SBC Disclosure

Bee Aa’1dahay1n7 d00 Bee Ak’4da’asti’7 Baa N1hane’: Ha’1t’7ish d77 Bee Ha’d7t’4h7
yee Ak’4’asti’ & Ha’1t’7ish Nih Bee !ka’an7da’awo’7 Bik’4da’asti’7 Bik’4h Nahil4h Bee Ak’4’asti’ Bee Hoo’a’7g77: [See Instructions]

: B1 Bee Ak’4’asti’7: | Ha’d7t’4h7 !t’4h7g77:

Nida’7d7kid Bidah0ln7h7g77	Bee N7dahane’7	Ha’1t’7ish Biniinaa D77 B0dah0ln77h:
Ha’1t’7ish b4eso 1d7l32j8’ nijil4h7g77 a[tsoh 1t’4?	$
Da’ b4eso 1d7l32j8’ nijil4h7g77 t’ahdoo b7ighah ajil4h7 bee 1ka’an7da’awo’7 bee ak’4da’asti’7 h0l=?
Bee 1ka’an7da’awo’7 t’11 7iyis77 b1h7g77 b1 n11n1 [a’ b4eso 1d7l32j8’ nijil4h7g77 b1 h0l=?	$
Ha’1t’7is d77 bee ha’d7t’4h7 b1 ats’aazisd00 nijil4h7 bee haz’3?	$
Ats’aazisd00 nijil4h7 bee haz’3 biyi’ ha’1t’7ish doo b00lt2’ da?
Da’ azee’ 77[’7n7 bi[ nida’anish7 chois7n7[’88dgo0sh t’11 y0y11h7go nid77l44[?
Da’ azee’ 77[’7n7 haniih7g77 bi[ yah anin1aho0sh naaltsoos bee i’iln7h7 ton7n7zin?

