v1.0 5 of 6 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.) • Cosmetic surgery • Non-emergency care when traveling outside U.S. • Routine foot care • Dental care (routine over age 13) • Private duty nursing • Weight loss programs • Long term care • Routine eye care (adult & child) Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Acupuncture (20 visits/yr) • Hearing aids (1/aid/ear/3 yrs/up to $2,500/ear; 1 bone anchored hearing aid/lifetime up to age 18) • Bariatric Surgery ($50,000 lifetime max) • Infertility treatment ($30,000 Rx/lifetime & $50,000 medical/lifetime) • Chiropractic care (20 visits/yr) • Wigs (1 wig/yr when related to cancer, surgery, burns, or alopecia; up to $500) 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 the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. 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 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 plan at 1-877-906-5730. You may also contact the U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. 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 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. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-877-906-5730; Portuguese (Portuguès): De assistència em Portuguès, ligue 1-877-906-5730 Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-877-906-5730 ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––