Blue Cross and Blue Shield Service Benefit Plan - PDF document

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Bee Ma’1hay1n7g77 d00 Bee Mk’4’asti’7g77 Bee Baa Hane’7g77: D77 Naaltsoos bee Ha’d7h’ Bee Mk’4’asti’ Niyi’ Hoolzhish7g77: 01/01/2020 – 12/31/2020 4h7g77 Ha’1h’77 Yee Ak’4’aghi’7[77 d00 Ha’1h’77 d77 Bee Ak’4da’aghi’7 H’11 Ni Bik’4h Na’ayil4h7[77 Blue Cross and Blue Shield Service Benefit Plan: Basic Option Bee Mk’4’asti’7g77 Biniiy4go: T’1 H0 T’e7y1, H0 d00 N11n1 [a’ doodgago H0 d00 Hooghan Haz’32gi | Naaltsoos bee Ha’d7t’4h7g77 !t’4: PPO 1 47 14 D77 Bee Ma’1hay1n7g77 d00 Bee Mk’4’asti’7g77 Bee Baa Hane’7g77 (SBC) binaaltsoos 47 d77 ats’77s n1nel’88h biniiy4 h1id77sh99 choid77[‘88[7g77 yee nika’iilyeed doolee[ naaltsoos bee ha’d7t’4h7g77 h1id77sh99 choid77[‘88[7g77 yee nika’iilyeed doolee[ D77 SBC 47 hait’4ego ni d00 naaltsoos bee ha’d7t’4h7g77 d77 ats’77s baa’1hay1n7g77 bee aka’an7da’awo’7g77 b22h da’il7n7g77 bi[ a[ka’an1nilwo’ doolee[7gi 1t’4ego yee nich’8’ 77shj1n7 7ill4eh doolee[. NMM’ !KON&N&ZIN: Baa hane’7g77 b33h 7l9n7g77 d77 naaltsoos bee ha’d7t’4h7g77 (koji’ hodiilnih al1ahdi 1n4elt’e’ bik’4h nidooly4[7g77 0oly4) b33h al7n7g77 bee 47 baa hane’7g77 t’11 sahdii h0l=. D77 ’47 t’00 bee baa hane’7g77 1t’4: H’11 sh--d7 FEHB Naaltsoos bee ha’d7h’4h7g77 biyi’ [RI 71-005] d77 naaltsoos bee ha’d7h’4h7[77 biyi’ bee a[[ha’da’deegh’1b7[77 h’11 1h’4 bik11’. FEHB Naaltsoos bee ha’d7t’4h7g77 biyi’ d77 bee aa’1dahay1n7g77 t’11 1’t4 t’11 ha’d7n7g77, bee nahaz’1n7g77, d00 doo bidadeet’i’7g77 dabik11’: Bee aa’1dahay1b7[77 h’11 a[22 1b11’bii[ doolee[ n11n1 [ad65’[0 naaltsoos had7h’4h7[77 bee bik’ih b11’aghi’[c, Medicare 1daah’4h7[77 dah. D77 saad dabik1’7[77 h’11 yi[n7n7g77 biniiy4, d77 1daah’4h7[7 da 1b4elh’e’ bee ah00h’i’7[77, bee 22h h11jil 1b4elh’e’ yidziih7g77, b4eso 1ch’33h baa’bil al22j,’ h’11 h0 nijil4h7g77, al22j,’ b4eso h’11 h0 nijil4h7g77, b44 hidi’b7[7[77, anee’ 77[7n7 an7daajah7g77, doodago n11n1 [a’ biyaa da’agdnch[c bee bahan’1b7[77 biniiy4 Naaltsoos Saad Bee $4dahozin7g77 biyi’ d7d77’,,[. FEHB Naaltsoos bee ha’d7h’4h7[77 kchj,’ fepblue.org/brochure, n7dii[ts0os doolee[, d00 Saad Nidad4esdzoo7g77 kchj,’ www.dol.gov/ebsa/healthreform biniiy4 baa nanit1a doolee[. Naaltsoos bee 44dahozin7g77 b44 da’alyaa7[77 [aâ€

