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20210101_CalChoice_Kaiser_Platinum_HMO_A_SBC Flipbook PDF
20210101_CalChoice_Kaiser_Platinum_HMO_A_SBC
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Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services : California Choice Platinum HMO A
Coverage Period: Beginning on or after 01/01/2021 1/01/2021 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, www.kp.org/plandocuments 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. You can view the Glossary at http://www.healthcare.gov/sbc-glossary or call 1-800-278-3296 (TTY: 711) to request a copy. Important Questions
Answers
What is the overall deductible?
$0
See the common Medical Events chart below for your costs for services this plan covers.
Not Applicable.
This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.
Are there services covered before you meet your deductible?
Are there other deductibles for specific No. services? What is the out-ofpocket limit for this plan?
You don’t have to meet deductibles for specific services.
The out-of-pocket limit is the most you could pay in a year for covered services. If you have Medical: $3,000 Individual / $6,000 Family other family members in this plan, they have to meet their own out-of-pocket limits until the Child Dental: $350 Child / $700 Children overall family out-of-pocket limit has been met.
Premiums, health care this plan doesn’t What is not included in cover, and services indicated in chart the out-of-pocket limit? starting on page 2. Will you pay less if you Yes. See www.kp.org or call 1-800-278use a network 3296 (TTY: 711) for a list of network provider? providers. Do you need a referral to see a specialist?
Why This Matters:
Yes, but you may self-refer to certain specialists.
Even though you pay these expenses, they don’t count toward the out–of–pocket limit. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist.
Plan ID: 13289 / 13290_2021
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All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event
If you visit a health care provider’s office or clinic
If you have a test
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.kp.org/formulary
If you have outpatient surgery
Services You May Need
What You Will Pay Non-Plan Provider Plan Provider (You will pay the (You will pay the least) most)
1/01/2021
Limitations, Exceptions, & Other Important Information
Primary care visit to treat an injury or illness
$10 / visit
Not covered
None
Specialist visit
$20 / visit
Not covered
Preventive care/screening/ immunization
No charge
Not covered
X-ray: $40 / encounter Lab tests: $20 / encounter
None You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.
Not covered
None
$150 / procedure
Not covered
None
Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs)
Up to a 30-day supply retail and a 100-day supply mail order. Female contraceptives are no charge. Subject to formulary guidelines. Up to a 30-day supply retail and a 100-day supply mail order. Female contraceptives are no charge. Subject to formulary guidelines. The cost-sharing for non-preferred brand drugs under this plan aligns with the cost-sharing for preferred brand drugs (Tier 2), when approved through the formulary exception process.
Generic drugs (Tier 1)
$5 / prescription (retail), $10 / prescription (mail order)
Not covered
Preferred brand drugs (Tier 2)
$15 / prescription (retail), $30 / prescription (mail order)
Not covered
Non-preferred brand drugs (Tier 2)
$15 / prescription (retail), $30 / prescription (mail order)
Not covered
Specialty drugs (Tier 4)
10% coinsurance up to $250 / prescription
Not covered
Up to a 30-day supply (retail). Subject to formulary guidelines.
Facility fee (e.g., ambulatory surgery center)
$300 / procedure
Not covered
None
Physician/surgeon fees
Not Applicable
Not covered
Physician/Surgeon Fee is included in the Facility Fee. 2 of 6
Common Medical Event
If you need immediate medical attention
If you have a hospital stay
If you need mental health, behavioral health, or substance abuse services
If you are pregnant
Services You May Need
What You Will Pay Non-Plan Provider Plan Provider (You will pay the (You will pay the least) most)
1/01/2021 Limitations, Exceptions, & Other Important Information
Emergency room care
$200 / visit
$200 / visit
Emergency medical transportation
Copayment is waived if admitted to hospital as inpatient.
$150 / trip
$150 / trip
None
Urgent care
$10 / visit
$10 / visit
Facility fee (e.g., hospital room)
Non-Plan providers covered when temporarily outside the service area.
$500 / admission
Not covered
None
Physician/surgeon fees
Not Applicable
Not covered
Outpatient services
Mental / Behavioral health: $10 / individual visit; No charge for other outpatient services. Substance Abuse: $10 / individual visit; $5 / day for other outpatient services.
Physician/Surgeon Fee is included in the Facility Fee.
