Kaiser Permanente DHMO 5500 Southern California SBC

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 04/01/2024-03/31/2025 : DEDUCTIBLE PLAN Coverage for: Individual/Family | Plan Type: DHMO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage see https://kp.org/plandocuments or call 1-800-278-3296 (TTY: 711). For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-800-278-3296 (TTY: 711) to request a copy. Important Questions Answers Why this Matters: Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the What is the overall $5,500 Individual / $11,000 Family plan, each family member must meet their own individual deductible until the deductible? total amount of deductible expenses paid by all family members meets the overall family deductible. This plan covers some items and services even if you haven’t yet met the Are there services deductible amount. But a copayment or coinsurance may apply. For example, Yes. Preventive care and services indicated in covered before you meet this plan covers certain preventive services without cost sharing and before you chart starting on page 2. your deductible? meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. Are there other deductibles for specific No. You don’t have to meet deductibles for specific services. services? The out-of-pocket limit is the most you could pay in a year for covered services. If What is the out-of-pocket $7,500 Individual / $15,000 Family you have other family members in this plan, they have to meet their own out-of- limit for this plan? pocket limits until the overall family out-of-pocket limit has been met. What is not included in Premiums, health care this plan doesn't cover, and Even though you pay these expenses, they don't count toward the out-of-pocket the out-of-pocket limit? services indicated in chart starting on page 2. limit. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and Will you pay less if you Yes. See www.kp.org or call 1-800-278-3296 (TTY: you might receive a bill from a provider for the difference between the provider’s use a network provider? 711) for a list of network providers. charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to This plan will pay some or all of the costs to see a specialist for covered services Yes, but you may self-refer to certain specialists. see a specialist? but only if you have a referral before you see the specialist. TOTAL EDUCATION SOLUTIONS PID:233882 CNTR:1 EU:-1 Plan ID:13859 SBC ID:544572 1 of 8

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. What You Will Pay What You Will Pay Common Services You May Limitations, Exceptions & Other Important Plan Provider Non-Plan Provider Medical Event Need Information (You will pay the least) (You will pay the most) Deductible waived for first three visits combined Primary care visit to for non-preventive primary care, urgent care, treat an injury or $50 / visit Not Covered mental/behavioral health and substance use illness disorder outpatient services. If you visit a health Specialist visit $50 / visit Not Covered None care provider's office or clinic You may have to pay for services that aren't Preventive care/ No Charge, deductible does not preventive. Ask your provider if the services screening/ Not Covered apply. needed are preventive. Then check what your immunization plan will pay for. Diagnostic test (x- 40% coinsurance Not Covered None ray, blood work) If you have a test Imaging (CT/PET 40% coinsurance Not Covered None scans, MRI's) Up to a 30-day supply retail or 100-day supply Generic drugs (Tier Retail: $15 / prescription; Mail mail order. Subject to formulary guidelines. No Not Covered 1) order: $30 / prescription Charge for Contraceptives, deductible does not apply. If you need drugs to treat your illness or Up to a 100-day supply retail and mail order. Preferred brand 40% coinsurance up to $100 / condition Not Covered Subject to formulary guidelines. No Charge for drugs (Tier 2) prescription More information Contraceptives, deductible does not apply. about prescription The cost sharing for non-preferred brand drugs drug coverage is Non-preferred brand 40% coinsurance up to $100 / under this plan aligns with the cost sharing for available at Not Covered drugs (Tier 2) prescription preferred brand drugs (Tier 2), when approved www.kp.org/formulary through the formulary exception process. Specialty drugs (Tier 40% coinsurance up to $250 / Up to a 30-day supply retail. Subject to Not Covered 4) prescription formulary guidelines. 2 of 8

What You Will Pay What You Will Pay Common Services You May Limitations, Exceptions & Other Important Plan Provider Non-Plan Provider Medical Event Need Information (You will pay the least) (You will pay the most) Facility fee (e.g., ambulatory surgery 40% coinsurance Not Covered None If you have center) outpatient surgery Physician/surgeon 40% coinsurance Not Covered None fees Emergency room 40% coinsurance 40% coinsurance None care Emergency medical 40% coinsurance 40% coinsurance None transportation If you need immediate medical Non-Plan providers covered when temporarily attention outside the service area: Deductible waived for first three visits combined for non-preventive Urgent care $50 / visit Not Covered primary care, urgent care, mental/behavioral health and substance use disorder outpatient services: $50 / visit. Facility fee (e.g., 40% coinsurance Not Covered None hospital room) If you have a hospital stay Physician/surgeon 40% coinsurance Not Covered None fee Mental / Behavioral Health: $50 / Mental / Behavioral Health: $25 / group visit; individual visit. 40% coinsurance Substance Abuse: $5 / group visit. Deductible for other outpatient services; If you need mental waived for first three visits combined for non- Outpatient services Substance Abuse: $50 / Not Covered health, behavioral preventive primary care, urgent care, mental/ individual visit. 40% coinsurance health, or substance behavioral health and substance use disorder up to $5 / day for other abuse services outpatient services. outpatient services Inpatient services 40% coinsurance Not Covered None 3 of 8