T’11 A[hx33h Ats’77s N1n4l’88h Bi[ N7dahoot’aah7	Bee !ka’an7da’awo’7 N7n7zin Doolee[7g77	Ha’1t’77sh99 Ni Nid77l4[7g77		Bee Nahaz’1n7g77, Bee Dahoo’aah7g77, & B7daholn7ihgo Bee Baa Dahane’7 N11n1 {a’
		Azee’ &7[’7n7 Y7ka’an1lwo’7 Bi[ Nida’anish7 (T’11 1[ch’7d7 nid77l44[)	Azee’ &7[’7n7 Y7ka’an1lwo’7 T[‘00d66’ Bi[ Nida’anish7 (L2’7 nid77l44[)
Azee’ 77[’7n7 y7ka’an1lwo’7 ats’77s 1t’4h7g77 yaa’1haly1n7 bi[ haz’1n7di bi[ yah 77n7y1ago	Atahodiig11h doodago ats’77s bich’8’ an1hoot’i’ b22h 4’4l’9h biniiy4 al22j8 aa’1hay3 yah an1’1d11h
	Azee’ 77[’7n7 haniih7 bi[ yah e’ed11h
	Ats’77s bich’33h na’abaah bee aa’1hay3/ats’77s n1n4l’9h/ Azee’ ats’77s yich’33h naabaah bee bi[ aa’ada’atsih
T’11 7iyis77 nanidi’doolkahgo	Na’alkaah bee 7da’neel’22h (agh1da’dildlaad, adi[ bee na’anish)
	Ats’77s ahxelkeed (CT/PET scans, MRIs)
Nits’77stah hodiniih doodago bee ni[ 1hoot’4h7g77 azee’ b22h 1dooln77[ n7n7zingo Azee’ aan7daa’ni[7 bee ak’4da’asti’7 bee baa hane’7 [a’ n11n1 kohj8’ h0l= www.[insert].com	Azee’ Binahj8’ !daat’4h7g77
	Azee’ bizhi’ dah h0l0n7 bee ch’7dabi’dit’1h7
	Doo-Azee’ bizhi’ dah h0l0n7 bee ch’7dabi’dit’1h7
	Azee’ t’11 7iyis77 bee daha’niih7
Azee’ 7l’98di yah 77n7y1ago nits’77s naalgishgo bina’azhnishgo	Bi[ Haz’32gi Bik’4h Niily4h7g77 (e.g., Azee’ &l’98di Yah E’ed1ahgo Ats’77s Naalgizhgo Bina’anish bi[ Haz’1n7g77)
	Azee’ &7[’7n7 Ats’77s Yaa’1haly1n7/Ats’77s Nei[gizh7 Bik’4h Niily4h7g77
Tsx98[go ats’77s d7n0ol’88[ n7n7zingo	Nitsihodidi[go Haz’1n7gi Aa’1hay3
	Ats’77s bi[ Nitsihodidi[go bee Naho’dig4h7
	Tsx98[go Aa’1hay3
Azee íl’į́h hotsaa góne’ sinídáa dooleełgo	Bi[ Haz’32gi Bik’4h Niily4h7g77 (e.g., Azee’ &l’9h Hotsaa G0ne’ Haz’1n7g77)
	Azee’ &7[’7n7 Ats’77s Yaa’1haly1n7/Ats’77s Nei[gizh7 Bik’4h Niily4h7g77
Ints4kees 1t’4h7g77, ha’1t’4’ 1t’4h7g77, doodago t’11 ha’1t’77sh99 bee 1ch’8’ nahojiiln1ago bee 1ka’an7da’awo’7 n7n7zingo	Azee’ Hotsaadi Yah An1’ad11h Bee !ka’an7da’awo’7
	Azee’ Hotsaadi Ad1h7g77 Bee !ka’an7da’awo’7
Y7n7lts32go	Yah An1’1d11h
	Aw44’ Yich7igo/Aw44’ Ji[ch7igo Naanish Bee &dl8h Bee !ka’an7da’wo’7
	Aw44’ Yich7h/Nida’iich77h Bi[ Haz’1n7g77 Bee !ka’an7da’wo’7
Hashch’e’ nin1n7d11h bee 1ka’e’eyeed n7n7zingo doodago n11n1 [a’ t'11 sahdii at’77s 1t’4h7g77 n7n7zingo	Hooghandi Ats’77s !t’4h7g77 Baa’1hay3
	Hashch’e’ Nin1’7d11h Bee !ka’an7da’awo’7
	Din4 Bits’77s Bich’8’ An1hoot’i’7g77 !daa’1haly3 Bee !ka’an7da’awo’7
	Azee’ Neik1h7 Aa’1haly3 Bi[ Haz’1n7g77
	Bee Nida’anish7 Ats’77s Bidziilgo Y7ka’iilyeed Biniiy4 Chodao’7n7g77
	Din4 Y4ego Bich’8’ An1hoot’i’go Bee !ka’an7da’wo’7
Ne’aw44’ awoo’ doodago an11’ baa’1hay3 yin7zingo	![ch7n7 Bin11’ N7dan4l’88h
	!{ch7n7 Bin1k’eeh Sinil7
	![ch7n7 Biwoo’ N7n1dan4l’88h

Bee !ka’an7da’awo’7 Doo Bidaolt2’7g77 & Bee !ka’an7da’wo’7 Bee Ak4da’asti’7 N11n1 {a’:

Bee !ka’an7da’awo’7 ni[ Bee Ha’d7t’4h7 !t’4h7gi !t’4ego DOO yee Ak’4’asti’7 (Bee baa dahane’7 [a’ n11n1 biniiy4 bee ni[ ha’d7t’4h7 doodago bee ha’d7t’4h7 binaaltsoos bee 44dahozin7 baa nan7t1h d00 bee 1ka’an7da’awo’7 doo bidaolt2’7g77 n11n1 [a’ t’11 h17d77 sh99 n11h4esdzoo7g77.)
		

Bee !ka’an7da’awo’7 N11n1 {a’ (D77 bee 1ka’an7da’awo’7 bee nidahaz’1n7g77 bee binida’anish doolee[. D77 doo a[tsoh n11h4esdzoh da. T’11 sh--d7 ni[ bee ha’d7t’4h7 binaaltsoos bee 44dahozin7 d7n77[’88[.)
		