Not covered
$5 / group visit
Inpatient services
$500 / admission
Not covered
None
Office visits
No charge
Not covered
Childbirth/delivery professional services
Not Applicable
Not covered
Childbirth/delivery facility services
$500 / admission
Not covered
Depending on the type of services, a copayment, coinsurance, or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound). Professional services are included in the Facility Fee. None
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Common Medical Event
If you need help recovering or have other special health needs
If your child needs dental or eye care
Services You May Need
What You Will Pay Non-Plan Provider Plan Provider (You will pay the (You will pay the least) most)
1/01/2021 Limitations, Exceptions, & Other Important Information
Home health care
No charge
Not covered
Up to 2 hours / visit, up to 3 visits / day, up to 100 visits / year.
Rehabilitation services
Inpatient: $500 / admission Outpatient: $10 / visit
Not covered
None
Habilitation services
Inpatient: $500 / admission Outpatient: $10 / visit
Not covered
None
Skilled nursing care
$250 / admission
Not covered
Up to 100 days limit / benefit period.
Durable medical equipment
10% coinsurance
Not covered
Up to $2,000 supplemental benefit limit / year for certain items. Requires prior authorization.
Hospice services
No charge
Not covered
None
Children’s eye exam
No charge
Not covered
None
Children’s glasses
No charge
Not covered
Limited to one pair of glasses/year from select frames and lenses
Children’s dental check-up
No charge
Not covered
Limited to two check-ups / year.
Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Infertility treatment • Cosmetic surgery • Private-duty nursing • Dental care (Adult) • Long-term care • Routine foot care • Non-emergency care when traveling outside the U.S • Hearing aids • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Routine eye care (Adult) • Abortion • Bariatric surgery • Acupuncture (20 visits limit/year combined • Chiropractic care (20 visits limit/year combined with with chiropractic) acupuncture)
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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 those 1/01/2021 agencies is shown in the chart below. 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 www.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 the agencies in the chart below.
Contact Information for Your Rights to Continue Coverage & Your Grievance and Appeals Rights: Kaiser Permanente Member Services 1-800-278-3296 (TTY: 711) or www.kp.org/memberservices Department of Labor’s Employee Benefits Security Administration
1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform
Department of Health & Human Services, Center for Consumer Information & Insurance Oversight
1-877-267-2323 x61565 or www.cciio.cms.gov
California Department of Insurance
1-800-927-HELP (4357) or www.insurance.ca.gov
California Department of Managed Healthcare
1-888-466-2219 or www.healthhelp.ca.gov/
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 1-800-788-0616 (TTY: 711) [Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-278-3296 (TTY: 711). [Chinese (中文): 如果需要中文的帮助, 请拨打这个号码1-800-757-7585 (TTY: 711) [Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-278-3296 (TTY: 711) To see examples of how this plan might cover costs for a sample medical situation, see the next section.
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1/01/2021
About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.
Managing Joe’s Type 2 Diabetes
Peg is Having a Baby
(9 months of in-network pre-natal care and a hospital delivery)
The plan’s overall deductible Specialist copayment Hospital (facility) copayment Other (blood work) copayment
Mia’s Simple Fracture
(a year of routine in-network care of a wellcontrolled condition)
$0 $20 $500 $20
The plan’s overall deductible Specialist copayment Hospital (facility) copayment Other (blood work) copayment
(in-network emergency room visit and follow up care)
$0 $20 $500 $20
The plan’s overall deductible Specialist copayment Hospital (facility) copayment Other (x-ray) copayment
$0 $20 $500 $40
This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)
This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)
This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)
Total Example Cost
Total Example Cost
Total Example Cost
In this example, Peg would pay: Cost Sharing Deductibles
$12,700
$0
In this example, Joe would pay: Cost Sharing Deductibles
$5,600
$0
In this example, Mia would pay: Cost Sharing Deductibles
$2,800
$0
Copayments
$800
Copayments
$500
Copayments
$500
Coinsurance
$0
Coinsurance
$50
Coinsurance
$0
What isn’t covered Limits or exclusions The total Peg would pay is
$50 $850
What isn’t covered Limits or exclusions The total Joe would pay is
$0 $550
What isn’t covered Limits or exclusions The total Mia would pay is
$0 $500
The plan would be responsible for the other costs of these EXAMPLE covered services. 6 of 6
1/01/2021 Nondiscrimination Notice Kaiser Permanente does not discriminate on the basis of age, race, ethnicity, color, national origin, cultural background, ancestry, religion, sex, gender identity, gender expression, sexual orientation, marital status, physical or mental disability, source of payment, genetic information, citizenship, primary language, or immigration status. Language assistance services are available from our Member Service Contact Center 24 hours a day, 7 days a week (except closed holidays). Interpreter services, including sign language, are available at no cost to you during all hours of operation. Auxiliary aids and services for individuals with disabilities are available at no cost to you during all hours of operation. We can also provide you, your family, and friends with any special assistance needed to access our facilities and services. You may request materials translated in your language at no cost to you. You may also request these materials in large text or in other formats to accommodate your needs at no cost to you. For more information, call 1-800-464-4000 (TTY 711). A grievance is any expression of dissatisfaction expressed by you or your authorized representative through the grievance process. For example, if you believe that we have discriminated against you, you can file a grievance. Please refer to your Evidence of Coverage or Certificate of Insurance or speak with a Member Services representative for the dispute-resolution options that apply to you. You may submit a grievance in the following ways: •
By phone: Call member services at 1-800-464-4000 (TTY 711) 24 hours a day, 7 days a week (except closed holidays).