What You Will Pay What You Will Pay Common Services You May Limitations, Exceptions & Other Important Plan Provider Non-Plan Provider Medical Event Need Information (You will pay the least) (You will pay the most) Depending on the type of services, a copayment, coinsurance, or deductible may No Charge, deductible does not Office visits Not covered apply. Maternity care may include tests and apply. services described elsewhere in the SBC (i.e. ultrasound). If you are pregnant Childbirth/delivery 40% coinsurance Not Covered None professional services Childbirth/delivery 40% coinsurance Not Covered None facility services No Charge, deductible does not 2-hour limit / visit, 3 visit limit / day, 100 visit Home health care Not Covered apply. limit / year. Rehabilitation Inpatient: 40% coinsurance; Not Covered None services Outpatient: $50 / visit If you need help Habilitation services $50 / visit Not Covered None recovering or have other special health Skilled nursing care 40% coinsurance Not Covered 100 day limit / benefit period. needs Durable medical 40% coinsurance, deductible Not Covered Requires prior authorization. equipment does not apply. No Charge, deductible does not Hospice service Not Covered None apply. No Charge for refractive exam, Children's eye exam Not Covered None deductible does not apply. If your child needs Children's glasses Not Covered Not Covered None dental or eye care Children's dental Not Covered Not Covered None check-up 4 of 8

Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) ● Children's glasses ● Hearing aids ● Private-duty nursing ● Chiropractic care ● Infertility treatment ● Routine foot care ● Cosmetic surgery ● Long-term care ● Weight loss programs ● Dental Care (Adult & Child) ● Non-emergency care when traveling outside the U.S. Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) ● Acupuncture (plan provider referred) ● Bariatric surgery ● Routine eye care (Adult) Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is shown in the chart below. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact the agencies in the chart below. Contact Information for Your Rights to Continue Coverage & Your Grievance and Appeals Rights: Kaiser Permanente Member Services 1-800-278-3296 (TTY: 711) or www.kp.org/memberservices Department of Labor’s Employee Benefits Security Administration 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform Department of Health & Human Services, Center for Consumer Information & Insurance Oversight 1-877-267-2323 x61565 or www.cciio.cms.gov California Department of Insurance 1-800-927-HELP (4357) or www.insurance.ca.gov California Department of Managed Healthcare 1-888-466-2219 or www.healthhelp.ca.gov/ Does this plan provide Minimum Essential Coverage? Yes. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 5 of 8

Language Access Services: SPANISH (Español): Para obtener asistencia en Español, llame al 1-800-788-0616 (TTY: 711) TAGALOG (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-278-3296 (TTY: 711) CHINESE (中文): 如果需要中文的帮助，请拨打这个号码 1-800-757-7585 (TTY: 711) NAVAJO (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-278-3296 (TTY: 711) To see examples of how this plan might cover costs for a sample medical situation, see the next section. 6 of 8

About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby Managing Joe's Type 2 Diabetes Mia's Simple Fracture (9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow up hospital delivery) controlled condition) care) The plan's overall deductible $5,500 The plan's overall deductible $5,500 The plan's overall deductible $5,500 Specialist copayment $50 Specialist copayment $50 Specialist copayment $50 40% 40% 40% Hospital (facility) coinsurance Hospital (facility) coinsurance Hospital (facility) coinsurance Other (blood work) coinsurance Other (blood work) coinsurance Other (x-ray) coinsurance 40% 40% 40% This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like: Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical supplies) Childbirth/Delivery Professional Services disease education) Diagnostic test (x-ray) Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment (crutches) Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy) Specialist visit (anesthesia) Durable medical equipment (glucose meter) Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800 In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $5,500 Deductibles $4,100 Deductibles $2,500 Copayments $10 Copayments $300 Copayments $10 Coinsurance $1,700 Coinsurance $200 Coinsurance $10 What isn't covered What isn't covered What isn't covered Limits or exclusions $50 Limits or exclusions $0 Limits or exclusions $0 The total Peg would pay is $7,260 The total Joe would pay is $4,600 The total Mia would pay is $2,520 The plan would be responsible for the other costs of these EXAMPLE covered services. 7 of 8

