Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services

Coverage Period: Beginning on or after 01/01/2024

: Gold 80 HMO 0/35 + 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,
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 Why This Matters:

What is the overall
$0 See the common Medical Events chart below for your costs for services this plan covers.
deductible?
This plan covers some items and services even if you haven’t yet met the deductible amount.
Are there services
But a copayment or coinsurance may apply. For example, this plan covers certain preventive
covered before you Not Applicable.
services without cost-sharing and before you meet your deductible. See a list of covered
meet your deductible?
preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other
deductibles for specific No. You don’t have to meet deductibles for specific services.
services?
What is the out-of- The out-of-pocket limit is the most you could pay in a year for covered services. If you have
$7,700 Individual / $15,400 Family. $350
pocket limit for this other family members in this plan, they have to meet their own out-of-pocket limits until the
Child / $700 Children for Child Dental.
plan? overall family out-of-pocket limit has been met.
Premiums, and health care services this
What is not included in
plan doesn’t cover, indicated in chart Even though you pay these expenses, they don’t count toward the out–of–pocket limit.
the out-of-pocket limit?
starting on page 2.
This plan uses a provider network. You will pay less if you use a provider in the plan’s
Will you pay less if you Yes. See www.kp.org or call 1-800-278- network. You will pay the most if you use an out-of-network provider, and you might receive a
use a network 3296 (TTY: 711) for a list of network bill from a provider for the difference between the provider’s charge and what your plan pays
provider? providers. (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.
Do you need a referral Yes, but you may self-refer to certain This plan will pay some or all of the costs to see a specialist for covered services but only if
to see a specialist? specialists. you have a referral before you see the specialist.

Plan ID: 16184/16185-40513CA0410051-00-EN-2024

1 of 6
 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

What You Will Pay

Common Medical Services You May Limitations, Exceptions, & Other Important
Event Need Plan Provider Non-Plan Provider Information
(You will pay the least) (You will pay the most)
Primary care visit to
$35 / visit Not covered None
treat an injury or illness
If you visit a health Specialist visit $60 / visit Not covered None
care provider’s You may have to pay for services that aren’t
office or clinic Preventive
preventive. Ask your provider if the services
care/screening/ No charge Not covered
needed are preventive. Then check what your
immunization
plan will pay for.
Diagnostic test (x-ray, X-ray: $40 / encounter
Not covered None
blood work) Lab tests: $30 / encounter
If you have a test
Imaging (CT/PET
$250 / procedure Not covered None
scans, MRIs)
Up to a 30-day supply retail and a 100-day supply
$15 / prescription (retail),
Generic drugs (Tier 1) Not covered mail order. Female contraceptives are no charge.
$30 / prescription (mail order)
If you need drugs to Subject to formulary guidelines.
treat your illness or Up to a 30-day supply retail and a 100-day supply
Preferred brand drugs $50 / prescription (retail),
condition Not covered mail order. Female contraceptives are no charge.
(Tier 2) $100 / prescription (mail order)
More information Subject to formulary guidelines.
about prescription The cost-sharing for non-preferred brand drugs
$50 / prescription (retail),
drug coverage is Non-preferred brand under this plan aligns with the cost-sharing for
$100 / prescription (mail order) Not covered
available at drugs (Tier 2) preferred brand drugs (Tier 2), when approved
www.kp.org/formulary through the formulary exception process.
20% coinsurance up to $250 / Up to a 30-day supply (retail). Subject to
Specialty drugs (Tier 4) Not covered
prescription formulary guidelines.
Facility fee (e.g.,
ambulatory surgery $320 / procedure Not covered None
If you have
center)
outpatient surgery
Physician/Surgeon Fee is included in the Facility
Physician/surgeon fees Not Applicable Not covered
Fee.
Copayment is waived if admitted to hospital as
If you need Emergency room care $350 / visit $350 / visit
inpatient.
immediate medical
Emergency medical
attention $250 / trip $250 / trip None
transportation
2 of 6
 What You Will Pay
Common Medical Services You May Limitations, Exceptions, & Other Important
Event Need Plan Provider Non-Plan Provider Information
(You will pay the least) (You will pay the most)
Non-Plan providers covered when temporarily
Urgent care $35 / visit Not covered
outside the service area: $35 / visit
Facility fee (e.g.,
$600 / day up to 5 days Not covered None
If you have a hospital room)
hospital stay Physician/Surgeon Fee is included in the Facility
Physician/surgeon fees Not Applicable Not covered
Fee.
Mental / Behavioral health: $35
/ individual visit. No charge for
If you need mental
other outpatient services Mental / Behavioral health: $17 / group visit
health, behavioral Outpatient services Not covered
Substance Abuse: $35 / Substance Abuse: $5 / group visit
health, or
individual visit. $5 / day for
substance abuse
other outpatient services
services
Inpatient services $600 / day up to 5 days Not covered None
Depending on the type of services, a copayment,
coinsurance, or deductible may apply. Maternity
Office visits No charge Not covered
care may include tests and services described
elsewhere in the SBC (i.e., ultrasound).
If you are pregnant Childbirth/delivery Professional services are included in the Facility
Not Applicable Not covered
professional services Fee.
Childbirth/delivery
$600 / day up to 5 days Not covered None
facility services
Up to 2 hours / visit, up to 3 visits / day, up to 100
Home health care No charge Not covered
visits / year.
Inpatient: $600 / day up to 5
Rehabilitation services Not covered None
days. Outpatient: $35 / visit
If you need help Inpatient: $600 / day up to 5
recovering or have Habilitation services Not covered None
days. Outpatient: $35 / visit
other special health Skilled nursing care $300 / day up to 5 days Not covered Up to 100 days limit / benefit period.
needs Durable medical Up to $2,000 supplemental benefit limit / year for
20% coinsurance Not covered
equipment certain items. Requires prior authorization.

