Page 7 of 8 Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your plan document for more information and a list of any other excluded services.) • Acupuncture • Bariatric surgery • Cosmetic surgery • Dental care (Adult) • Hearing aids • Infertility treatment • Non-emergency care when traveling outside the U.S. • Long term care • Routine eye care (Adult) • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Chiropractic care (No visit limit) • Private duty nursing • Routine foot care (for certain conditions) 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 the agency is the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 877-267-2323 x61565 or www.cms.gov/cciio. You may also contact Surest Member Services at 1-866-683-6440. 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 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: Surest Member Services at 1-866-683-6440. 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. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al [1-866-633-2446]. Traditional Chinese (中文): 如果需要中文的幫助, 請撥打這個號碼 [1-866-633-2446]. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' [1-866-633-2446]. Pennsylvania Dutch (Deitsch): Fer Hilf griege in Deitsch, ruf [1-866-633-2446] uff. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa [1-866-633-2446]. Samoan (Gagana Samoa): Mo se fesoasoani i le Gagana Samoa, vala’au mai i le numera telefoni [1-866-633-2446]. Carolinian (Kapasal Falawasch): ngere aukke ghut alillis reel kapasal Falawasch au fafaingi tilifon ye [1-866-633-2446]. Chamorro (Chamoru): Para un ma ayuda gi finu Chamoru, å’gang [1-866-633-2446]. To see examples of how this plan might cover costs for a sample medical situation, see the next section.