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Nondiscrimination Notice Discrimination is against the law. Kaiser Permanente follows State and Federal civil rights laws. Kaiser Permanente does not unlawfully discriminate, exclude people, or treat them differently because of age, race, ethnic group identification, color, national origin, cultural background, ancestry, religion, sex, gender, gender identity, gender expression, sexual orientation, marital status, physical or mental disability, medical condition, source of payment, genetic information, citizenship, primary language, or immigration status. Kaiser Permanente provides the following services: ● No-cost aids and services to people with disabilities to help them communicate better with us, such as: ♦ Qualified sign language interpreters ♦ Written information in other formats (braille, large print, audio, accessible electronic formats, and other formats) ● No-cost language services to people whose primary language is not English, such as: ♦ Qualified interpreters ♦ Information written in other languages If you need these services, call our Member Service Contact Center at 1 800-464-4000 (TTY 711), 24 hours a day, 7 days a week (except closed holidays). If you cannot hear or speak well, please call 711. Upon request, this document can be made available to you in braille, large print, audiocassette, or electronic form. To obtain a copy in one of these alternative formats, or another format, call our Member Service Contact Center and ask for the format you need. How to file a grievance with Kaiser Permanente You can file a discrimination grievance with Kaiser Permanente if you believe we have failed to provide these services or unlawfully discriminated in another way. Please refer to your Evidence of Coverage or Certificate of Insurance for details. You may also speak with a Member Services representative about the options that apply to you. Please call Member Services if you need help filing a grievance. You may submit a discrimination grievance in the following ways: ● By phone: Call member services at 1-800-464-4000 (TTY 711) 24 hours a day, 7 days a week (except closed holidays) ● By mail: Call us at 1-800-464-4000 (TTY 711) and ask to have a form sent to you ● In person: Fill out a Complaint or Benefit Claim/Request form at a member services office located at a Plan Facility (go to your provider directory at kp.org/facilities for addresses) ● Online: Use the online form on our website at kp.org You may also contact the Kaiser Permanente Civil Rights Coordinators directly at the addresses below:

Attn: Kaiser Permanente Civil Rights Coordinator Member Relations Grievance Operations P.O. Box 939001 San Diego CA 92193 How to file a grievance with the California Department of Health Care Services Office of Civil Rights (For Medi-Cal Beneficiaries Only) You can also file a civil rights complaint with the California Department of Health Care Services Office of Civil Rights in writing, by phone or by email: ● By phone: Call DHCS Office of Civil Rights at 916-440-7370 (TTY 711) ● By mail: Fill out a complaint form or send a letter to: Deputy Director, Office of Civil Rights Department of Health Care Services Office of Civil Rights P.O. Box 997413, MS 0009 Sacramento, CA 95899-7413 Complaint forms are available at: http://www.dhcs.ca.gov/Pages/Language_Access.aspx ● Online: Send an email to [email protected] How to file a grievance with the U.S. Department of Health and Human Services Office of Civil Rights You can file a discrimination complaint with the U.S. Department of Health and Human Services Office for Civil Rights. You can file your complaint in writing, by phone, or online: ● By phone: Call 1-800-368-1019 (TTY 711 or 1-800-537-7697) ● By mail: Fill out a complaint form or send a letter to: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 Complaint forms are available at: http:www.hhs.gov/ocr/office/file/index.html ● Online: Visit the Office of Civil Rights Complaint Portal at: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf.

Aviso de no discriminación La discriminación es ilegal. Kaiser Permanente cumple con las leyes de los derechos civiles federales y estatales. Kaiser Permanente no discrimina ilícitamente, excluye ni trata a ninguna persona de forma distinta por motivos de edad, raza, identificación de grupo étnico, color, país de origen, antecedentes culturales, ascendencia, religión, sexo, género, identidad de género, expresión de género, orientación sexual, estado civil, discapacidad física o mental, condición médica, fuente de pago, información genética, ciudadanía, lengua materna o estado migratorio. Kaiser Permanente ofrece los siguientes servicios: ● Ayuda y servicios sin costo a personas con discapacidades para que puedan comunicarse mejor con nosotros, como lo siguiente: ♦ intérpretes calificados de lenguaje de señas, ♦ información escrita en otros formatos (braille, impresión en letra grande, audio, formatos electrónicos accesibles y otros formatos). ● Servicios de idiomas sin costo a las personas cuya lengua materna no es el inglés, como: ♦ intérpretes calificados, ♦ información escrita en otros idiomas. Si necesita nuestros servicios, llame a nuestra Central de Llamadas de Servicio a los Miembros al 1-800-464-4000 (TTY 711) las 24 horas del día, los 7 días de la semana (excepto los días festivos). Si tiene deficiencias auditivas o del habla, llame al 711. Este documento estará disponible en braille, letra grande, casete de audio o en formato electrónico a solicitud. Para obtener una copia en uno de estos formatos alternativos o en otro formato, llame a nuestra Central de Llamadas de Servicio a los Miembros y solicite el formato que necesita. Cómo presentar una queja ante Kaiser Permanente Usted puede presentar una queja por discriminación ante Kaiser Permanente si siente que no le hemos ofrecido estos servicios o lo hemos discriminado ilícitamente de otra forma. Consulte su Evidencia de Cobertura (Evidence of Coverage) o Certificado de Seguro (Certificate of Insurance) para obtener más información. También puede hablar con un representante de Servicio a los Miembros sobre las opciones que se apliquen a su caso. Llame a Servicio a los Miembros si necesita ayuda para presentar una queja. Puede presentar una queja por discriminación de las siguientes maneras: ● Por teléfono: llame a Servicio a los Miembros al 1 800-464-4000 (TTY 711), las 24 horas del día, los 7 días de la semana (excepto los días festivos). ● Por correo postal: llámenos al 1 800-464-4000 (TTY 711) y pida que se le envíe un formulario. ● En persona: llene un formulario de Queja o reclamación/solicitud de beneficios en una oficina de Servicio a los Miembros ubicada en un centro del plan (consulte su directorio de proveedores en kp.org/facilities [cambie el idioma a español] para obtener las direcciones). ● En línea: utilice el formulario en línea en nuestro sitio web en kp.org/espanol.