Hospice services No charge Not covered None

3 of 6
 What You Will Pay
Common Medical Services You May Limitations, Exceptions, & Other Important
Event Need Plan Provider Non-Plan Provider Information
(You will pay the least) (You will pay the most)
Children’s eye exam No charge Not covered None
If your child needs Limited to one pair of glasses/year from select
Children’s glasses No charge Not covered
dental or eye care frames and lenses
Children’s dental
No charge Not covered Limited to two check-ups / year
check-up
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.)
• Cosmetic surgery • Infertility treatment • Private-duty nursing
• Dental care (Adult) • Long-term care • Routine foot care
• Hearing aids • Non-emergency care when traveling outside the U.S • Weight loss programs
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
• Abortion • Bariatric surgery • Routine eye care (Adult)
• Acupuncture (20 visit limit / year combined • Chiropractic care (20 visit limit / year combined with
with chiropractic) acupuncture)
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
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.dmhc.ca.gov

4 of 6
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.

5 of 6
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.

Peg is Having a Baby Managing Joe’s Type 2 Diabetes Mia’s Simple Fracture
(9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow up
hospital delivery) controlled condition) care)

• The plan’s overall deductible $0 • The plan’s overall deductible $0 • The plan’s overall deductible $0
• Specialist copayment $60 • Specialist copayment $60 • Specialist copayment $60
• Hospital (facility) copayment $600 • Hospital (facility) copayment $600 • Hospital (facility) copayment $600
• Other (blood work) copayment $30 • Other (blood work) copayment $30 • Other (x-ray) copayment $40

This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:
Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical
Childbirth/Delivery Professional Services disease education) supplies)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Diagnostic test (x-ray)
Diagnostic tests (ultrasounds and blood work) Prescription drugs Durable medical equipment (crutches)
Specialist visit (anesthesia) Durable medical equipment (glucose meter) Rehabilitation services (physical therapy)

Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800
In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost Sharing Cost Sharing Cost Sharing
Deductibles $0 Deductibles $0 Deductibles $0
Copayments $800 Copayments $1,300 Copayments $900
Coinsurance $0 Coinsurance $100 Coinsurance $10
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $60 Limits or exclusions $0 Limits or exclusions $0
The total Peg would pay is $860 The total Joe would pay is $1,400 The total Mia would pay is $910

The plan would be responsible for the other costs of these EXAMPLE covered services.

6 of 6
 Nondiscrimination Notice
Discrimination is against the law. Kaiser Permanente follows State and Federal civil rights laws.

Kaiser Permanente does not unlawfully discriminate, exclude people, or treat them differently because of age, race, ethnic group
identification, color, national origin, cultural background, ancestry, religion, sex, gender, gender identity, gender expression, sexual
orientation, marital status, physical or mental disability, medical condition, source of payment, genetic information, citizenship, primary
language, or immigration status.

Kaiser Permanente provides the following services:

● No-cost aids and services to people with disabilities to help them communicate better with us, such as:

♦ Qualified sign language interpreters

♦ Written information in other formats (braille, large print, audio, accessible electronic formats, and other formats)

● No-cost language services to people whose primary language is not English, such as:

♦ Qualified interpreters

♦ Information written in other languages

If you need these services, call our Member Service Contact Center at 1 800-464-4000 (TTY 711), 24 hours a day, 7 days a week
(except closed holidays). If you cannot hear or speak well, please call 711.