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€™, 7bcalh2’7 hadinilaago bib1’d77dl44[ ako nidi bee han’1b7[i 1h’4e[c eii yizi[7g77 biyi’ ahg’77g baa’ah1y32[c bee ak’4’aghi’7[77 nee h0l=- b7h’65[c bib1’idl4h7[77 h’00 bi’dcclbih. Da’ d77 naaltsoos bee ha’d7t’4h7g77sh b7ighah 1yosin M’ohgo T’11 Nik’ehgo Nahaz’1n7g77? [Moo’] Ni naaltsoos bee ha’d7h’4h7[77 doo 7ighah 77l44hg00go A’ch[c H’11 Bik’eh[c Nahan’1b7[77, bee da b1’ahcch’i’ doolee[ 7b0alh2’7 bee aa’hajccba’7[77 1b4elh’e’ naaly4h7g77 47 bik1’1dcclkc[ bi’d77l44[[c naaltsoos bee ha’d7h’4h7[77 Nida’iibiih Bi[ Nahan’1b7[77. Saad Bee !ka’an7da’awo’7g77: [Naakaii Bizaadj7 (Español): Para obtener asistencia en español, llame al servicio de atención al cliente al número que aparece en su tarjeta de identificación.] [Tagalog (Tagalog): Para sa tulong sa Tagalog, tumawag sa numero ng serbisyo sa customer na nasa inyong ID card.] [N11hg’0g7 Bizaadj7 (中文): 請撥打您 ID 卡上的客服號碼以尋求中文協助。] [Din4 Bizaadj7 (Dine): Diné k’ehjí yá’áhi’ bee shíká’adcckcł nohsingo naaltsoos nihaa halbe’[c nidaahtinígíí bibe’déé’ Customer Service bibéésh bee habe’é biká’ígíí bich’į’ dahodoołnih.] –––––––––––––––––––––– D7n4esh’88[ n7n7zingo biniiy4 binahj8’ hane’7g77 d77 naaltsoos bee ha’d7h’4h7[77 hait’4ego b33h al7n7g77 yee yik’4’asti’ doolee[7g77 at’s77s n7dan4l’88h d00 azee’ 22h 1l’7n7g77 bi[ haz’32gi, dini[’88[ n11n1 dzoh7g77 biyi’ kohj8’–––––––––––––––––––––– 13 47 14 D77 naaltsoos bee ha’d7t’4h7g77 47 d77 BINAHJ*’ HAN9’&G&& bee ak’4da’aghi’7[77 b33h da’il7b7[77 bee b0holn77h doolee[. Joe Ash88h {ikan Mts’77s yich’8’ Naa[niih 2 at’3h7g77 (b11haij,’ !h’4h7[77 b1 baa’1hay1b7[77 hcbe’4 bi[ bida’abigh7[77 bee aa’1hay1b7[77 h’11 haih’4e[c da h’11 hanh0’0 b1’0clnib7[77) Peg Ne’aw44’ Haleeh (n7deezid hcbe’4 bi[ bida’abigh7[77 oots43go b7dahcdi’b4[,,h[c bee aa’1hay1b7[77 d00 anee’ 7[‘9 hotsaa [0be’ ach7h7g77)  D77 naaltsoos bee ha’d7t’4h7g77 t’11 1t’4go haan4elt’e’ $0  Mzee’ 27[‘7n7 Dahaniih7g77 [b33h al7n7g77 a[ts’33j7 hodeet’i’7g77] $40  Mzee’ &l9 Hotsaa (haz’1n7g77) [b33h al7n7g77 a[ts’33j7 hodeet’i’7g77] $175 

