsoos haa’7da kileledi, ah komw anahne koahl nempe me ឬប្សិននេះគឺᾶលិខិតជូនដណំ ឹ yoo[k1a[go hait’1oda 7’d77l77[ ni[n7igo 47 nitsaa sansalehr ohng owmi palien wehi pwe komwi en ងដែលតម្殼វឲ䮙អ䮓កាត់វ䮶នζរិ ត្រមζលបរចិ្ᯁទᾶក់ hahoodzoj7 47 doodago t’11 aadi nahós’a’di ata’ lokaiaieng owmi tungoal soun kawehwe. 澶ក់ សូមទូរស័ព䮑ទៅលេខដែល厶នផ䮊ល់ជូនសម្ប់រដ䮋 dahalne’7g77 bich’8’ h0lne’go bee bi[ ahi[ hod77lnih. Português (Portuguese): Você tem o direito de ឬតំបន់របស់អ䮓កដ�ើម្នប ិ架យទៅζន់អ䮓កបកប្រ។ नेपाली (Nepali): तपाℂसगं कुनै शुल् नदिइ आफ्न obter ajuda em seu idioma sem nenhum custo. 한국어 (Korean): 귀하에게는 한국어 통역서비스를 भाषामा सहायता पाउने अधिकार छ । तपा℁संग Se você tiver dúvidas sobre sua solicitação ou 무료로 받으실 수 있는 권리가 있습니다. आफ्न आवेदन बारे वा Kaiser Permanente cobertura por meio da Kaiser Permanente, ou se Kaiser Permanente를 통한 귀하의 보험 신청서나 मार㔫 त कवरेज बारेमा कुनै प्रश्नह셂 भए, वा यो este aviso exigir que você tome alguma medida 보험 보장 범위에 관해 질문이 있을 경우 또는 नोटिस अनुसार तपा℁ले कुनै निर्धरित मितिमा कुनै até uma data específica, ligue para o número 이 통지서의 요구대로 어느 날짜까지 조취를 कार्वाही गर्न परꅇ आवश्कता भएमा, दोभाषेसंग fornecido para seu estado ou região para falar 취해야만 하는 경우, 귀하의 주 및 지역의 제공된 कुराकानी गर् तपा℁को राज् वा 啍षत्रका लागि com um intérprete. 전화번호로 연락해 통역사와 통화하십시오. दिइएको नम्रमा कल गर्नहोस ् । ਪੰਜਾਬੀ (Punjabi): ਤੁਹਾਨੂੰ ਬਿਨ拓 ਕਿਸੇ ਸ਼ੁਲਕ ਤੇ ਆਪਣੀ ਭਾਸ਼ਾ Afaan Oromoo (Oromo): Baasii malee afaan (Laotian): ລາວ ທ່ານມີສິດທີ່ຈະໄດ້ຮັບການຊ່ວຍເຫຼືອ keetiin gargaarsa argachuudhaaf mirga ਵਿਚ ਮਦਦ ਪਾਉਣ ਦਾ ਹੱਕ ਹੈ. ਜੇਕਰ ਤੁਹਾਡੇ ਆਪਣੀ ਅਰਜ਼ ਜ拓 Kaiser Permanente ໃນພາສາຂອງທ່ານໂດຍບໍ່ເສັຽຄ່າ. ຖ້າວ່າ ທ່ານມີຄ�ຳຖາ qabda. Waa’ee iyyata keetii yookaan tajaajila ਰਾਹȂ ਕਵਰੇਜ ਬਾਰੇ ਸਵਾਲ ਹਨ, ਜ拓 ມກ່ຽວກັບການສະໝັກຂອງທ່ານ ຫຼື ການຄຸ້ມຄອງຜ່ານ Kaiser Permanente hammatu ilaalchisee ਇਸ ਨੋ ਟਿਸ ਵਜ⸂ ਤੁਹਾਨੂੰ ਕਿਸੇ ਨਿਸ਼ਚਿਤ ਮਿਤੀ ਤੱਕ ਕਾਰਵਾਈ gaaffii yoo qabaatte, yookaan yoo kun ਕਰਨ ਦੀ ਲੋੜ ਪਵੇ, ਤ拓 ਦੁਭਾਸ਼ੀਏ ਨਾਲ ਗੱਲ ਕਰਨ ਲਈ ਆਪਣੇ Kaiser Permanente, ຫຼື ຖ້າອັນນີ້ເປັນແຈ້ງການທີ່ຮຽກ beeksisa guyyaa murtaa’e irratti tarkaanfii akka ਰਾਜ ਜ拓 ਇਲਾਕ ੇ ਲਈ ਮੁਹੱਈਆ ਕਰਵਾਏ ਗਏ ਨੰਬਰ ਤੇ ਫਨ਼ ਕਰੋ. ຮ້ອງໃຫ້ທ່ານດ�ຳເນີນການພາຍໃນວັນທີທີ່ເຈາະຈົງໃດໜຶ່ງ, ati fudhattu gaafatu ta’e, lakkoofsa bilbilaa ໃຫ້ໂທຕາມໝາຍເລກທີ່ໃຫ້ໄວ້ສ�ຳລັບລັດ ຫຼື ເຂດຂອງທ່ານ naannoo yookaan goodina keetiif kenname bilbiluudhaan turjumaana haasofsiisi. ເພື່ອຂໍລົມກັບນາຍພາສາ.

Have questions? Call us at 1-800-494-5314. • Go to buykp.org/apply. • Or contact your agent or broker.

