Page 14 - QCHC.19 Employee Benefits
P. 14
Page 5 of 6 OHPSMP BEN1711538792887-00044
Non-emergency care when traveling outside the U.S.
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
Routine Eye Care (Adult) Routine Foot Care Weight Loss Programs
• • • •
Dental Care (Adult) Hearing Aids Infertility Treatment Long-Term Care Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.) Private-Duty Nursing 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: the Department of Labor's Employee Benefits Security Administration at 866-444-EBSA (3272) or dol.gov/ebsa/healthreform, your state insurance department at 800-686-1526 and the Department of Health and Human Services, Center
• • • • • Does this plan provide Minimum Essential Coverage? Yes.
Excluded Services & Other Covered Services:
Acupuncture Bariatric Surgery Children's dental check-up Children's glasses Cosmetic Surgery Chiropractic Care 800-540-2583. that you have health coverage for that month. Does this plan meet Minimum Value Standards? Yes. costs may be lower.
• • • • • •