•
By mail: Call us at 1-800-464-4000 (TTY 711) and ask to have a form sent to you.
•
In person: Fill out a Complaint or Benefit Claim/Request form at a member services office located at a Plan Facility (go to your provider directory at kp.org/facilities for addresses)
•
Online: Use the online form on our website at kp.org
Please call our Member Service Contact Center if you need help submitting a grievance. The Kaiser Permanente Civil Rights Coordinator will be notified of all grievances related to discrimination on the basis of race, color, national origin, sex, age, or disability. You may also contact the Kaiser Permanente Civil Rights Coordinator directly at: Northern California Civil Rights/ADA Coordinator 1800 Harrison St. 16th Floor Oakland, CA 94612
Southern California Civil Rights/ADA Coordinator SCAL Compliance and Privacy 393 East Walnut St., Pasadena, CA 91188
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Ave. SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 1-800-537-7697 (TTY). Complaint forms are available at hhs.gov/ocr/office/file/index.html.
1/01/2021 Aviso de no discriminación Kaiser Permanente no discrimina a ninguna persona por su edad, raza, etnia, color, país de origen, antecedentes culturales, ascendencia, religión, sexo, identidad de género, expresión de género, orientación sexual, estado civil, discapacidad física o mental, fuente de pago, información genética, ciudadanía, lengua materna o estado migratorio. La Central de Llamadas de Servicio a los Miembros brinda servicios de asistencia con el idioma las 24 horas del día, los 7 días de la semana (excepto los días festivos). Se ofrecen servicios de interpretación sin costo alguno para usted durante el horario de atención, incluido el lenguaje de señas. Se ofrecen aparatos y servicios auxiliares para personas con discapacidades sin costo alguno durante el horario de atención. También podemos ofrecerle a usted, a sus familiares y amigos cualquier ayuda especial que necesiten para acceder a nuestros centros de atención y servicios. Puede solicitar los materiales traducidos a su idioma sin costo para usted. También los puede solicitar con letra grande o en otros formatos que se adapten a sus necesidades sin costo para usted. Para obtener más información, llame al 1-800-788-0616 (TTY 711). Una queja es una expresión de inconformidad que manifiesta usted o su representante autorizado a través del proceso de quejas. Por ejemplo, si usted cree que ha sufrido discriminación de nuestra parte, puede presentar una queja. Consulte su Evidencia de Cobertura (Evidence of Coverage) o Certificado de Seguro (Certificate of Insurance), o comuníquese con un representante de Servicio a los Miembros para conocer las opciones de resolución de disputas que le corresponden. Puede presentar una queja de las siguientes maneras: •
Por teléfono: Llame a servicio a los miembros al 1-800-788-0616 (TTY 711) las 24 horas del día, los 7 días de la semana (excepto los días festivos).
•
Por correo postal: Llámenos al 1-800-788-0616 (TTY 711) y pida que se le envíe un formulario.
•
En persona: Llene un formulario de Queja Formal o Reclamo/Solicitud de Beneficios en una oficina de servicio a los miembros ubicada en un Centro de Atención del Plan (consulte su directorio de proveedores en kp.org/facilities [haga clic en “Español”] para obtener las direcciones).
•
En línea: Use el formulario en línea en nuestro sitio web en kp.org/espanol.