Upon request, this document can be made available to you in braille, large print, audiocassette, or electronic form. To obtain a copy in
one of these alternative formats, or another format, call our Member Service Contact Center and ask for the format you need.

How to file a grievance with Kaiser Permanente

You can file a discrimination grievance with Kaiser Permanente if you believe we have failed to provide these services or unlawfully
discriminated in another way. Please refer to your Evidence of Coverage or Certificate of Insurance for details. You may also speak with
a Member Services representative about the options that apply to you. Please call Member Services if you need help filing a grievance.

You may submit a discrimination 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

You may also contact the Kaiser Permanente Civil Rights Coordinators directly at the addresses below:
 Attn: Kaiser Permanente Civil Rights Coordinator
Member Relations Grievance Operations
P.O. Box 939001
San Diego CA 92193

How to file a grievance with the California Department of Health Care Services Office of Civil Rights (For Medi-Cal Beneficiaries Only)

You can also file a civil rights complaint with the California Department of Health Care Services Office of Civil Rights in writing, by phone
or by email:

● By phone: Call DHCS Office of Civil Rights at 916-440-7370 (TTY 711)

● By mail: Fill out a complaint form or send a letter to:

Deputy Director, Office of Civil Rights

Department of Health Care Services
Office of Civil Rights
P.O. Box 997413, MS 0009
Sacramento, CA 95899-7413
Complaint forms are available at: http://www.dhcs.ca.gov/Pages/Language_Access.aspx

● Online: Send an email to CivilRights@dhcs.ca.gov

How to file a grievance with the U.S. Department of Health and Human Services Office of Civil Rights

You can file a discrimination complaint with the U.S. Department of Health and Human Services Office for Civil Rights. You can file your
complaint in writing, by phone, or online:

● By phone: Call 1-800-368-1019 (TTY 711 or 1-800-537-7697)

● By mail: Fill out a complaint form or send a letter to:

U.S. Department of Health and Human Services

200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201

Complaint forms are available at:

http:www.hhs.gov/ocr/office/file/index.html
● Online: Visit the Office of Civil Rights Complaint Portal at:
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf.
 Aviso de no discriminación
La discriminación es ilegal. Kaiser Permanente cumple con las leyes de los derechos civiles federales y estatales.

Kaiser Permanente no discrimina ilícitamente, excluye ni trata a ninguna persona de forma distinta por motivos de edad, raza,
identificación de grupo étnico, color, país de origen, antecedentes culturales, ascendencia, religión, sexo, género, identidad de género,
expresión de género, orientación sexual, estado civil, discapacidad física o mental, condición médica, fuente de pago, información
genética, ciudadanía, lengua materna o estado migratorio.
Kaiser Permanente ofrece los siguientes servicios:

● Ayuda y servicios sin costo a personas con discapacidades para que puedan comunicarse mejor con nosotros, como lo siguiente:

♦ intérpretes calificados de lenguaje de señas,

♦ información escrita en otros formatos (braille, impresión en letra grande, audio, formatos electrónicos accesibles y otros
formatos).
● Servicios de idiomas sin costo a las personas cuya lengua materna no es el inglés, como:

♦ intérpretes calificados,

♦ información escrita en otros idiomas.

Si necesita nuestros servicios, llame a nuestra Central de Llamadas de Servicio a los Miembros al 1-800-464-4000 (TTY 711) las 24
horas del día, los 7 días de la semana (excepto los días festivos). Si tiene deficiencias auditivas o del habla, llame al 711.
Este documento estará disponible en braille, letra grande, casete de audio o en formato electrónico a solicitud. Para obtener una copia
en uno de estos formatos alternativos o en otro formato, llame a nuestra Central de Llamadas de Servicio a los Miembros y solicite el
formato que necesita.

Cómo presentar una queja ante Kaiser Permanente

Usted puede presentar una queja por discriminación ante Kaiser Permanente si siente que no le hemos ofrecido estos servicios o lo
hemos discriminado ilícitamente de otra forma. Consulte su Evidencia de Cobertura (Evidence of Coverage) o Certificado de Seguro
(Certificate of Insurance) para obtener más información. También puede hablar con un representante de Servicio a los Miembros sobre
las opciones que se apliquen a su caso. Llame a Servicio a los Miembros si necesita ayuda para presentar una queja.