También puede comunicarse directamente con el coordinador de derechos civiles (Civil Rights Coordinator) de Kaiser Permanente a la siguiente dirección: Attn: Kaiser Permanente Civil Rights Coordinator Member Relations Grievance Operations P.O. Box 939001 San Diego CA 92193 Cómo presentar una queja ante la Oficina de Derechos Civiles del Departamento de Servicios de Atención Médica de California (Solo para beneficiarios de Medi-Cal) También puede presentar una queja sobre derechos civiles ante la Oficina de Derechos Civiles (Office of Civil Rights) del Departamento de Servicios de Atención Médica de California (California Department of Health Care Services) por escrito, por teléfono o por correo electrónico: ● Por teléfono: llame a la Oficina de Derechos Civiles del Departamento de Servicios de Atención Médica (Department of Health Care Services, DHCS) al 916-440-7370 (TTY 711). ● Por correo postal: llene un formulario de queja o envíe una carta a: Deputy Director, Office of Civil Rights Department of Health Care Services Office of Civil Rights P.O. Box 997413, MS 0009 Sacramento, CA 95899-7413 Los formularios de queja están disponibles en: http://www.dhcs.ca.gov/Pages/Language_Access.aspx (en inglés). ● En línea: envíe un correo electrónico a [email protected]. Cómo presentar una queja ante la Oficina de Derechos Civiles del Departamento de Salud y Servicios Humanos de los EE. UU. Puede presentar una queja por discriminación ante la Oficina de Derechos Civiles del Departamento de Salud y Servicios Humanos de EE. UU. (U.S. Department of Health and Human Services). Puede presentar su queja por escrito, por teléfono o en línea: ● Por teléfono: llame al 1-800-368-1019 (TTY 711 o al 1-800-537-7697). ● Por correo postal: llene un formulario de queja o envíe una carta a: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 Los formularios de quejas están disponibles en http://www.hhs.gov/ocr/office/file/index.html (en inglés). ● En línea: visite el Portal de quejas de la Oficina de Derechos Civiles en: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf (en inglés).

反歧視聲明 歧視是違反法律的行為。Kaiser Permanente遵守州政府與聯邦政府的民權法。 Kaiser Permanente 不因年齡、人種、族群認同、膚色、原國籍、文化背景、祖籍、宗教、生理性別、社會性別、性認同、性表現、性取向、 婚姻狀況、身體或精神殘障、病況、付款來源、遺傳資訊、公民身份、母語或移民身份而非法歧視、排斥或差別對待任何人。 Kaiser Permanente 提供下列服務： ● 為殘障人士提供免費協助與服務以幫助其更好地與我們溝通，例如： ♦ 合格手語翻譯員 ♦ 其他格式的書面資訊（盲文版、大字版、語音版、通用電子格式及其他格式） ● 為母語非英語的人士提供免費語言服務，例如： ♦ 合格口譯員 ♦ 其他語言的書面資訊 如果您需要上述服務，請打電話1-800-464-4000 (TTY 711) 給會員服務聯絡中心，每週7天，每天24小時（節假日除外）。如果您有聽力或 語言困難，請打電話711。 若您提出要求，我們可為您提供本文件的盲文版、大字版、錄音卡帶或電子格式。如要得到上述一種替代格式或其他格式的版本，請打電 話給會員服務聯絡中心並索取您需要的格式。 如何向Kaiser Permanente投訴 如果您認為我們未能提供上述服務或有其他形式的非法歧視行為，您可向Kaiser Permanente提出歧視投訴。請參閱您的《承保範圍說明 書》(Evidence of Coverage) 或《保險證明》(Certificate of Insurance) 瞭解詳情。您也可以向會員服務部代表諮詢適用於您的選項。如果您在投 訴時需要協助，請打電話給會員服務部。 您可透過下列方式投訴歧視： ● 電話： 打電話1 800-464-4000 (TTY 711) 聯絡會員服務部，每週7天，每天24小時（節假日除外） ● 郵寄： 打電話1 800-464-4000 (TTY 711) 與我們聯絡，要求將投訴表寄給您 ● 親自提出： 在保險計劃下屬設施的會員服務辦公室填寫投訴或索賠／申請表（請在kp.org/facilities網站的保健業者名錄上查詢地 址） ● 線上： 使用kp.org網站上的線上表格 您也可直接與Kaiser Permanente民權事務協調員聯絡，地址如下：