N11n1 [a’ [b33h al7n7g77
N11n1 [a’ [b33h al7n7g77 a[ts’33j7 hodeet’i’7g77] 30% D77 NINMHJ6’ HMNE’2S22 bi[ nidahoot’aah7g77 d77 bee 1ka’an7da’wo’ y7yo[ta’7g77 47: Anee’ 77[‘7b7 Dah Haniih7g77 bi[ yah ab1’ad1h7[77 (oots32go bee aa’1hay1n7g77) Ak44’ Nidahach77h7g77/ Ak44’ Hadayiin77[ Yee Dahaniih7g77 Bee !ka’ab7da’akc’7[77 Ak44’ Nidahach77h7g77/ Ak44’ Haha’b77[ Bi[ Nahan’1b7[i Bee !ka’ab7da’akc’7[77 Na’alkaah bee 7’beel’22h7[77 (ats’77s biyi’di hodiits’a’7g77 bee agh1da’dildlaad d00 di[ bi[ na’anish) Anee’ 77[‘7b7 Dah Haniih7g77 bi[ yah ab1’ad1h7[77 (azee’ bi[ aa’ada’atsihgo hats’77stah doo ahaly32 da 1yii[‘88h7g77) Ninahj8’ Hane’go T’11 !t’4 B33h Al7n7g77 $12,700 D77 binahj8’ hane’7g77, Peg naidool4[7g77: B33h &l7n7g77 Bee Ahaanits7j1kees7g77 B44 8ahidi’b7[7[77 $0 Al22j,’ B4eso H’11 H0 Nijil4h7g77 $200 B4eso Ach’33h Naa’bil Al22j,’ H’11 H0 Nijil4h7g77 $0 Ha’1t’77sh99 doo bee ak’4’asti’7g77 Bee Nahan’1b7[77 doodago doo b00lh2’ daa7g77 $60 Peg t’11 1’t4 naidool4[7g77 47 $260  D77 naaltsoos bee ha’d7t’4h7g77 t’11 1t’4go haan4elt’e’ $0  Mzee’ 27[‘7n7 Dahaniih7g77 [b33h al7n7g77 a[ts’33j7 hodeet’i’7g77] $40  Mzee’ &l9 Hotsaa (haz’1n7g77) [b33h al7n7g77 a[ts’33j7 hodeet’i’7g77] $175  N11n1 [a’ [b33h al7n7g77 a[ts’33j7 hodeet’i’7g77] 30% D77 NINMHJ6’ HMNE’2S22 bi[ nidahoot’aah7g77 d77 bee 1ka’an7da’wo’ y7yo[ta’7g77 47: Hg’7d1 1[ts4 aa’1hay2b7[77 anee’ 77[‘7b7 bi[ yah ab1’ad1h7[77 (t’11 ha’1t’77sh99 naa[niih 1daat’4h7g77 b7na’niltin) Na’alkaah bee 7’beel’22h7[77 (di[ bi[ na’anish) Anee’ 77[‘7b7 anee’ h’11 h0 haab1’bi[7[77 Bee bida’abigh7 bee ah’g77g dab4l’7b7[77 (glucose woly4h7g77 bee b7’neel’22h7g77) Bee Mk’4’asti’7 Ninahj8’ Dahane’7g77 Biniiy4h7g77: D77 doo b33h da’il7n7g77 a[h7iyiiz0h7g77 1t’4e da. Bee 22h 1da’al7b7[77 47 h’00 bibahj,’ habe’7[77 1h’4 haih’4e[c d77 naaltsoos bee ha’d7h’4h7[77 ah’g77g b7dab4l’,,h d00 anee’ 22h 1l’7b7[77 bee aa’1hay1b7[77 yik’4’aghi’ doolee[7g77 1h’4. H’11 haih’4h7[77 bee baa’1h1y2’b7[77 bibahj,’ d77 h’11 7iyis77 b33h al7n7g77 ni anee’ 77[7n7 an7daajah7g77 y33h 7[7n7g77, d00 n11n1 [a’ bidad44h’i’7[77 bee [ahgo 1h’4e doolee[, B33h da’il7b7[