60436922 National 2016 Kaiser Permanente for Individuals and Families

اُردو )Urdu(: آپ کوکوئی بھی قیمت ادا کئے بغیر اپنی زبان Română (Romanian): Aveți dreptul de a solicita Tagalog (Tagalog): Mayroon kang karapatang میں مدد حاصل کرنے کا حق ہے۔ اگر آپ کے ذہن میں اپنی ajutor care să vă fie oferit în mod gratuit în limba humingi ng tulong sa iyong wika nang walang درخواست یا Kaiser Permanente کے ذریعہ کوریج کے dumneavoastră. Dacă aveți întrebări legate de bayad. Kung mayroon kang mga katanungan متعلق کوئی بھی سواالت ہیں، یا اگر اس نوٹس کی وجہ سے آپ solicitarea dumneavoastră sau de acoperirea tungkol sa iyong aplikasyon o coverage sa کو کسی مخصوص تاریخ تک عمل انجام دینے کی ضرورت oferită de Kaiser Permanente sau dacă acest aviz pamamagitang ng Kaiser Permanente, o kung ito ہوگی تو، کسی مترجم سے بات چیت کرنے کے لئے آپ کی vă solicită să luați măsuri până la o anumită dată, ay abisong nangangailangan ng iyong aksyon ریاست ای عالقہ کے لئے فراہم کئے گئے نمبر پر کال کریں۔ sunați la numărul de telefon furnizat pentru statul sa tiyak na petsa, tumawag sa numerong ibinigay sau regiunea dumneavoastră pentru a sta de para sa iyong estado o rehiyon para makipag-usap vorbă cu un interpret. sa isang interpreter. Tiếng Việt (Vietnamese): Quý vị có quyền được nhận trợ giúp miễn phí bằng ngôn ngữ của mình. Pусский (Russian): У вас есть право получить ไทย (Thai): ท่านมีสทธิที่จะไดิ ้รับความชวยเหลือใน่ Nếu quý vị có các câu hỏi về mẫu đơn hoặc mức бесплатную помощь на своем языке. Если у ภาษาของท่านโดยไม่เสยค่าใชี จ่าย้ หากท่านมีค�ำถาม bảo hiểm của mình thông qua Kaiser Permanente, вас имеются вопросы относительно вашего เกี่ยวกับการสมัครของท่าน หรือความคุ ้มครองผ่าน hoặc đây là thông báo yêu cầu quý vị thực hiện заявления или медицинского страхования Kaiser Permanente หรือหากนี่คือหนังสอที่ตื ้องการ vào một ngày cụ thể, hãy gọi đến số điện thoại в Kaiser Permanente, либо если такое ให ้ท่านด�ำเนินการภายในวันที่ที่ก�ำหนดไว ้ โปรดติดต่อ được cung cấp cho bang hoặc khu vực của quý vị уведомление требует от вас каких-либо หมายเลขที่ให ้ไว้ส�ำหรับรัฐหรือเขตพื้นที่ของท่านเพื่อ để trò chuyện với phiên dịch viên. действий к определенной дате, позвоните คุยกับล่าม по номеру телефона для своего штата или Yorùbá (Yoruba): O ní ẹ̀ tọ́ láti rí ìrànlọ́ wọ́ gbà nípa региона, чтобы поговорить с переводчиком. Lea Faka-Tonga (Tongan): ‘Oku ‘ia ho totonu ke èdè rẹ láìsan owó. Bí o bá ní ìbéèrè nípa ìwé tí o ke ma’u ha fakatonulea ta’etotongi. Kapau ‘oku kọ tàbí ìṣedéédé nípaṣẹ̀ Kaiser Permanente, tàbí Faa-Samoa (Samoan): E iai lou ‘aia e maua se ‘i ai ha’o fehu’i ki ho tohi kole na’e fakafonu ki he ìfitọnilétí yìí jẹ́ èyí o nílò láti ìgbésẹ̀ kan ní ọjọ́ kan fesoasoani i lou gagana e aunoa ma le totogi. malu’i ‘inisiua ‘a e Kaiser Permanente, pea kapau patọ́ , pé nọ́ mbà tí a pèsè fún ìpínlẹ̀ tàbí agbègbè Afai e iai ni fesili e uiga i lou tusi apalai po o ko e tohini ‘oku fiema’u keke fai ha me’a ki ai pe rẹ láti bá òǹgbifọ̀ kan sọ̀ rọ̀ . puipuiga e ala mai Kaiser Permanente, po o ko ha ‘aho na’e tuku pau atu ke fai ia, taa ki he fika lenei tusi e manaomia ona e gaoioi i se taimi kuo ‘oatu ki ho siteiti pe ko e vahefonua ‘oku ke atofaina, vili le numera ua fuafuaina mo lou ‘i ai ke talanoa mo ha tokotaha tene fakatonu lea setete po o oganuu e fesoota’i i se faaliliu. atu kiate koe.

Español (Spanish): Usted tiene derecho a Українська (Ukrainian): У Вас є право на obtener ayuda en su idioma sin costo alguno. Si отримання допомоги безкоштовно на Вашій tiene preguntas acerca de su solicitud o cobertura рідній мові. Якщо Ви маєте питання стосовно a través de Kaiser Permanente, o si este es un Вашого звернення чи страхового покриття aviso que requiere que usted tome alguna в Kaiser Permanente, чи якщо відповідно до medida antes de una fecha determinada, llame al такого повідомлення Вам треба буде здійснити número de teléfono que se proporciona para su певну дію до конкретної дати, подзвоніть по estado o región para hablar con un intérprete. номеру, що відповідає Вашій країні чи регіону, щоб поговорити з перекладачем.

Have questions? Call us at 1-800-494-5314. • Go to buykp.org/apply. • Or contact your agent or broker.

60436922 National 2016