Laserfiche WebLink
City of Lakewood : Plan 2 Coverage Period: 01/01/2614. 12131(2014 <br />Summary of Benefits and Coverage: What This Plan Covers 8 What It Costs Coverage for: Single or Family I Plan Type: PPO <br />Excluded Services & Other Covered Services: <br />Services Your Plan Does NOT Cover (This Ienl a complete list. Check your policy or plan document for other excluded services.) <br />• Acupuncture <br />Hearing Aids Routine Eye Care (Adult) <br />• Cosmetic Surgery <br />Infertility Treatment Routine Foot Care <br />• Dental check -up (Child) <br />Long -Tenn Care Weight Loss Programs <br />• Dental Care (Adult) <br />Non - emergency care when traveling outside the <br />• Glasses <br />U.S. <br />Other Covered Services (This isn't a complete list. Check your polloy or plan document for other covered services and your costs for these services.) <br />• Bariatric Surgery • Chiropractic Care • Private-Duty Nursing <br />Your Rights to Continue Coverage: <br />It you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. 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 pay while covered under 0e 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 stale 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 877.267.2323 X61565 or <br />www.ccno.cros.gov. <br />Questions: Call 800.5401583 or visit us at MedMutuaLCOmISBC. <br />If you aren't clear about any of the unde dined terms used in this form, see the Glossary. You can view the Glossary sc<sssaea <br />at MedMutudl.comlSBC or call SK5401583 to request a copy. BENIBIMM30 13 X*25 <br />City of Lakewood: Plan 2 Coverage Period: 0110112014 .1 213112 01 4 <br />Summary of Benefits and Coverage: what This Plan Covers a What it Coats Coverage for: Single or Family I Plan Type: PPO <br />Your Grievance and Appeals Rights: <br />If you have a complaint or are dissatisfied with a denial of coverage for Jaime under your plan, you maybe able to agpgg(or files grievance, For questions about your <br />rights, this notice, or assistance, you can contact the plan at800 .540.2583. You may also contact the Department of Labors Employee Benefits Security Administration <br />at 866.444.EBSA ( 3273) orwww .dol.gov /ebsalhealihreform. <br />Does this Coverage Provide Minimum Essential Coverage? <br />The Affordable Care Act requires most people to have health ore coverage that qualifies as'minimum essential caverage `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 health coverage <br />does meet the minimum value standard for the benefits it provides. <br />37 <br />