Puede presentar una queja por discriminación de las siguientes maneras:

● Por teléfono: llame a Servicio a los Miembros al 1 800-464-4000 (TTY 711), las 24 horas del día, los 7 días de la semana
(excepto los días festivos).
● Por correo postal: llámenos al 1 800-464-4000 (TTY 711) y pida que se le envíe un formulario.

● En persona: llene un formulario de Queja o reclamación/solicitud de beneficios en una oficina de Servicio a los Miembros ubicada
en un centro del plan (consulte su directorio de proveedores en kp.org/facilities [cambie el idioma a español] para obtener las
direcciones).
● En línea: utilice el formulario en línea en nuestro sitio web en kp.org/espanol.
También puede comunicarse directamente con el coordinador de derechos civiles (Civil Rights Coordinator) de Kaiser Permanente a la
siguiente dirección:

Attn: Kaiser Permanente Civil Rights Coordinator

Member Relations Grievance Operations
P.O. Box 939001
San Diego CA 92193

Cómo presentar una queja ante la Oficina de Derechos Civiles del Departamento de Servicios de Atención Médica de California (Solo
para beneficiarios de Medi-Cal)
También puede presentar una queja sobre derechos civiles ante la Oficina de Derechos Civiles (Office of Civil Rights) del Departamento
de Servicios de Atención Médica de California (California Department of Health Care Services) por escrito, por teléfono o por correo
electrónico:

● Por teléfono: llame a la Oficina de Derechos Civiles del Departamento de Servicios de Atención Médica (Department of Health
Care Services, DHCS) al 916-440-7370 (TTY 711).
● Por correo postal: llene un formulario de queja o envíe una carta a:

Deputy Director, Office of Civil Rights

Department of Health Care Services
Office of Civil Rights
P.O. Box 997413, MS 0009
Sacramento, CA 95899-7413

Los formularios de queja están disponibles en: http://www.dhcs.ca.gov/Pages/Language_Access.aspx (en inglés).

● En línea: envíe un correo electrónico a CivilRights@dhcs.ca.gov.

Cómo presentar una queja ante la Oficina de Derechos Civiles del Departamento de Salud y Servicios Humanos de los EE. UU.

Puede presentar una queja por discriminación ante la Oficina de Derechos Civiles del Departamento de Salud y Servicios Humanos de
EE. UU. (U.S. Department of Health and Human Services). Puede presentar su queja por escrito, por teléfono o en línea:

● Por teléfono: llame al 1-800-368-1019 (TTY 711 o al 1-800-537-7697).

● Por correo postal: llene un formulario de queja o envíe una carta a:

U.S. Department of Health and Human Services

200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201

Los formularios de quejas están disponibles en

http://www.hhs.gov/ocr/office/file/index.html (en inglés).

● En línea: visite el Portal de quejas de la Oficina de Derechos Civiles en:

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf (en inglés).
 反歧視聲明
歧視是違反法律的行為。Kaiser Permanente 遵守州政府與聯邦政府的民權法。

Kaiser Permanente 不因年齡、人種、族群認同、膚色、原國籍、文化背景、祖籍、宗教、生理性別、社會性別、性認同、性表現、性取向、

婚姻狀況、身體或精神殘障、病況、付款來源、遺傳資訊、公民身份、母語或移民身份而非法歧視、排斥或差別對待任何人。

Kaiser Permanente 提供下列服務：

● 為殘障人士提供免費協助與服務以幫助其更好地與我們溝通，例如：

♦ 合格手語翻譯員

♦ 其他格式的書面資訊（盲文版、大字版、語音版、通用電子格式及其他格式）

● 為母語非英語的人士提供免費語言服務，例如：

♦ 合格口譯員

♦ 其他語言的書面資訊

如果您需要上述服務，請打電話 1-800-464-4000 (TTY 711) 給會員服務聯絡中心，每週 7 天，每天 24 小時（節假日除外）。如果您有聽力或

語言困難，請打電話 711。

若您提出要求，我們可為您提供本文件的盲文版、大字版、錄音卡帶或電子格式。如要得到上述一種替代格式或其他格式的版本，請打電
話給會員服務聯絡中心並索取您需要的格式。

如何向 Kaiser Permanente 投訴

如果您認為我們未能提供上述服務或有其他形式的非法歧視行為，您可向 Kaiser Permanente 提出歧視投訴。請參閱您的《承保範圍說明

書》(Evidence of Coverage) 或《保險證明》(Certificate of Insurance) 瞭解詳情。您也可以向會員服務部代表諮詢適用於您的選項。如果您在投
訴時需要協助，請打電話給會員服務部。

