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<br /> <br /> <br /> 5 of 6 <br /> <br /> Excluded Services & Other Covered Services: <br />Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) <br />• Acupuncture • Long-term care • Routine foot care <br />• Bariatric surgery • Non-emergency care when traveling outside the U.S. • Weight loss programs <br />• Cosmetic surgery with the exception of port wine <br />stain removal and reconstructive surgery <br />• Non-formulary drugs without a formulary exception • <br />• Infertility treatment • Private-duty nursing • <br /> <br />Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) <br />• Chiropractic care • Hearing aids • <br />• Dental care (Children) • Routine eye care (Adult) • <br />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 <br />agencies is: Your plan at 1-800-883-2177, the Department of Labor’s Employee Benefits Security Administration at 1 -866-444-EBSA (3272) or <br />www.dol.gov/ebsa/healthreform or MN Dept of Health at 651-201-5100 / 1-800-657-3916.Other coverage options may be available to you too, including buying <br />individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.mnsure.org or call 1-855-366-7873. <br />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 <br />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 <br />provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, <br />contact: Your plan at 1-800-883-2177, the Department of Labor’s Employee Benefits Security Administration at 1 -866-444-EBSA (3272) or <br />www.dol.gov/ebsa/healthreform or MN Dept of Health at 651-201-5100 / 1-800-657-3916. <br />Does this plan provide Minimum Essential Coverage? Yes. <br />Minimum Essential Coverage generally includes plan, health insurance available through the Marketplace or other individual market policies, Medicare, <br />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 <br />tax credit. <br />Does this plan meet Minimum Value Standards? Yes. <br />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. <br />Language Access Services: <br />Spanish (Español): Para obtener asistencia en Español, llame al 1 -866-398-9119. <br />Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-883-2177. <br />Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-800-883-2177. <br />Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1 -800-883-2177. <br />––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.–––––––––––––––––––––– <br />