Llame a nuestra Central de Llamadas de Servicio a los Miembros si necesita ayuda para presentar una queja. Se le informará al Coordinador de Derechos Civiles de Kaiser Permanente (Civil Rights Coordinator) de todas las quejas relacionadas con la discriminación por motivos de raza, color, país de origen, género, edad o discapacidad. También puede comunicarse directamente con el coordinador de derechos civiles de Kaiser Permanente en: Northern California Southern California Civil Rights/ADA Coordinator Civil Rights/ADA Coordinator 1800 Harrison St. SCAL Compliance and Privacy 16th Floor 393 East Walnut St., Oakland, CA 94612 Pasadena, CA 91188 También puede presentar una queja formal de derechos civiles de forma electrónica ante la Oficina de Derechos Civiles (Office for Civil Rights) en el Departamento de Salud y Servicios Humanos de los Estados Unidos (U.S. Department of Health and Human Services) mediante el Portal de Quejas Formales de la Oficina de Derechos Civiles (Office for Civil Rights Complaint Portal), en ocrportal.hhs.gov/ocr/portal/lobby.jsf (en inglés) o por correo postal o por teléfono a: U.S. Department of Health and Human Services, 200 Independence Ave. SW, Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 1-800-537-7697 (TTY). Los formularios de queja formal están disponibles en hhs.gov/ocr/office/file/index.html (en inglés).
1/01/2021 無歧視公告 Kaiser Permanente禁止以年齡、人種、族裔、膚色、原國籍、文化背景、血統、宗教、性別、性別認同、性別表達、性取向、婚姻狀況、 生理或心理殘障、付款來源、遺傳資訊、公民身份、主要語言或移民身份為由而歧視任何人。 會員服務聯絡中心每週7天每天24小時提供語言協助服務（節假日除外）。本機構在全部營業時間內免費為您提供口譯服務，包括手語服 務，以及殘障人士輔助器材和服務。我們還可為您和您的親友提供使用本機構設施與服務所需要的任何特別協助。您可免費索取翻譯成 您的語言的資料。您還可免費索取符合您需求的大號字體或其他格式的版本。若需更多資訊，請致電1-800-757-7585（TTY 711）。 申訴指任何您或您的授權代表透過申訴程序來表達不滿的做法。例如，如果您認為自己受到歧視，即可提出申訴。若需瞭解適用於自己的 爭議解決選項，請參閱《承保範圍說明書》(Evidence of Coverage) 或《保險證明書》(Certificate of Insurance)，或諮詢會員服務代表。 您可透過以下方式提出申訴： •
透過電話：請致電1-800-757-7585（TTY 711）與會員服務部聯絡，服務時間為每週7天，每天24小時（節假日除外）。
•
透過郵件：請致電1-800-757-7585（TTY 711）與我們聯絡並請我們將表格寄給您。
•
親自遞交：在計劃設施的會員服務辦事處填寫投訴或福利理索賠／申請表（請參閱kp.org/facilities上的保健業者名錄以查看地址）
•
線上：使用我們網站上的線上表格，網址為kp.org
如果您在提交申訴時需要協助，請致電我們的會員服務聯絡中心。 涉及人種、膚色、原國籍、性別、年齡或殘障歧視的一切申訴都將通知Kaiser Permanente的民權事務協調員 (Civil Rights Coordinator)。 您也可與Kaiser Permanente的民權事務協調員直接聯絡，地址： Northern California Civil Rights/ADA Coordinator 1800 Harrison St. 16th Floor Oakland, CA 94612
Southern California Civil Rights/ADA Coordinator SCAL Compliance and Privacy 393 East Walnut St., Pasadena, CA 91188
您還可以電子方式透過民權辦公室的投訴入口網站 (Office for Civil Rights Complaint Portal) 向美國衛生與民眾服務部 (U.S. Department of Health and Human Services) 民權辦公室 (Office for Civil Rights) 提出民權投訴，網址是ocrportal.hhs.gov/ocr/portal/lobby.jsf或者按照如下資 訊採用郵寄或電話方式聯絡：U.S. Department of Health and Human Services, 200 Independence Ave. SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 1-800-537-7697 (TTY)。投訴表可從網站hhs.gov/ocr/office/file/index.html下載。