您可透過下列方式投訴歧視：

● 電話： 打電話 1 800-464-4000 (TTY 711) 聯絡會員服務部，每週 7 天，每天 24 小時（節假日除外）

● 郵寄： 打電話 1 800-464-4000 (TTY 711) 與我們聯絡，要求將投訴表寄給您

● 親自提出： 在保險計劃下屬設施的會員服務辦公室填寫投訴或索賠／申請表（請在 kp.org/facilities 網站的保健業者名錄上查詢地

址）

● 線上： 使用 kp.org 網站上的線上表格

您也可直接與 Kaiser Permanente 民權事務協調員聯絡，地址如下：

 Attn: Kaiser Permanente Civil Rights Coordinator
Member Relations Grievance Operations
P.O. Box 939001
San Diego CA 92193

如何向加州保健服務部民權辦公室投訴（僅限 Medi-Cal 受益人）

您也可透過書面方式、電話或電子郵件向加州保健服務部民權辦公室提出民權投訴：

● 電話：打電話 916-440-7370 (TTY 711) 聯絡保健服務部 (DHCS) 民權辦公室

● 郵寄：填寫投訴表或寄信至：

Deputy Director, Office of Civil Rights

Department of Health Care Services
Office of Civil Rights
P.O. Box 997413, MS 0009
Sacramento, CA 95899-7413
您可在網站上 http://www.dhcs.ca.gov/Pages/Language_Access.aspx 取得投訴表

● 線上：發送電子郵件至 CivilRights@dhcs.ca.gov

如何向美國健康與民眾服務部民權辦公室投訴

您可向美國健康與民眾服務部民權辦公室提出歧視投訴。您可透過書面、電話或線上提出投訴：

● 電話：打電話 1-800-368-1019（TTY 711 或 1-800-537-7697）

● 郵寄：填寫投訴表或寄信至：

U.S. Department of Health and Human Services

200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
您可在網站上取得投訴表：
http:www.hhs.gov/ocr/office/file/index.html 取得投訴表

● 郵寄：訪問民權辦公室投訴入口網站：
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf。
 Thông Báo Không Phân Biệt Đối Xử
Phân biệt đối xử là trái với pháp luật. Kaiser Permanente tuân thủ các luật dân quyền của Tiểu Bang và Liên Bang.

Kaiser Permanente không phân biệt đối xử trái pháp luật, loại trừ hay đối xử khác biệt với người nào đó vì lý do tuổi tác, chủng tộc, nhận
dạng nhóm sắc tộc, màu da, nguồn gốc quốc gia, nền tảng văn hóa, tổ tiên, tôn giáo, giới tính, nhận dạng giới tính, cách thể hiện giới
tính, khuynh hướng giới tính, tình trạng hôn nhân, tình trạng khuyết tật về thể chất hoặc tinh thần, bệnh trạng, nguồn thanh toán, thông
tin di truyền, quyền công dân, ngôn ngữ mẹ đẻ hoặc tình trạng nhập cư.
Kaiser Permanente cung cấp các dịch vụ sau:

● Phương tiện hỗ trợ và dịch vụ miễn phí cho người khuyết tật để giúp họ giao tiếp hiệu quả hơn với chúng tôi, chẳng hạn như:

♦ Thông dịch viên ngôn ngữ ký hiệu đủ trình độ

♦ Thông tin bằng văn bản theo các định dạng khác (chữ nổi braille, bản in khổ chữ lớn, âm thanh, định dạng điện tử dễ truy
cập và các định dạng khác)
● Dịch vụ ngôn ngữ miễn phí cho những người có ngôn ngữ chính không phải là tiếng Anh, chẳng hạn như:

♦ Thông dịch viên đủ trình độ

♦ Thông tin được trình bày bằng các ngôn ngữ khác

Nếu quý vị cần những dịch vụ này, xin gọi đến Trung Tâm Liên Lạc ban Dịch Vụ Hội Viên của chúng tôi theo số 1-800-464-4000 (TTY
711), 24 giờ trong ngày, 7 ngày trong tuần (đóng cửa ngày lễ). Nếu quý vị không thể nói hay nghe rõ, vui lòng gọi 711.

Theo yêu cầu, tài liệu này có thể được cung cấp cho quý vị dưới dạng chữ nổi braille, bản in khổ chữ lớn, băng thu âm hay dạng điện tử.
Để lấy một bản sao theo một trong những định dạng thay thế này hay định dạng khác, xin gọi đến Trung Tâm Liên Lạc ban Dịch Vụ Hội
Viên của chúng tôi và yêu cầu định dạng mà quý vị cần.