Attn: Kaiser Permanente Civil Rights Coordinator Member Relations Grievance Operations P.O. Box 939001 San Diego CA 92193 如何向加州保健服務部民權辦公室投訴（僅限Medi-Cal受益人） 您也可透過書面方式、電話或電子郵件向加州保健服務部民權辦公室提出民權投訴： ● 電話：打電話916-440-7370 (TTY 711) 聯絡保健服務部 (DHCS) 民權辦公室 ● 郵寄：填寫投訴表或寄信至： Deputy Director, Office of Civil Rights Department of Health Care Services Office of Civil Rights P.O. Box 997413, MS 0009 Sacramento, CA 95899-7413 您可在網站上http://www.dhcs.ca.gov/Pages/Language_Access.aspx 取得投訴表 ● 線上：發送電子郵件至[email protected] 如何向美國健康與民眾服務部民權辦公室投訴 您可向美國健康與民眾服務部民權辦公室提出歧視投訴。您可透過書面、電話或線上提出投訴： ● 電話：打電話1-800-368-1019（TTY 711或1-800-537-7697） ● 郵寄：填寫投訴表或寄信至： U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 您可在網站上取得投訴表： http:www.hhs.gov/ocr/office/file/index.html 取得投訴表 ● 郵寄：訪問民權辦公室投訴入口網站： https://ocrportal.hhs.gov/ocr/portal/lobby.jsf。

Thông Báo Không Phân Biệt Đối Xử Phân biệt đối xử là trái với pháp luật. Kaiser Permanente tuân thủ các luật dân quyền của Tiểu Bang và Liên Bang. Kaiser Permanente không phân biệt đối xử trái pháp luật, loại trừ hay đối xử khác biệt với người nào đó vì lý do tuổi tác, chủng tộc, nhận dạng nhóm sắc tộc, màu da, nguồn gốc quốc gia, nền tảng văn hóa, tổ tiên, tôn giáo, giới tính, nhận dạng giới tính, cách thể hiện giới tính, khuynh hướng giới tính, tình trạng hôn nhân, tình trạng khuyết tật về thể chất hoặc tinh thần, bệnh trạng, nguồn thanh toán, thông tin di truyền, quyền công dân, ngôn ngữ mẹ đẻ hoặc tình trạng nhập cư. Kaiser Permanente cung cấp các dịch vụ sau: ● Phương tiện hỗ trợ và dịch vụ miễn phí cho người khuyết tật để giúp họ giao tiếp hiệu quả hơn với chúng tôi, chẳng hạn như: ♦ Thông dịch viên ngôn ngữ ký hiệu đủ trình độ ♦ Thông tin bằng văn bản theo các định dạng khác (chữ nổi braille, bản in khổ chữ lớn, âm thanh, định dạng điện tử dễ truy cập và các định dạng khác) ● Dịch vụ ngôn ngữ miễn phí cho những người có ngôn ngữ chính không phải là tiếng Anh, chẳng hạn như: ♦ Thông dịch viên đủ trình độ ♦ Thông tin được trình bày bằng các ngôn ngữ khác Nếu quý vị cần những dịch vụ này, xin gọi đến Trung Tâm Liên Lạc ban Dịch Vụ Hội Viên của chúng tôi theo số 1-800-464-4000 (TTY 711), 24 giờ trong ngày, 7 ngày trong tuần (đóng cửa ngày lễ). Nếu quý vị không thể nói hay nghe rõ, vui lòng gọi 711. Theo yêu cầu, tài liệu này có thể được cung cấp cho quý vị dưới dạng chữ nổi braille, bản in khổ chữ lớn, băng thu âm hay dạng điện tử. Để lấy một bản sao theo một trong những định dạng thay thế này hay định dạng khác, xin gọi đến Trung Tâm Liên Lạc ban Dịch Vụ Hội Viên của chúng tôi và yêu cầu định dạng mà quý vị cần. Cách đệ trình phàn nàn với Kaiser Permanente Quý vị có thể đệ trình phàn nàn về phân biệt đối xử với Kaiser Permanente nếu quý vị tin rằng chúng tôi đã không cung cấp những dịch vụ này hay phân biệt đối xử trái pháp luật theo cách khác. Vui lòng tham khảo Chứng Từ Bảo Hiểm (Evidence of Coverage) hay Chứng Nhận Bảo Hiểm (Certificate of Insurance) của quý vị để biết thêm chi tiết. Quý vị cũng có thể nói chuyện với nhân viên ban Dịch Vụ Hội Viên về những lựa chọn áp dụng cho quý vị. Vui lòng gọi đến ban Dịch Vụ Hội Viên nếu quý vị cần được trợ giúp để đệ trình phàn nàn. Quý vị có thể đệ trình phàn nàn về phân biệt đối xử bằng các cách sau đây: ● Qua điện thoại: Gọi đến ban Dịch Vụ Hội Viên theo số 1-800-464-4000 (TTY 711) 24 giờ trong ngày, 7 ngày trong tuần (đóng cửa ngày lễ) ● Qua thư tín: Gọi chúng tôi theo số 1-800-464-4000 (TTY 711) và yêu cầu gửi mẫu đơn cho quý vị ● Trực tiếp: Hoàn tất mẫu đơn Than Phiền hay Yêu Cầu Thanh Toán/Yêu Cầu Quyền Lợi tại văn phòng dịch vụ hội viên ở một Cơ Sở Thuộc Chương Trình (truy cập danh mục nhà cung cấp của quý vị tại kp.org/facilities để biết địa chỉ) ● Trực tuyến: Sử dụng mẫu đơn trực tuyến trên trang mạng của chúng tôi tại kp.org