1/01/2021 Thông Báo Không Kỳ Thị Kaiser Permanente không phân biệt đối xử dựa trên tuổi tác, chủng tộc, sắc tộc, màu da, nguyên quán, hoàn cảnh văn hóa, tổ tiên, tôn giáo, giới tính, nhận dạng giới tính, cách thể hiện giới tính, khuynh hướng tình dục, gia cảnh, khuyết tật về thể chất hoặc tinh thần, nguồn tiền thanh toán, thông tin di truyền, quốc tịch, ngôn ngữ chính, hay tình trạng di trú. Các dịch vụ trợ giúp ngôn ngữ hiện có từ Trung Tâm Liên Lạc ban Dịch Vụ Hội Viên của chúng tôi 24 giờ trong ngày, 7 ngày trong tuần (ngoại trừ ngày lễ). Dịch vụ thông dịch, kể cả ngôn ngữ ký hiệu, được cung cấp miễn phí cho quý vị trong giờ làm việc. Các phương tiện trợ giúp và dịch vụ bổ sung cho những người khuyết tật được cung cấp miễn phí cho quý vị trong giờ làm việc. Chúng tôi cũng có thể cung cấp cho quý vị, gia đình và bạn bè quý vị mọi hỗ trợ đặc biệt cần thiết để sử dụng cơ sở và dịch vụ của chúng tôi. Quý vị có thể yêu cầu miễn phí tài liệu được dịch ra ngôn ngữ của quý vị. Quý vị cũng có thể yêu cầu miễn phí các tài liệu này dưới dạng chữ lớn hoặc dưới các dạng khác để đáp ứng nhu cầu của quý vị. Để biết thêm thông tin, gọi 1-800-464-4000 (TTY 711). Một phàn nàn là bất cứ thể hiện bất mãn nào được quý vị hay vị đại diện được ủy quyền của quý vị trình bày qua thủ tục phàn nàn. Ví dụ, nếu quý vị tin rằng chúng tôi đã kỳ phân biệt đối xử với vị, quý vị có thể đệ đơn phàn nàn. Vui lòng tham khảo Chứng Từ Bảo Hiểm (Evidence of Insurance) hay Chứng Nhận Bảo Hiểm (Certificate of Insurance), hoặc nói chuyện với một nhân viên ban Dịch Vụ Hội Viên để biết các lựa chọn giải quyết tranh chấp có thể áp dụng cho quý vị. Quý vị có thể nộp đơn phàn nàn bằng các hình thức sau đây: •
Qua điện thoại: Gọi cho ban dịch vụ hội viên theo số 1-800-464-4000 (TTY 711) 24 giờ trong ngày, 7 ngày trong tuần (ngoại trừ đóng cửa ngày lễ).
•
Qua bưu điện: Gọi cho chúng tôi theo số 1-800-464-4000 (TTY 711) và yêu cầu được gửi một mẫu đơn.
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Trực tiếp: Điền một mẫu đơn Than Phiền hay Yêu Cầu Quyền Lợi/Yêu Cầu tại một văn phòng ban dịch vụ hội viên tại một Cơ Sở Thuộc Chương Trình (xem danh mục nhà cung cấp của quý vị tại kp.org/facilities để biết địa chỉ)
• Trực tuyến: Sử dụng mẫu đơn trực tuyến trên trang mạng của chúng tôi tại kp.org Xin gọi Trung Tâm Liên Lạc ban Dịch Vụ Hội Viên của chúng tôi nếu quý vị cần trợ giúp nộp đơn phàn nàn. Điều Phối Viên Dân Quyền (Civil Rights Coordinator) Kaiser Permanente sẽ được thông báo về tất cả phàn nàn liên quan tới việc kỳ thị trên cơ sở chủng tộc, màu da, nguyên quán, giới tính, tuổi tác, hay tình trạng khuyết tật. Quý vị cũng có thể liên lạc trực tiếp với Điều Phối Viên Dân Quyền Kaiser Permanente tại: Northern California Civil Rights/ADA Coordinator 1800 Harrison St. 16th Floor Oakland, CA 94612
Southern California Civil Rights/ADA Coordinator SCAL Compliance and Privacy 393 East Walnut St., Pasadena, CA 91188
Quý vị cũng có thể đệ đơn than phiền về dân quyền với Bộ Y Tế và Nhân Sinh Hoa Kỳ (U.S. Department of Health and Human Services), Phòng Dân Quyền (Office of Civil Rights) bằng đường điện tử thông qua Cổng Thông Tin Phòng Phụ Trách Khiếu Nại về Dân Quyền (Office for Civil Rights Complaint Portal), hiện có tại ocrportal.hhs.gov/ocr/portal/lobby.jsf, hay bằng đường bưu điện hoặc điện thoại tại: U.S. Department of Health and Human Services, 200 Independence Ave. SW, Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 1-800-537-7697 (TTY). Mẫu đơn than phiền hiện có tại hhs.gov/ocr/office/file/index.html.