Cách đệ trình phàn nàn với Kaiser Permanente

Quý vị có thể đệ trình phàn nàn về phân biệt đối xử với Kaiser Permanente nếu quý vị tin rằng chúng tôi đã không cung cấp những dịch
vụ này hay phân biệt đối xử trái pháp luật theo cách khác. Vui lòng tham khảo Chứng Từ Bảo Hiểm (Evidence of Coverage) hay Chứng
Nhận Bảo Hiểm (Certificate of Insurance) của quý vị để biết thêm chi tiết. Quý vị cũng có thể nói chuyện với nhân viên ban Dịch Vụ Hội
Viên về những lựa chọn áp dụng cho quý vị. Vui lòng gọi đến ban Dịch Vụ Hội Viên nếu quý vị cần được trợ giúp để đệ trình phàn nàn.

Quý vị có thể đệ trình phàn nàn về phân biệt đối xử bằng các cách sau đây:
● Qua điện thoại: Gọi đến ban Dịch Vụ Hội Viên theo số 1-800-464-4000 (TTY 711) 24 giờ trong ngày, 7 ngày trong tuần (đóng cửa
ngày lễ)
● Qua thư tín: Gọi chúng tôi theo số 1-800-464-4000 (TTY 711) và yêu cầu gửi mẫu đơn cho quý vị
● Trực tiếp: Hoàn tất mẫu đơn Than Phiền hay Yêu Cầu Thanh Toán/Yêu Cầu Quyền Lợi tại văn phòng dịch vụ hội viên ở một Cơ
Sở Thuộc Chương Trình (truy cập 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
Quý vị cũng có thể liên hệ trực tiếp với Điều Phối Viên Dân Quyền của Kaiser Permanente theo địa chỉ dưới đây:

Attn: Kaiser Permanente Civil Rights Coordinator

Member Relations Grievance Operations
P.O. Box 939001
San Diego CA 92193

Cách đệ trình phàn nàn với Văn Phòng Dân Quyền Ban Dịch Vụ Y Tế California (Dành Riêng Cho Người Thụ Hưởng Medi-Cal)

Quý vị cũng có thể đệ trình than phiền về dân quyền với Văn Phòng Dân Quyền Ban Dịch Vụ Y Tế California bằng văn bản, qua điện
thoại hay qua email:

● Qua điện thoại: Gọi đến Văn Phòng Dân Quyền Ban Dịch Vụ Y Tế (Department of Health Care Services, DHCS) theo số
916-440-7370 (TTY 711)
● Qua thư tín: Điền mẫu đơn than phiền và hay gửi thư đến:

Deputy Director, Office of Civil Rights

Department of Health Care Services
Office of Civil Rights
P.O. Box 997413, MS 0009
Sacramento, CA 95899-7413

Mẫu đơn than phiền hiện có tại: http://www.dhcs.ca.gov/Pages/Language_Access.aspx

● Trực tuyến: Gửi email đến CivilRights@dhcs.ca.gov

Cách đệ trình phàn nàn với Văn Phòng Dân Quyền của Bộ Y Tế và Dịch Vụ Nhân Sinh Hoa Kỳ.

Quý vị cũng có quyền đệ trình than phiền về phân biệt đối xử với Văn Phòng Dân Quyền của Bộ Y Tế và Dịch Vụ Nhân Sinh Hoa Kỳ.
Quý vị có thể đệ trình than phiền bằng văn bản, qua điện thoại hoặc trực tuyến:

● Qua điện thoại: Gọi 1-800-368-1019 (TTY 711 hay 1-800-537-7697)

● Qua thư tín: Điền mẫu đơn than phiền và hay gửi thư đến:

U.S. Department of Health and Human Services

200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201

Mẫu đơn than phiền hiện có tại

http:www.hhs.gov/ocr/office/file/index.html

● Trực tuyến: Truy cập Cổng Thông Tin Than Phiền của Văn Phòng Dân Quyền tại:
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf.
 NOTICE OF LANGUAGE ASSISTANCE

