2014? - Archdiocese of Kansas City in Kansas

Transcription

Archdiocese of Kansas City
Employee Benefits Enrollment Guide
Plan Year: 2014
Section
Page
2014 Guide to Benefits
3
Effects of Health Care Reform
5
What’s Changing for 2014?
6
Enrollment Instructions
7
Archdiocese Online Benefits Portal
10
Cost to Participate
11
Health Benefits
12
Prescription Drug Benefits
13
Medication Management – Tria Health
14
Navigate Cancer
16
Dental Insurance
17
Voluntary Accident Insurance
18
Vision and Life/Disability Benefits
19
Voluntary Critical Illness
22
Flexible Spending Accounts
23
Contact Information
25
Legal Notices
26
Summary of Benefits and Coverage (Health Plan)
33
Enrollment/Application Forms
Archdiocese Enrollment Form
43
2
Welcome to the Archdiocese of Kansas City
in Kansas’ 2014 guide to employee benefits!
2014 Open Enrollment Information
This year OPEN ENROLLMENT begins on October 21nd and ends on November 1st. Elections
you make during open enrollment will become effective January 1, 2014.
2014 New Hire Enrollment Information
Because all benefit options are voluntary, newly hired employees are required to enroll or waive
enrollment in the Archdiocese benefits. You must complete an enrollment or waiver form within
31 days of your date of hire. Coverage in all benefits will begin first of the month following your
date of hire.
The Archdiocese offers you and your eligible family members a comprehensive and valuable
benefits program. We encourage you to take the time to educate yourself about your options
and choose the best coverage for you and your family.
This guide describes your benefit options for 2014. Please read it carefully for important
information you will need in order to make decisions about your benefit elections.
3
Who is Eligible?
An employee who works at least an average of 30 hours per week for the
school or calendar year is eligible to participate in all of the Archdiocese
Benefit Plans. You may elect coverage for your eligible dependents which
include your legal spouse or dependent child(ren) (until the end of the year
in which they turn 26).
If you work less than 30 hours a week, you may be eligible to participate in
the Flexible Spending Accounts. Please see your local benefits
administrator if you have questions.
How to Enroll
Open enrollment will be completed via our online self-service portal again
this year. Instructions can be found on page 7.
New hires are asked to continue to use the paper enrollment form located
in the back of this booklet.
For both open enrollment and new hire enrollment, please remember,
once you have made your elections, you will not be able to change them
until the next open enrollment period unless you have a qualified change in
status.
When to Enroll
This year Open Enrollment begins October 21st and ends November 1st,
2013. During this period you may elect, change or waive coverage in the
health, dental or vision plans. All employees are required to go online,
review their benefits to ensure you are enrolled in the desired plans, and if
you have any questions, contact your local Benefits Administrator. Your
next opportunity to enroll or make changes in benefits will be the next
Open Enrollment period, unless you have a qualifying status change.
All part-time employees working 20 or more hours per week must also
enroll online, verify your information and enroll/waive the flexible spending
benefit.
How to Make Changes
After your initial enrollment, you cannot make changes to the benefits you
elect until the next open enrollment period unless you have a qualified
change in status. Qualified changes in status include: birth, death,
marriage, divorce, adoption of a child, change in child’s dependent status,
or a significant change in benefits coverage for you or your spouse
because of your spouse’s employment. A request for change in status
must be received within 31 days of the event. If you wish to enroll or make
changes to your Life and Disability benefits, you will be required to provide
proof of insurability before the enrollment or change is approved. Please
choose your benefits carefully.
4
Effects of Health Care Reform
Summary of Benefits and Coverage
Under the Patient Protection and Affordable Care Act (PPACA), insurance companies and group health
plans will provide consumers with a concise document detailing, in plain language, simple and consistent
information about health plan benefits and coverage. This Summary of Benefits and Coverage (SBC)
document will help consumers better understand the coverage they have and, for the first time, allow them
to easily compare different coverage options. It will summarize the key features of the plan or coverage,
such as the covered benefits, cost-sharing provisions, and coverage limitations and exceptions.
A copy of the SBC can be found on page 33 of this booklet.
Grandfathered Status
The Archdiocese Health Plan is a
“grandfathered health plan” under the PPACA.