NOTICE OF LANGUAGE ASSISTANCE
1/01/2021
English: This is important information from Kaiser Permanente. If you need help understanding this information, please call 1-800-464-4000 and ask for language assistance. Help is available 24 hours a day, 7 days a week, excluding holidays. المساعدة. وطلب مساعدة لغوية1-800-464-4000 يرجى الاتصال على الرقم، إذا كنت بحاجة للمساعدة في فهم هذه المعلومات.Kaiser Permanente تحتوي هذه الوثيقة على معلومات مهمة من:Arabic . باستثناء أيام العطلات الرسمية،متوفرة على مدار الساعة طيلة أيام الأسبوع Armenian: Սա կարևոր տեղեկություն է «Kaiser Permanente»-ից: Եթե այս տեղեկությունը հասկանալու համար Ձեզ օգնություն է հարկավոր, խնդրում ենք զանգահարել 1-800-464-4000 հեռախոսահամարով և օժանդակություն ստանալ լեզվի հարցում: Զանգահարեք օրը 24 ժամ, շաբաթը 7 օր` բացի տոն օրերից: Chinese: 這是來自 Kaiser Permanente 的重要資訊。如果您需要協助瞭解此資訊，請致電 1-800-757-7585 尋求語言協助。我們每週 7 天，每天 24 小時皆提供 協助（節假日休息）。 کمک. تماس گرفته و برای امداد زبانی درخواست کنيد1-800-464-4000 لطفا ً با شماره، اگر در فهميدن اين اطلاعات به کمک نياز داريد. می باشدKaiser Permanente اين اطلاعات مهمی از سوی:Farsi . شامل روزهای تعطيل موجود است، روز هفته7 ساعت شبانروز و24 و راهنمايی در Hindi: यह Kaiser Permanente की ओर से महत्वपर ू ्ण सच ू ना है । यदि आपको इस सच ू ना को समझने के लिए मिि की जरूरत है , तो कृपया 1-800-464-4000 पर फोन करें और भाषा सहायता के लिए पछ ू ें । सहायता छुद्टियों को छोड़कर, सप्ताह के सातों दिन, दिन के 24 घंटे, उपिब्ध है । Hmong: Qhov xov xwm no tseem ceeb los ntawm Kaiser Permanente. Yog koj xav tau kev pab kom nkag siab cov xov xwm no, thov hu rau 1-800-464-4000 thiab thov kev pab txhais lus. Muaj kev pab 24 teev ib hnub twg, 7 hnub ib lim tiam twg, tsis xam cov hnub caiv. Japanese: Kaiser Permanente から重要なお知らせがあります。この情報を理解するためにヘルプが必要な場合は、 1-800-464-4000 に電話して、言語サー ビスを依頼してください。このサービスは年中無休（祝祭日を除く）でご利用いただけます。 Khmer:នេះគឺជាព័ត៌មាេសំខាេ់ មកពី Kaiser Permanente។ នបសសនេ្នកករតវការជំំេយយ ឲ្យបាេយល់ដឹងព័ត៌មាេនេះ សូមទូជស័ព្ទនៅនលខ 1-800-464-4000 េនងនសកសសំំំេយយខាង ភាសា។ ំំេយយគឺមាេ 24 នមា្ងមយយ្ងៃងៃ 7 ្ងៃងៃមយយអាទនត្យ ជយមទាំង្ងៃងៃបំណ្យផង។ Korean: 본 정보는 Kaiser Permanente 에서 전하는 중요한 메시지입니다. 본 정보를 이해하는 데 도움이 필요하시면, 1-800-464-4000 번으로 전화해 언어 지원 서비스를 요청하십시오. 