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City of Lakewood: Plan 1 Coverage Period: 01101/2017-1213112017 <br />Summary of Benefits and Coverage: What This Plan Covers &What It Costs Coverage for: Single or Family l Plan Type: PPO <br />Excluded Services & Other Covered Services: <br />Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.) <br />• Acupuncture <br />Herring Aids Routine Eye Cafe (Adult) <br />• Cosmetic Surgery <br />Infertility Treatment Routine Foot Care <br />• Dental check-up (Child) <br />Long Term 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 policy or plan document for other covered services and your costs for these services.) <br />Bedside 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 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 the plan. <br />Other limitations on your rights to continue coverage may also apply. <br />For more information on your dghis to continue coverage, contact the plan at 800 540 2583. You may also contact your slate insurance department, the U.S. Department of <br />Labor, Employee Benefits Security Administration at 866.444 3272 or www.dol gov/ebsa, or the U S. Department of Health and Human Services at 877.267.2323 X61565 or <br />www.ccro.cros.guv <br />City of Lakewood : Plan 1 Coverage Period: 01/0112017. 1213112017 <br />Summary of Benefits and Coverage: What This Plan Covers& What it Costs 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 claims under your plan, you may be able to appeal or file a grievance. For questions about your <br />rights, this notice, or assistance, you can contact the plan at 800.640.2683. You may also contact the Department of Labors Employee Benefits Security Administration <br />at 866 444.EBSA (3273) or www.dol govlelhosheallhrefonn. <br />Does this Coverage Provide Minimum Essential Coverage? <br />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 <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 />51 <br />