English: This is important information from Kaiser Permanente. If you need help
understanding this information, please call 1-800-464-4000 TTY 711 and ask for
language assistance. Help is available 24 hours a day, 7 days a week, excluding
holidays. We can also help you with auxiliary aids and alternative formats.
‫ باستثناء أيام‬،‫ المساعدة متوفرة على مدار الساعة طيلة أيام الأسبوع‬.‫ وطلب مساعدة لغوية‬.Kaiser Permanente ‫ تحتوي هذه الوثيقة على معلومات مهمة من‬:Arabic
.‫العطلات الرسمية‬
‫ باستثناء‬،‫ المساعدة متوفرة على مدار الساعة طيلة أيام الأسبوع‬.‫( وطلب مساعدة لغوية‬TTY: 711)1-800-464-4000 ‫الرقم‬
.‫يمكننا أيضا ً تزويدك بمساعدات إضافية وتنسيقات بديلة‬
Armenian: Սա կարևոր տեղեկություն է «Kaiser Permanente»-ից: Եթե այս տեղեկությունը հասկանալու համար Ձեզ օգնություն է
հարկավոր, խնդրում ենք զանգահարել 1-800-464-4000 (TTY 711)հեռախոսահամարով և օժանդակություն ստանալ լեզվի հարցում:
Զանգահարեք օրը 24 ժամ, շաբաթը 7 օր` բացի տոն օրերից: Մենք նաև կարող ենք օգնել Ձեզ օժանդակ օգնության և այլընտրանքային
ձևաչափերի հարցում:

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 (TTY 專線 711) 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）。我們還可以幫助您獲取輔助設備和其它格式。

‫ لطفا ً با شماره‬،‫ اگر در فهميدن اين اطلاعات به کمک نياز داريد‬.‫ می باشد‬Kaiser Permanente ‫ اين اطلاعات مهمی از سوی‬:Farsi
‫ شامل‬،‫ روز هفته‬7 ‫ ساعت شبانروز و‬24 ‫ کمک و راهنمايی در‬.‫(تماس گرفته و برای امداد زبانی درخواست کنيد‬TTY 711) 1-800-464-4000
.‫ ما همچنين می توانيم برای شما کمکهای جانبی و به صورتهای ديگر را فراهم کنيم‬.‫روزهای تعطيل موجود است‬

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 (TTY 711) पर फोन करें और भाषा सहायता के लिए पछ ू ें । सहायता छुद्टियों को छोड़कर, सप्ताह के सातों दिन, दिन के 24 घंटे,
उपिब्ध है । हम सहायक साधनों और वैकल्पपक प्रारूपों को प्राप्त करने में भी आपकी मिि कर सकते हैं।
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 (TTY 711) 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. Peb kuj muab tau lwm yam kev pab rau koj thiab ua lwm yam ntaub ntawv.

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

(TTY 回線 711) 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。補
助器具・サービスや別のフォーマットについてもご相談いただけます。

Khmer:នេះគឺជាព័ត៌មាេសំខាេ់ មកពី Kaiser Permanente។ នបសសនេ្នកករតវការជំំេយយ ឲ្យបាេយល់ដឹងព័ត៌មាេនេះ សូមទូជស័ព្ទនៅនលខ 1-800-464-4000

(TTY 711) េនងនសកសសំំំេយយខាងសា។។ ំំេយយគឺមាេ 24 នមា្ងមយយ្ងៃងៃ 7 ្ងៃងៃមយយអាទនត្យ ជយមទាំង្ងៃងៃបំណ្យផង។
នយសងកអាអាជំយយ្នកកជាមយយេឹងបបកជណជំំេយយទំនាក់ទំេងសរមាប់្នកកពនរជេនងជាទរមង់ំំេយសនផ្េងៗ។
Korean: 본 정보는 Kaiser Permanente 에서 전하는 중요한 메시지입니다. 본 정보를 이해하는 데 도움이 필요하시면, 1-800-464-4000
(TTY 711) 번으로 전화해 언어 지원 서비스를 요청하십시오. 요일 및 시간에 관계없이 언제든지 도움을 제공해 드립니다(공휴일 제외).
또한 보조기구 및 대체 형식의 자료를 지원해 드릴 수 있습니다.
Laotian: ນີແ້ ມນຂໍ
່ ມ ້ ນ
ູ ສ ໍຳຄ ັນຈຳກ Kaiser Permanente. ຖຳ້ ວຳ່ ທຳ່ ນຕອ ້ ງກຳນຄວຳມຊວ ່ ຍເຫຼືອໃນກຳນຊວ ່ ຍໃຫເ້ ຂົ້ຳໃຈຂໍມ້ ນ ູ ນີ,້ ກະຣຸນຳໂທຣ
1-800-464-4000 (TTY 711) ແລະຂໍເອົ ຳກຳນຊວ ່ ຍເຫຼ ອ
ື ້ດ ຳ ນພຳສຳ. ກຳນຊ ວ
່ ຍເຫຼ ື ອ ມີ
ໃ ຫ ຕ
້ ະຫຼ ອ ດ 24 ຊ່ ວ
ົ ໂມງ, 7 ວ ັນຕໍ່ ອຳທິ ດ, ບໍ່ ລວມວ ັນພ ັກຕຳ່ ງໆ. ພວກ
ເຮົຳຍ ັງສຳມຳດຊວ ່ ຍທຳ່ ນໃນດຳ້ ນອຸປະກອນຊວ ່ ຍເສີມ ແລະ ຮູບແບບທຳງເລືອກອື່ ນໄດ.້
Mien: Naaiv se benx jienv sic dauh waac-fienx yiem naaiv Kaiser Permanente bun daaih. Beiv taux meih qiemx longc mienh tengx doqc
naaiv deix waac-fienx liouh porv bun bieqc hnyouv nor, daaix luic douc waac daaih lorx 1-800-464-4000 (TTY 711) aengx caux tov heuc
tengx nzie faan waac bun muangx. Mbenc nzoih liouh tengx yiem yietc hnoi benx 24 norm ziangh hoc, yietc norm liv baaiz mbenc maaih
7 hnoi, simv cuotv hnoi-gec oc. Yie mbuo corc haih mbenc wuotc ginc jaa-dorngx tengx nzie goux aengx caux liouh bun ginv longc
sou-guv daan puix horpc meih.