Bee Ak’4’ast’7 N11sg00 Bee Oonish Bee N1’adahazt’i’7g77: Bee nik’4’asti’7 ne’ 1dzaa bik44d00 t’11 n11sg00 sh1 nee oonish doolee[ n7n7zingo naanish bi[ nahaz’1n7 yee n7ka’adoojahgo b7ighah7g77 dah0l=. D77 naanish bi[ nahaz’1n7 hane’ bee bich’8’ al’7n7 bee baa shane’7 47: [insert State, HHS, DOL, and/or other applicable agency contact information]. N11n1 [a’ bee ak’4da’asti’7 bee adahazt’i’7 [a’ n1 h0l=- doolee[, d77 b4eso 1ch’33h naa’nil t’11 sh1h7 bee ak’4’asti’7 Health Insurance Marketplace bi[ nah7[niih7g77 b00lt2’. Marketplace bee baa dahahne’7 [a’ n11n1 biniiy4go, kohj8’ www.HealthCare.gov baa nan7t1h doodago kohj8’ 1-800-318- 2596 hod7ilnih.

T'11 Ha’1t’77sh99 Doo Hwi[ Y1’1t’4h7g77 d00 Naaltsoos Tsx98[go Bee )keed7 Bee N1’adahazt’i’7g77: Nil bee ah’d7t’4h7 naaltsoos bee n1’0keed7 dooda nid77diid biniinaa bik’ihj8’ naaltsoos bee n77n7[tsoozgo naanish bi[ nahaz’1n7g77 eii yee n7ka’adoojah7g77 dah0l=. D77 naaltsoos niilts0s7 47 D77 t’11 ha’1t’77sh99 doo hwi[ y1’1t’4h7g77 doodago naaltsoos tsx98go bee 0keed7 woly4. Bee n1’adahazt’i’7 b22h bee dahane’4 [a’ n11n1 biniiy4go, eii ats’77s n1n4l’88h naaltsoos bee n1’0keed7 bee aa’1dahay1n7 baa n1hane’ n7dii[ts0s7g77. Ni[ bee ha’d7t’4h7 naaltsoos bee 44dahozin7 haash yit’4ego naaltsoos bee n1’0keed7, naaltsoos tsx98[go bee 0keed7, doodago t’11 ha’1t’77sh99 doo hwi[ y1’1t’4h7g77 ni[ bee ha’d7t’4h7. Bik’ihj8’ t’11 ha’1t’77sh99 biniinaa nin7[ts0s7g77 a[tsoh bee baa dahane’7 a[d0’ h0l=-go 1y0sin. Bee n1’adahazt’i’7, d77 bee i[ hane’7 bee baa dahane’7 [a’ n11n1, doodago 1ka’e’eyeed biniiy4, d77 bich’8’ hane’ anil44h: [insert applicable contact information from instructions].

Da’ d77 bee ha’d7t’4h7 Minimum Essential Coverage h0l=-go 1y0sin? [Aoo’/Nidiga’]

Minimum Essential Coverage 1t’4h7gi 1t’4ego d77 Marketplace doodago n11n1 [a’ t’11 sah7 baa nida’iiniih7 bee bi[ hada’d7t’4h7, Medicare, Medicaid, CHIP, TRICARE, d00 n11n1 [a’ bee ak’4da’asti’7 haash99 daat’4h7g77 bi[ d77 bee hada’d7t’4h7, ats’77s b4eso bee 1ch’33h naa’nil7 hol=-go 1day0sin. Minimum Essential Coverage t’11 haash99 daat’4h7g77 bee n1’ahoot’i’go, d77 al1adi inaolt2’7 n3t’33’ aan1’n7[7g77 daats’7 doo bee n1’ahoot’i’ da doolee[.

Da’ d77 bee ha’d7t’4h7 Minimum Value Bee Nidahaz’1n7g77 7ighah ayiilaa? [Aoo’/Nidiga’/Doo Bideet’i’ Da]

Bee ni[ If your bee ha’d7t’4h7 d77 Minimum Value Standards, doo 7ighah ayiilaa7g00 d77 al1adi inaolt2’7 n3t’33’ aan1’n7[7g77 daats’7 bee n1’ahoot’i’ 1ko Marketplace bi[ bee ha’d7t’4h7 bik’4h na’iily4egi yee n7ka’an1lwo’ doolee[.

Saad Bich’8’ Adahazt’i’ Bee !ka’an7da’awo’7:

Spanish (Español): Para obtener asistencia en Español, llame al [insert telephone number].

