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:________ | Bee 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?	$	!t’4h7gi 1t’4ego, you must pay all of the costs from azee’ 77[’7n7 y7ka’an7lwo’7d66’ b33h da’al’7n7g77 t’11 7iyis77 a[tsoh bik’4h ni’d77l44[ nil47 b4eso 1d7l32j8’ nijil4h7g77 1n4elt’e’j8’ d77 bee ha’d7t’4h7 yik’4h ni’iil4 bits4edi. [For family coverage, see instructions for additional applicable language.]
Da’ b4eso 1d7l32j8’ nijil4h7g77 t’ahdoo b7ighah ajil4h7 bee 1ka’an7da’awo’7 bee ak’4da’asti’7 h0l=?	Aoo’. [Insert: major categories]	T’1adoole’4 d00 bee 1ka’an7da’wo’7 [a’ d77 bee ha’d7t’4h7 yik’4’asti’ azh3sh99 b4eso 1dil32j8’ nijil4h7g77 an4elt’e’7g77 t’ahdoo b7ighah anil4eh da nidi. Nidi b4eso al22j8’ t’11 h0 nijil4h7g77 doodago b4eso 1ch’33h naa’nil b4eso al22j8’ t’11 h0 nijil4h7g77 yee doolnish. [For non-grandfathered plans, insert: "Binahj8’ hane’7g77, d77 bee ha’d7t’4h7 bee 1ka’an7da’awo’7 bee 1ch’33h na’abaah7 haash99 daat’4h7g77 yik’4’asti’ b33h al’7n7g77 a[hxidin7[n1h bee a[ka’e’eyeed t’11g44d d00 t’ahdoo nib4eso 1dil32j8’ an7l4h7g77 b7ighah anil4h7. Bee 1ka’an7da’awo’7 bee 1ch’33h na’abaah7 bee ak’4da’asti’7 n11h4esdzoo7g77 kohj8’ d7n77[’88[ https://www.healthcare.gov/coverage/preventive-care-benefits/."]
Bee 1ka’an7da’awo’7 t’11 7iyis77 b1h7g77 b1 n11n1 [a’ b4eso 1d7l32j8’ nijil4h7g77 b1 h0l=?	Aoo’. $	D77 bee 1ka’an7da’awo’7 b33h da’7l’7n7g77 t’11 1t’4 t’11 7iyis77 bik’4h ni’d77l44[ nil47 b4eso 1dil32j8’ nijil4h7g77 t’11 7iyis77 1n4elt’e’j8’ bee ha’d7t’4h7 d77 bee 1ka’an7da’awo’7 t’ahdoo yik’4h ni’il4h7.
Ha’1t’7is d77 bee ha’d7t’4h7 b1 ats’aazisd00 nijil4h7 bee haz’3?	$	N11haij8’ bee 1ka’an7da’awo’7 bee ak’4da’asti’7 biniiy4 ats’aazisd00 nijl4h7 bee haz’1n7 47 al1ahdi nanil4ego b7ighah. [For family coverage, see instructions for additional applicable language.]
Ats’aazisd00 nijil4h7 bee haz’3 biyi’ ha’1t’7ish doo b00lt2’ da?	[Insert: major exceptions]	Azh3sh99 d77 bik’4h nida’iily4’7 bik’4h na’a7l4e nidi, doo ats’aazisd00 nahaly4h7g77 bik’ihj8’ w0lta’ da.
Da’ azee’ 77[’7n7 bi[ nida’anish7 chois7n7[’88dgo0sh t’11 y0y11h7go nid77l44[?	Aoo’. Azee’ 77[’7n7 y7ka’an1jah7 bi[ nida’anish7 n11h4esdzoo7g77 biniiy4 kohj8’ www.[insert].com d7n77[’88[ doodago kohj8’ 1-800-[insert] hod7ilnih.	D77 bee ha’d7t’4h7 azee’ 77[’7n7 y7ka’an1lwo’7 bi[ nida’anish7g77 choyoo[’9h. Bee ha’d7t’4h7 yi[ nidaalnish7g77 biyi’ azee’ 77[’7n7 y7ka’an1lwo’7 choin7[’98go t’11 h0y11h7gi nid77l44[. T[’00d66’-bi[-nida’anish7 azee’ 77[’7n7 y7ka’an1alwo’7 chois7n7[’88dgo t’11 l2’7 bik’4h nan7l4e doolee[ d00 azee’ 77[’7n7 y7ka’an1lwo’7 azee’ 77[’7n7 y7ka’an1lwo’7 yee 22hay77tsih7g77 d00 ha’1t’77 bee ni[ ha’d7t’4h7 yik4h niiy7l4h7g77 (bee 22h11jil b77’oh7g77) bita’gi bee a[22 1n4elt’e’7g77 bee 22h11’1h n7din77[tsos. T’11 baa’1kon7n7zin, bee 1ka’an7da’awo’7 [a’ (d77 na’alkaah bina’anish) biniiy4 ne’azee’ 77[’7n7 y7ka’an1lwo’7 bi[ nida’anish7 daats’7 azee’ 77[’7n7 y7ka’an1lwo’7 t[’00d66’-bi[-nida’anish7 choidoo[’88[. Bee 1ka’an7da’awo’7 bee nika’e’eyeed bits4edi azee’ 77[’7n7 y7ka’an1lwo’7 bi[ baa nan7t1h.
Da’ azee’ 77[’7n7 haniih7g77 bi[ yah anin1aho0sh naaltsoos bee i’iln7h7 ton7n7zin?	Aoo’.	Bee 1ka’an7da’awo’7 bee ak’4da’asti’7 biniiy4 azee’ 77[’7n7 haniih7 bi[ yah anin1ahgo d77 bee ha’d7t’4h7 b33h da’7l7n7 [a’ doodago t’11 1t’4 yik’4h ni’ily4e doolee[, nidi t’ahdoo azee’ 77[’7n7 haniih7 bi[ yah anin1h7 1[ts4 naaltsoos bee i’7ln7h7 nee h0l=- doolee[.

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