Navajo: Díí éí hane’ bíhólníihii át’éego Kaiser Permanente yee nihalne’. Díí hane’ígíí doo hazhó’ó bik’i’diitįįhgóó t’áá shǫǫdí koji’ hodíílnih
1-800-464-4000 (TTY 711) áko saad bee áká i’iilyeed yídííkił. Kwe’é áká aná’álwo’ t’áá áłahjį’ naadiindįį́ ’́ ahéé’ílkidgóó dóó tsosts’id jį́ ąą’át’é.
Dahodílzingóne’ éí dá’deelkaal. Áádóó hane’ bee bik’i’ di’díítííłígíí dóó t’áá łahgo át’éego hane’ nich’į ádoolnííł.

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
(TTY 711) '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। ਅਸੀਂ ਸਹਾਇਕ ਸਾਧਨਾਂ ਅਤੇ
ਕਵਕਲਕਪਕ ਫਾਰਮੈਟਾਂ ਕਵੱ ਚ ਵੀ ਤੁਹਾਡੀ ਮਦਦ ਕਰ ਸਕਦੇ ਹਾਂ।

Russian: Это важная информация от Kaiser Permanente. Если Вам требуется помощь, чтобы понять эту информацию,
позвоните по номеру 1-800-464-4000 (линия TTY 711) и попросите предоставить Вам услуги переводчика. Помощь доступна
24 часа в сутки, 7 дней в неделю, кроме праздничных дней. Мы также можем помочь вам с вспомогательными средствами и
альтернативными форматами.

Spanish: La presente incluye información importante de Kaiser Permanente. Si necesita ayuda para entender esta información, llame
al 1-800-788-0616 (TTY 711) y pida ayuda linguística. Hay ayuda disponible 24 horas al día, siete días a la semana, excluidos los días
festivos. También podemos ayudarle con recursos para discapacidades y formatos alternativos.

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 (TTY 711) 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. Matutulungan din namin kayo sa mga
pantulong na gamit o serbisyo at mga alternatibong format.

Thai: นีเ่ ป็ นข ้อมูลสําคัญจาก Kaiser Permanente หากคุณต ้องการความชว่ ยเหลือในการทําความเข ้าใจข ้อมูลนี้ โปรด โทร 1-800-464-4000 (โหมด
TTY 711) และขอความชว่ ยเหลือด ้านภาษา เราพร ้อมให ้ความชว่ ยเหลือตลอด 24 ชวั่ โมง 7 วันต่อสป ั ดาห์ ยกเว ้นวันหยุดราชการ เรายังสามารถจัดหา
อุปกรณ์และวัสดุชว่ ยเหลือในรูปแบบอืน ่ ได ้อีกด ้วย

Ukranian:У цьому повідомленні міститься важлива інформація від Kaiser Permanente. Якщо надана інформація не зрозуміла й
вам потрібна допомога, зателефонуйте за номером 1-800-464-4000 (TTY 711) і попросіть надати вам послугу перекладача. Наші
співробітники надають допомогу цілодобово, 7 днів на тиждень, за винятком святкових днів. Також ми можемо допомогти вам,
надавши допоміжні засоби й матеріали в альтернативних форматах.

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 (TTY 711) 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. Chúng tôi cũng có thể giúp quý vị với các phương tiện trợ giúp bổ trợ và hình thức thay thế.