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa [insert telephone number].

Chinese (中文): 如果需要中文的帮助, 请拨打这个号码 [insert telephone number].

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' [insert telephone number].

Pennsylvania Dutch (Deitsch): Fer Hilf griege in Deitsch, ruf [insert telephone number] uff.

Samoan (Gagana Samoa): Mo se fesoasoani i le Gagana Samoa, vala’au mai i le numera telefoni [insert telephone number].

Carolinian (Kapasal Falawasch): ngere aukke ghut alillis reel kapasal Falawasch au fafaingi tilifon ye [insert telephone number].

Chamorro (Chamoru): Para un ma ayuda gi finu Chamoru, å’gang [insert telephone number].

Haash yit’4ego d77 bee ha’d7t’4h7 costs for a ats’77s n1n4l’88h bee bi[ 1hot’4h7g77 bee binahj8’ dahane’7g77 b33h da’al’7n7 yee ak’4’asti’7 bee binahj8’ dahane’7g77 biniiy4, 1k0ne’ dah n11n1shjaa’7g77 d7n77[’88[.

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1146. The time required to complete this information collection is estimated to average 0.02 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland
21244-1850.

D77 Bee Ak’4da’asti’7 Bee Binahj8’ Dahane’7 B22h:

Peg Aw44’ bee Haleeh (9 n7deezid h0ne’7-bi[ nida’anish oots32go bee aa’1hay3 d00 azee’ 7l’9h hotsaadi ach7h)				Joe !sh88h {ikan Type 2 Diabetes Yinaagh1 (N11hai t’11 hoolzhishee h0ne’7-bi[ nida’anish hazh0’0-bik’eh ad4est’99’ bi[ 1hoot’4h7 bee aa’1hay3)			Mia Bits’in T’88d7go Yisk’is (H0ne’7-bi[ nida’anish nitsihodidi[go b1 haz’1n7 yah e’ed11h d00 nin11hodin4l’9h bee aa’1hay3)
■ Bee’ ha’d7t’4h7 bi b4eso 1d7l32j8’ nijil4h7g77 t’11 a[tsoh		$		■ Bee’ ha’d7t’4h7 bi b4eso 1d7l32j8’ nijil4h7g77 t’11 a[tsoh	$		■ Bee’ ha’d7t’4h7 bi b4eso 1d7l32j8’ nijil4h7g77 t’11 a[tsoh	$
■ Azee’ &7[’7n7 Haniih7 [ b4eso 1d7l32j8’ nijil4h7g77 bee a[hidin7[n1h niily4h7g77]		$		■ Azee’ &7[’7n7 Haniih7 [ b4eso 1d7l32j8’ nijil4h7g77 bee a[hidin7[n1h niily4h7g77]	$		■ Azee’ &7[’7n7 Haniih7 [ b4eso 1d7l32j8’ nijil4h7g77 bee a[hidin7[n1h niily4h7g77]	$
■ Azee’ 7l’9h hotsaa7 (ha’1n7g77) [b4eso 1d7l32j8’ nijil4h7g77 bee a[hidin7[n1h niily4h7g77]		%		■ Azee’ 7l’9h hotsaa7 (ha’1n7g77) [b4eso 1d7l32j8’ nijil4h7g77 bee a[hidin7[n1h niily4h7g77]	%		■ Azee’ 7l’9h hotsaa7 (ha’1n7g77) [b4eso 1d7l32j8’ nijil4h7g77 bee a[hidin7[n1h niily4h7g77]	%
■ N11n1 [a’ [b4eso 1d7l32j8’ nijil4h7g77 bee a[hidin7[n1h niily4h7g77]		%		■ N11n1 [a’ [b4eso 1d7l32j8’ nijil4h7g77 bee a[hidin7[n1h niily4h7g77]	%		■ N11n1 [a’ [b4eso 1d7l32j8’ nijil4h7g77 bee a[hidin7[n1h niily4h7g77]	%