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77 bee ahaanits1h1kees7g77 1b4elh’4’7[77 (b44 hidi’b7 [7g77, al22j,’ b4eso h’11 h0 nijil4h7g77 d00 b4eso 1ch’33h baa’bil al22j,’ h’11 h0 nijil4h7g77) d00 bee 1ka’ab7da’akc’ doo bidcalh2’7[77 biyaad007g77 y4ego b7b7[‘9h naaltsoos bee ha’d7h’4h7[77. D77 chcid77[‘,,[b33h da’al7b7[77 bi[ a[h22h naninilgo bee habe’7[77 47 n11n1 [a’ ah’g77g naaltsoos bee ha’d7h’4h7[77 H’11 sh==d7 d77 bee ak’4’aghi’ bibahj7’ habe’7[77 47 h’11 h0-h’e7y1 bee ak’4’aghi’7[77 bibahj,’ habe’ ah’4. 14 47 14 D77 naaltsoos bee ha’d7t’4h7g77 47 d77 BINAHJ*’ HAN9’&G&& bee ak’4da’aghi’7[77 b33h da’il7b7[77 bee b0holn77h doolee[. Mia bitsin t’11 a[ts77s7’go k’4’4ltl--h (h0be’4-bi[bida’abigh7[77 nitsihodidi[go da’b4l’9 b1 han’1b7 [0be’ d00 bik44d00 bee aa’1hay1b7[77) Ninahj8’ Hane’go T’11 !t’4 B33h Al7n7g77 $7,400 D77 binahj8’ hane’7g77 biyi’, Joe niidool4[7g77: B33h &l7n7g77 Bee Ahaanits7j1kees7g77 B44 8ahidi’b7[7[77 $0 Al22j,’ B4eso H’11 H0 Nijil4h7g77 $2,000 B4eso Ach’33h Naa’bil Al22j,’ H’11 H0 Nijil4h7g77 $0 Ha’1t’77sh99 doo bee ak’4’asti’7g77 Bee Nahan’1b7[77 doodago doo b00lh2’ daa7g77 $60 Joe t’11 1’t4 naidool4[7g77 47 $2,060  D77 naaltsoos bee ha’d7t’4h7g77 t’11 1t’4go haan4elt’e’ $0  Mzee’ &7[‘7n7 Dahaniih7g77 t [b33h al7n7g77 a[ts’33j7 hodeet’i’7g77] $40  Mzee’ &l9 Hotsaa (haz’1n7g77) [b33h al7n7g77 a[ts’33j7 hodeet’i’7g77] $175  N11n1 [a’ [b33h al7n7g77 a[ts’33j7 hodeet’i’7g77] 30% D77 NINMHJ6’ HMNE’2S22 bi[ nidahoot’aah7g77 d77 bee 1ka’an7da’wo’ y7yo[ta’7g77 47: nitsihodidi[go da’b4l’9 b1 han’1b7 [0be’ (ats’77s dan4l’7n7g77 chdoa’7n7g77) Na’alkaah bee 7’beel’22h7[77 (agh1da’dildlaad, di[ bi[ na’anish) Bee bida’abigh7 bee ah’g77g dab4l’7b7[77(gish) H’11 haih’4e[i da ahg’77g b1k’22g bee 1ka’ab7da’akc’7[77 (ats’77s n1k’22s) Ninahj8’ Hane’go T’11 !t’4 B33h Al7n7g77 $1,900 D77 binahj8’ hane’7g77, Mia neidool4[7g77 B33h &l7n7g77 Bee Ahaanits7j1kees7g77 B44 8ahidi’b7[7[77 $0 Al22j,’ B4eso H’11 H0 Nijil4h7g77 $400 B4eso Ach’33h Naa’bil Al22j,’ H’11 H0 Nijil4h7g77 $60 Ha’1t’77sh99 doo bee ak’4’asti’7g77 Bee Nahan’1b7[77 doodago doo b00lh2’ daa7g77 $0 Mia dikw77h neidool4l7g77 47 $46