Transcription of Kaiser Permanente Summary of Benefits and Coverage: Gold ...
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Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2022. : Gold 80 HMO 0/30 + Child Dental Alt Coverage for: Individual / Family | Plan Type: HMO. The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a Summary . For more information about your coverage, or to get a copy of the complete terms of coverage, or call 1-800-278-3296 (TTY: 711). For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary.
Limited to two check-ups / year. Excluded Services & Other Covered Services: ... 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
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