D77 BINAHJ*’ HANE’& bi[ hoo’ah7g77 bee 1ka’an7da’awo’7 b00lt2’7g77: Azee’ &7[’7n7 Haniih7 bi[ haz’1n7di bi[ yah e’ed11h (oots32go aa’ah1y3) Aw44’ Yich7igo/Aw44’ Ji[ch7igo Naanish Bee &dl8h Bee !ka’an7da’wo’7 Aw44’ Yich7h/Nida’iich77h Bi[ Haz’1n7g77 Bee !ka’an7da’wo’7 Na’alkaah bee 7da’neel’22h7 (ultrasounds d00 di[ nida’anish) Azee’ &7[’7n7 Haniih7 yah e’ed11h (azee’ bich’8’ ats’77stah doo 1haly32 da ayii[’88h7)				D77 BINAHJ*’ HANE’& bi[ hoo’ah7g77 bee 1ka’an7da’awo’7 b00lt2’7g77: Al22j8’ Azee’ &7[’7n7 Aa’1haly1n7 bi[ haz’1n7di bi[ yah e’ed11h ({00d binaa[niih bina’niltin b00lt2’) Na’alkaah bee 7da’neel’22h7 (di[ nida’anish) Azee’ aan7daa’ni[7 Bee Nida’anish7 Ats’77s Bidziilgo Y7ka’iilyeed Biniiy4 Chodao’7n7g77 (glucose meter)			D77 BINAHJ*’ HANE’& bi[ hoo’ah7g77 bee 1ka’an7da’awo’7 b00lt2’7g77: Nitsihodidi[go Haz’1n7gi Aa’1hay3 (ats’77s n1n4l’88h bee 1dahodoon7[7g77 b00lt2’) Na’alkaah bee 7da’neel’22h7 (x-ray) Bee Nida’anish7 Ats’77s Bidziilgo Y7ka’iilyeed Biniiy4 Chodao’7n7g77 (gish) Hashch’e’ Nin1’7d11h Bee !ka’an7da’awo’7 (ats’77stah n1k’22s)
B11h &l’9h Binahj8’ Hane’7 T’11 !t’4	$12,700			B11h &l’9h Binahj8’ Hane’7 T’11 !t’4	$5,600		B11h &l’9h Binahj8’ Hane’7 T’11 !t’4	$2,800
D77 binahj8’ hane’7 biyi’, Peg neidool4[7g77:				D77 binahj8’ hane’7 biyi’, Joe neidool4[7g77:			D77 binahj8’ hane’7 biyi’, Mia neidool4[7g77:
B4eso !d7l32j8’ Nijil4h7g77 bee A[hidin7[n1h Niily4h7g77				B4eso !d7l32j8’ Nijil4h7g77 bee A[hidin7[n1h Niily4h7g77			B4eso !d7l32j8’ Nijil4h7g77 bee A[hidin7[n1h Niily4h7g77
B4eso 1d7l32j8’ nijil4h7g77	$			B4eso 1d7l32j8’ nijil4h7g77	$		B4eso 1d7l32j8’ nijil4h7g77	$
B4eso al22j8’ t’11 h0 nijil4h7g77	$			B4eso al22j8’ t’11 h0 nijil4h7g77	$		B4eso al22j8’ t’11 h0 nijil4h7g77	$
B4eso 1ch’33h naa’nil b4eso al22j8’ t’11 h0 nijil4h7g77	$			B4eso 1ch’33h naa’nil b4eso al22j8’ t’11 h0 nijil4h7g77	$		B4eso 1ch’33h naa’nil b4eso al22j8’ t’11 h0 nijil4h7g77	$
Ha’1t’7ish doo bee ak’4’asti’ da				Ha’1t’7ish doo bee ak’4’asti’ da			Ha’1t’7ish doo bee ak’4’asti’ da
Bee Nhahaz’1n7 doodago doo bidaolt2’7g77	$			Bee Nhahaz’1n7 doodago doo bidaolt2’7g77	$		Bee Nhahaz’1n7 doodago doo bidaolt2’7g77	$
Peg t’11 1t’4 yik’4h ni’dool4[7g77	$			Joe t’11 1t’4 yik’4h ni’dool4[7g77	$		Mia t’11 1t’4 yik’4h ni’dool4[7g77	$

D77 bee 1ka’an7da’awo’7 BINAHJ*’ HANE’& n11n1 [a’ b33h da’7l’7n7g77 bee ha’d7t’4h7 bideet’i’ doolee[.

(OMB control number: 0938-1146/ Expiration date: 05/31/2026)

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