Insurance Company 1: Plan Option 1 Coverage Period: 01/01/2013 – 12/31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Spouse | Plan Type: PPO Your Rights to Continue Coverage: ** Individual health insurance sample – ** Group health coverage sample – Federal and State laws may provide protections that allow you If you lose coverage under the plan, then, depending upon the to keep this health insurance coverage as long as you pay your circumstances, Federal and State laws may provide protections premium. There are exceptions, however, such as if: OR that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, You commit fraud which may be significantly higher than the premium you pay The insurer stops offering services in the State while covered under the plan. Other limitations on your rights to continue coverage may also apply. You move outside the coverage area For more information on your rights to continue coverage, For more information on your rights to continue coverage, contact the plan at [contact number]. You may also contact your contact the insurer at [contact number]. You may also contact state insurance department, the U.S. Department of Labor, your state insurance department at [insert applicable State Employee Benefits Security Administration at 1-866-444-3272 Department of Insurance contact information]. or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov. Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: [insert applicable contact information from instructions]. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– Questions: Call 1-800-[insert] or visit us at www.[insert]. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 6 of 8 at www.[insert] or call 1-800-[insert] to request a copy.