Quý vị cũng có thể liên hệ trực tiếp với Điều Phối Viên Dân Quyền của Kaiser Permanente theo địa chỉ dưới đây: Attn: Kaiser Permanente Civil Rights Coordinator Member Relations Grievance Operations P.O. Box 939001 San Diego CA 92193 Cách đệ trình phàn nàn với Văn Phòng Dân Quyền Ban Dịch Vụ Y Tế California (Dành Riêng Cho Người Thụ Hưởng Medi-Cal) Quý vị cũng có thể đệ trình than phiền về dân quyền với Văn Phòng Dân Quyền Ban Dịch Vụ Y Tế California bằng văn bản, qua điện thoại hay qua email: ● Qua điện thoại: Gọi đến Văn Phòng Dân Quyền Ban Dịch Vụ Y Tế (Department of Health Care Services, DHCS) theo số 916-440-7370 (TTY 711) ● Qua thư tín: Điền mẫu đơn than phiền và hay gửi thư đến: Deputy Director, Office of Civil Rights Department of Health Care Services Office of Civil Rights P.O. Box 997413, MS 0009 Sacramento, CA 95899-7413 Mẫu đơn than phiền hiện có tại: http://www.dhcs.ca.gov/Pages/Language_Access.aspx ● Trực tuyến: Gửi email đến [email protected] Cách đệ trình phàn nàn với Văn Phòng Dân Quyền của Bộ Y Tế và Dịch Vụ Nhân Sinh Hoa Kỳ. Quý vị cũng có quyền đệ trình than phiền về phân biệt đối xử với Văn Phòng Dân Quyền của Bộ Y Tế và Dịch Vụ Nhân Sinh Hoa Kỳ. Quý vị có thể đệ trình than phiền bằng văn bản, qua điện thoại hoặc trực tuyến: ● Qua điện thoại: Gọi 1-800-368-1019 (TTY 711 hay 1-800-537-7697) ● Qua thư tín: Điền mẫu đơn than phiền và hay gửi thư đến: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 Mẫu đơn than phiền hiện có tại http:www.hhs.gov/ocr/office/file/index.html ● Trực tuyến: Truy cập Cổng Thông Tin Than Phiền của Văn Phòng Dân Quyền tại: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf.