요일 및 시간에 관계없이 언제든지 도움을 제공해 드립니다(공휴일 제외). ້ ມນຂໍ ້ ນ ້ ນ Laotian: ນີແ ູ ສ ໍຳຄ ັນຈຳກ Kaiser Permanente. ຖຳ້ ວຳ່ ທຳ່ ນຕອ ູ ນີ,້ ກະຣຸນຳໂທຣ 1-800-464-4000 ແລະຂໍເອົ ຳກຳນ ່ ມ ້ ງກຳນຄວຳມຊວ ່ ຍເຫຼືອໃນກຳນຊວ ່ ຍໃຫເ້ ຂົ້ຳໃຈຂໍມ ຊວ ່ ຍເຫຼືອດຳ້ ນພຳສຳ. ກຳນຊວ ່ ຍເຫຼືອມີໃຫຕ ້ ະຫຼ ອດ 24 ຊ່ວົ ໂມງ, 7 ວ ັນຕໍ່ອຳທິດ, ບໍ່ ລວມວ ັນພ ັກຕຳ່ ງໆ. Navajo: D77 47 hane’ b7h0ln7ihii 1t’4ego Kaiser Permanente yee nihalne’. D77 hane’7g77 doo hazh0’0 bik’i’diit88hg00 t’11 sh--d7 koji’ hod77lnih 1-800-464-4000 1ko saad bee 1k1 i’iilyeed y7d77ki[. Kwe’4 1k1 an1’1lwo’ t’11 1[ahj8’ naadiind99’ ah44’7lkidg00 d00 tsosts’id j9 22’1t’4. Dahod7lzing0ne’ 47 d1’deelkaal. Punjabi: ਇਹ Kaiser Permanente ਵਲੋਂ ਜ਼ਰੂਰੀ ਜਾਣਕਾਰੀ ਹੈ। ਜੇ ਤੁਹਾਨੂੰ ਇਸ ਜਾਣਕਾਰੀ ਨੂੰ ਸਮਝਣ ਲਈ ਮਦਦ ਦੀ ਲੋ ੜ ਹੈ, ਤਾਂ ਕਕਰਪਾ ਕਰਕੇ 1-800-464-4000 'ਤੇ ਫ਼ੋਨ ਕਰੋ ਅਤੇ ਭਾਸ਼ਾ ਸਹਾਇਤਾ ਲਈ ਪੁੱ ਛੋ। ਮਦਦ, ਛੁੱ ਟੀਆਂ ਨੂੰ ਛੱ ਡ ਕੇ, ਹਫ਼ਤੇ ਦੇ 7 ਕਦਨ, ਅਤੇ ਕਦਨ ਦੇ 24 ਘੰ ਟੇ ਮੌਜੂਦ ਹੈ। Russian: Это важная информация от Kaiser Permanente. Если Вам требуется помощь, чтобы понять эту информацию, позвоните по номеру 1-800-464-4000 и попросите предоставить Вам услуги переводчика. Помощь доступна 24 часа в сутки, 7 дней в неделю, кроме праздничных дней.
Spanish: La presente incluye información importante de Kaiser Permanente. Si necesita ayuda para entender esta información, llame al 1-800-788-0616 y 1/01/2021 pida ayuda linguística. Hay ayuda disponible 24 horas al día, siete días a la semana, excluidos los días festivos. Tagalog: Ito ay importanteng impormasyon mula sa Kaiser Permanente. Kung kailangan ninyo ng tulong para maunawan ang impormasyong ito, mangyaring tumawag sa 1-800-464-4000 at humingi ng tulong kaugnay sa lengguwahe. May makukuhang tulong 24 na oras bawat araw, 7 araw bawat linggo, maliban sa mga araw na pista opisyal. Thai: นีเ่ ป็ นข ้อมูลสําคัญจาก Kaiser Permanente หากคุณต ้องการความช่วยเหลือในการทําความเข ้าใจข ้อมูลนี้ กรุณาโทรไปยังหมายเลข 1-800-464-4000 เพือ ่ ขอความช่วย เหลือด ้านภาษา สามารถโทรติดต่อได ้ตลอด 24 ชัว่ โมงทุกวัน ยกเว ้นวันหยุดเทศกาล. Vietnamese: Đây là thông tin quan trọng từ Kaiser Permanente. Nếu quý vị cần được giúp đỡ để hiểu rõ thông tin này, vui lòng gọi số 1-800-464-4000 và yêu cầu được cấp dịch vụ về ngôn ngữ. Quý vị sẽ được giúp đỡ 24 giờ trong ngày, 7 ngày trong tuần, trừ ngày lễ.