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City of Lakewood: Plan 1 <br />Summary of Benefits and Coverage: What This Plan Covers & What It Coats <br />Excluded Services & Other Covered Services: <br />Coverage Period: 0110 1014 , 1213112014 <br />Coverage for: Single or Family l Plan Type: FPO <br />Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other ezeluded services.) <br />• Acupuncture <br />Hearing Aids • Routine Eye Care (Adult) <br />• Cosmetic Surgery <br />Infertility Treatment • Routine FOOL Care <br />• Dental check -up (Child) <br />Long -Term Care • Weight Loss Programs <br />• Dental Care (Adult) <br />Nonemergency care when traveling outside the <br />• Glasses <br />U.S. <br />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.) <br />Badatric Surgery • Chiropractic Care • Private -Duty Nursing <br />Your Rights to Continue Coverage: <br />If you lose coverage under the plan, then, depending upon the circumstances. Federal and Stale laws may provide protections that allow you to keep health overage. Any <br />such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you paywhile covered under the plan. <br />Other limitations on your rights to continue coverage may also apply. <br />For more information on your rights to continue coverage, contact the plan at 800.5402583. You may also contact your state insurance department the U.S. Department of <br />Labor, Employee Benefits Security Administration at 866.444.3272 or www.dol.govlebsa, or the U.S. Department of Health and Human Services at 877.2672323 X61565 or <br />wrov.ociioxmis.gov. <br />Questions: Call 800.540.2583 or visit us at MedMutual.comtSBC. 1` g, 5 or S <br />If you aren't clear about any of the underfeed terms used in this form, see the Glossary. You can view the Glossary su535sss <br />at MedMutual.comlSBC or oil 800540.2583 to request copy. BEN1231053a6aN ON23 <br />City of Lakewood : Plan 1 Coverage Period: 0110112014- 1213112014 <br />Summary of Benefits and Coverage: WhatThia Plan Covers & What It Coate Coverage for: Single or Family 1 Plan Type: PPO <br />Your Grievance and Appeals Rights: <br />It you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you maybe able to appeal or file a rleg vane For questions about your <br />rights, this notice, or assistance, you can contact: the plan at 800.5402583. You may also contact the Department of Laboes Employee Benefits Security Administration <br />at 866A44.EBSA (3273) or vnvw.dol.gov /ebsalbealthretomi. <br />Does this Coverage Provide Minimum Essential Coverage? <br />The Affordable Care Act requires most people to have health ore overage that qualifies as °minimum essential coverage.' This plan or policy does provide minimum <br />essential coverage. <br />Does this Coverage Meet the Minimum Value Standard? <br />The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This heats coverage <br />does meet the minimum value standard for the benefits it provides, <br />33 <br />