NOTICE OF LANGUAGE ASSISTANCE English: This is important information from Kaiser Permanente. If you need help understanding this information, please call 1-800-464-4000 (TTY 711) and ask for language assistance. Help is available 24 hours a day, 7 days a week, excluding holidays. We can also help you with auxiliary aids and alternative formats. (TTY: 711) مقرلا ىلع لاصتالا ىجري ،تامولعملا هذه مهف يف ةدعاسملل ةجاحب تنك اذإ .Kaiser Permanente نم ةمهم تامولعم ىلع ةقيثولا هذه يوتحت :Arabic ً .ةليدب تاقيسنتو ةيفاضإ تادعاسمب كديوزت اضيأ اننكمي .ةيمسرلا تالطعلا مايأ ءانثتساب ،عوبسألا مايأ ةليط ةعاسلا رادم ىلع ةرفوتم ةدعاسملا .ةيوغل ةدعاسم بلطو1-800-464-4000 Armenian: Սա կարևոր տեղեկություն է «Kaiser Permanente»-ից: Եթե այս տեղեկությունը հասկանալու համար Ձեզ օգնություն է հարկավոր, խնդրում ենք զանգահարել 1-800-464-4000 (TTY 711) հեռախոսահամարով և օժանդակություն ստանալ լեզվի հարցում: Զանգահարեք օրը 24 ժամ, շաբաթը 7 օր` բացի տոն օրերից: Մենք նաև կարող ենք օգնել Ձեզ օժանդակ օգնության և այլընտրանքային ձևաչափերի հարցում: Chinese: 這是來自Kaiser Permanente的重要資訊。如果您需要協助瞭解此資訊，請致電1-800-757-7585 (TTY 專線 711) 尋求語言協助。我們 每週7天，每天24小時皆提供協助（節假日休息）。我們還可以幫助您獲取輔助設備和其它格式。 ً هرامش اب افطل ،ديراد زاين کمک هب تاعالطا نيا نديمهف رد رگا .دشاب یم Kaiser Permanente یوس زا یمهم تاعالطا نيا :Farsi یم نينچمه ام .تسا دوجوم ليطعت یاهزور لماش ،هتفه زور 7 و زورنابش تعاس 24 رد یيامنهار و کمک .دينک تساوخرد ینابز دادما یارب و هتفرگ سامت (TTY 711) 1-800-464-4000 .مينک مهارف ار رگيد یاهتروص هب و یبناج یاهکمک امش یارب ميناوت Hindi: यह Kaiser Permanente की ओर से महत्वपर ्ण सचना है। यदि आपको इस सचना को समझने के लिए मिि की जरूरत है, तो कपया ू ू ू ृ 1-800-464-4000 (TTY 711) पर फोन कर और भाषा सहायता के लिए पछ। सहायता छदटኌयों को छोड़कर, सप्ताह के सातों दिन, दिन के 24 घंटे, ें ें ू ु उपिब्ध है। हम सहायक साधनों और वैकल्पपक ्ቚारूपों को ्ቚाप्त करने म भी आपकी मिि कर सकत े ह। ें ैं Hmong: Qhov xov xwm no tseem ceeb los ntawm Kaiser Permanente. Yog koj xav tau kev pab kom nkag siab cov xov xwm no, thov hu rau 1-800-464-4000 (TTY 711) thiab thov kev pab txhais lus. Muaj kev pab 24 teev ib hnub twg, 7 hnub ib lim tiam twg, tsis xam cov hnub caiv. Peb kuj muab tau lwm yam kev pab rau koj thiab ua lwm yam ntaub ntawv. Japanese: Kaiser Permanenteから重要なお知らせがあります。この情報を理解するためにヘルプが必要な場合は、1-800-464-4000 (TTY 回 線 711) に電話して、言語サービスを依頼してください。このサービスは年中無休（祝祭日を除く）でご利用いただけます。補助器具・サー ビスや別のフォーマットについてもご相談いただけます。 Khmer:នេះគឺជាព័ត៌មាេសំខាេ់ មកពី Kaiser Permanente។ ន់សសនេ្នកករតវការជំំេយយ ឲ្យបាេយល់ដឹងព័ត៌មាេនេះ សូមទូជស័ព្ទនៅនលខ 1-800-464-4000 (TTY 711) េនងនសកសសំំំំេយយខាងសា។។ ំំេយយគឺមាេ 24 នមាú្ងមយយ្ងៃងៃ 7 ្ងៃងៃកកុងមយយសបា្ត្ហ៍ នលសកែលង្ងៃងៃប់់សរមាក។ នយសងកអាចជំយយ្នកកជាមយយេឹងប់កជ៍៍ំំេយយទំនាក់ទំេងសរមា់់្នកកពនរជេនងជាទរមង់ំំេយសន្្េងៗ។ Korean: 본 정보는 Kaiser Permanente 에서 전하는 중요한 메시지입니다. 본 정보를 이해하는 데 도움이 필요하시면, 1-800-464-4000 (TTY 711) 번으로 전화해 언어 지원 서비스를 요청하십시오. 요일 및 시간에 관계없이 언제든지 도움을 제공해 드립니다(공휴일 제외). 또한 보조기구 및 대체 형식의 자료를 지원해 드릴 수 있습니다.

້ ້ ້ ້ ້ Laotian: ນແມນຂມນສູ ຳຄນຈຳກ Kaiser Permanente. ຖຳວຳ ທຳນຕອງກຳນຄວຳມຊວຍເຫອໃນກຳນຊວຍໃຫເຂຳໃຈຂມນນູ , ກະຣນຳໂທຣຸ 1-800-464-4000 ຼ ີ ໍ ໍ ັ ື ົ ໍ ີ ່ ້ ່ ່ ້ ່ ່ ້ ່ ່ ່ (TTY 711) ແລະຂເອຳກຳນຊວຍເຫອດຳນພຳສຳ. ກຳນຊວຍເຫອມໃຫຕະຫອດ 24 ຊວໂມງ, 7 ວນຕອຳທດ, ບລວມວນພກຕຳງໆ. ພວກເຮຳຍງສຳມຳດຊວຍທຳນໃນ ຼ ຼ ຼ ໍ ົ ື ື ີ ົ ັ ໍ ິ ໍ ັ ັ ົ ັ ່ ້ ່ ້ ່ ່ ່ ່ ດຳນອປະກອນຊຸ ວຍເສມ ແລະ ຮບແບບທຳງເລູ ອກອນໄດ. ີ ື ື ້ ່ ້ Mien: Naaiv se benx jienv sic dauh waac-fienx yiem naaiv Kaiser Permanente bun daaih. Beiv taux meih qiemx longc mienh tengx doqc naaiv deix waac-fienx liouh porv bun bieqc hnyouv nor, daaix luic douc waac daaih lorx 1-800-464-4000 (TTY 711) aengx caux tov heuc tengx nzie faan waac bun muangx. Mbenc nzoih liouh tengx yiem yietc hnoi benx 24 norm ziangh hoc, yietc norm liv baaiz mbenc maaih 7 hnoi, simv cuotv hnoi-gec oc. Yie mbuo corc haih mbenc wuotc ginc jaa-dorngx tengx nzie goux aengx caux liouh bun ginv longc sou-guv daan puix horpc meih. Navajo: Díí éí hane’ bíhólníihii át’éego Kaiser Permanente yee nihalne’. Díí hane’ígíí doo hazhó’ó bik’i’diitįįhgóó t’áá shǫǫdí koji’ hodíílnih 1-800-464-4000 (TTY 711) áko saad bee áká i’iilyeed yídííkił. Kwe’é áká aná’álwo’ t’áá áłahjį’ naadiindįį’ ahéé’ílkidgóó dóó tsosts’id jį ąą’át’é. ́ ́ ́ Dahodílzingóne’ éí dá’deelkaal. Áádóó hane’ bee bik’i’ di’díítííłígíí dóó t’áá łahgo át’éego hane’ nich’į ádoolnííł. Punjabi: ਇਹ Kaiser Permanente ਵਲੋਂ ਜ਼ਰੂਰੀ ਜਾਣਕਾਰੀ ਹੈ। ਜੇ ਤੁਹਾਨੰ ੂ ਇਸ ਜਾਣਕਾਰੀ ਨੰ ੂ ਸਮਝਣ ਲਈ ਮਦਦ ਦੀ ਲੋੜ ਹੈ, ਤਾਂ ਕਕਰਪਾ ਕਰਕੇ 1-800-464-4000 (TTY 711) 'ਤੇ ਫ਼ੋਨ ਕਰੋ ਅਤੇ ਭਾਸ਼ਾ ਸਹਾਇਤਾ ਲਈ ਪੁੱਛੋ। ਮਦਦ, ਛੁੱਟੀਆਂ ਨੰ ੂ ਛੱਡ ਕੇ, ਹਫ਼ਤੇ ਦੇ 7 ਕਦਨ, ਅਤੇ ਕਦਨ ਦੇ 24 ਘੰਟੇ ਮੌਜੂਦ ਹੈ। ਅਸੀਂ ਸਹਾਇਕ ਸਾਧਨਾਂ ਅਤੇ ਕਵਕਲਕਪਕ ਫਾਰਮੈਟਾਂ ਕਵੱਚ ਵੀ ਤੁਹਾਡੀ ਮਦਦ ਕਰ ਸਕਦੇ ਹਾਂ। Russian: Это важная информация от Kaiser Permanente. Если Вам требуется помощь, чтобы понять эту информацию, позвоните по номеру 1-800-464-4000 (линия TTY 711) и попросите предоставить Вам услуги переводчика. Помощь доступна 24 часа в сутки, 7 дней в неделю, кроме праздничных дней. Мы также можем помочь вам с вспомогательными средствами и альтернативными форматами. Spanish: La presente incluye información importante de Kaiser Permanente. Si necesita ayuda para entender esta información, llame al 1-800-788-0616 (TTY 711) y pida ayuda linguística. Hay ayuda disponible 24 horas al día, siete días a la semana, excluidos los días festivos. También podemos ayudarle con recursos para discapacidades y formatos alternativos. Tagalog: Ito ay importanteng impormasyon mula sa Kaiser Permanente. Kung kailangan ninyo ng tulong para maunawan ang impormasyong ito, mangyaring tumawag sa 1-800-464-4000 (TTY 711) at humingi ng tulong kaugnay sa lengguwahe. May makukuhang tulong 24 na oras bawat araw, 7 araw bawat linggo, maliban sa mga araw na pista opisyal. Matutulungan din namin kayo sa mga pantulong na gamit o serbisyo at mga alternatibong format. ํ ่ Thai: นเปี่ ็ นขอม้ ลสู าคญจากั Kaiser Permanente หากคณตุ องการความช้ วยเหลอในการทื ํ าความเขาใจข้ อม้ ลนู ี้ โปรด โทร 1-800-464-4000 (โหมด TTY ่ ่ ั่ ั 711) และขอความชวยเหลอดื านภาษา้ เราพรอมให้ ความช้ วยเหลอตลอดื 24 ชวโมง 7 วนตั อส่ ปดาห ์ ยกเวนว้ นหยั ดราชการุ เรายงสามารถจั ัดหาอปกรณุ และ์ ่ วสดั ชุ วยเหลอในรื ปแบบอู นไดื่ อ้ กดี วย้ Ukranian: У цьому повідомленні міститься важлива інформація від Kaiser Permanente. Якщо надана інформація не зрозуміла й вам потрібна допомога, зателефонуйте за номером 1-800-464-4000 (TTY 711) і попросіть надати вам послугу перекладача. Наші співробітники надають допомогу цілодобово, 7 днів на тиждень, за винятком святкових днів. Також ми можемо допомогти вам, надавши допоміжні засоби й матеріали в альтернативних форматах. Vietnamese: Đây là thông tin quan trọng từ Kaiser Permanente. Nếu quý vị cần được giúp đỡ để hiểu rõ thông tin này, vui lòng gọi số 1-800-464-4000 (TTY 711) và yêu cầu được cấp dịch vụ về ngôn ngữ. Quý vị sẽ được giúp đỡ 24 giờ trong ngày, 7 ngày trong tuần, trừ ngày lễ. Chúng tôi cũng có thể giúp quý vị với các phương tiện trợ giúp bổ trợ và hình thức thay thế.