As permitted by PPACA, a grandfathered
health plan can preserve certain basic health
coverage that was already in effect when that
law was enacted. Being a grandfathered health
plan means that your plan may not include certain
consumer protections of the PPACA that apply to other
plans, for example, the requirement for the provision of
preventive health services without any cost sharing. However,
grandfathered health plans must comply with certain other
consumer protections in the PPACA, for example, the elimination of lifetime limits on benefits.
Questions regarding which protections apply and which protections do not apply to a grandfathered health
plan and what might cause a plan to change from grandfathered health plan status can be directed to the
Human Resources office of the Archdiocese.
Women’s Preventive Care Guidelines
In August, 2011, the US Department of Health and Human Services (HHS) announced additional
preventive care services, developed by the independent Institute of Medicine, to cover women’s
preventive services without charging a copayment, coinsurance or a deductible. In addition to requiring
100% coverage for well-women visits and various types of screenings, the HHS has included coverage for
FDA-approved contraception methods. The Archdiocese Health Plan is a “grandfathered health plan”,
these guidelines will not apply as long as we maintain “grandfathered” status.
Even though the health plan is not required to comply with these guidelines, our health plan covers routine
preventive services at 100% up to a $500 benefit maximum per calendar year for all members. Once the
$500 maximum is met, all services are subject to applicable coinsurance and deductible. In addition, the
health plan also covers one mammogram and one colonoscopy per calendar year at 100%, regardless if it
is a routine or diagnostic service. Coverage for contraception is not included in our health plan.
5
What’s Changing for
2014?
The value of our work at the Archdiocese of Kansas City in Kansas makes an impact within our
community and we are committed to positively impact the lives of our employees. With that in mind, the
Archdiocese Benefit Plan is designed to recognize the diverse needs of our workforce. Because the
Archdiocese self-insures the health and dental plans, our health care costs are driven by our own claims
experience and utilization of services. Having self-insured benefit plans affords us greater control over
our health and dental plan designs and also helps us eliminate large administrative costs and enhance
our claims processing.
Please take the time to become familiar with the changes for our upcoming plan year so that you
can make informed decisions about your benefit elections. Below is a brief description of the
changes taking place:
 Employee Premiums – Medical plan premiums will increase 2%. Dental and Vision
premiums will remain unchanged
 Medical Plan – In order to comply with the Affordable Care Act in 2014 we will remove
both the $2 million annual benefit maximum and pre-existing condition limitations for all
members.
 Prescription Drug – In addition to our MedTrak prescription drug benefit, we are
implementing a new medication management program through Tria Health. The program
is designed to improve your health, reduce your healthcare costs and ensure you are
receiving the best care from your medications. See page 14 for more information.
 Dental Plan – We are pleased to announce enhancements to our dental plan for 2014.
The annual benefit and lifetime orthodontia maximums will increase from $2,000 to
$2,500. We are reducing the plan deductible from $50 to $25 per individual and we are
adding coverage for dental implants.
 Natural Family Planning Benefits will now be administered by The Archdiocese Human
Resource Office.
6
Open Enrollment Instructions
Start the enrollment process at the following link:
http://archkck.benergy.com
User ID:
Password:
ArchKCKLayEEs
benefits
Once on the Archdiocese Human Resources page, please take a few minutes to review a variety of
human resources benefit information they have posted. Then when you are ready to enroll, click on
the HUMAN RESOURCES tab at the top of the page, scroll down and click OPEN ENROLLMENT.
The OPEN ENROLLMENT tab will direct you to a new page that looks like this:
Note: Be sure the Capability
icon is blue if using Microsoft
Explorer.
If you haven’t logged in before, ignore the log in box above and click the “CLICK HERE” on the
Employees only sentence at the bottom of the page.
You will now be redirected to a page where you will create a personal log in ID and password.
When finished creating your log in ID and password you will be redirected to the login screen.
If you have used our self-service portal before, log in using your username and your password as
indicated below.
Your user name is last name, first name, a period and then the last four digits of your social
security number. Ex. SmithJohn.1234
After you have successfully logged in, you will be directed to a page that looks like this:
7
Open Enrollment Instructions (cont’d)
Start by updating your personal information under the “MY INFO” tab. Please be sure to add any
relevant personal contact information such as your phone number, e-mail address and any other
sections that appear blank. Ignore the employee ID field.
Pay close attention to your beneficiary designations, especially your Retirement Beneficiary.
Keeping these updated is important because it determines how your final wishes are carried out. You
should consider updating beneficiary designations if you have: changed your marital status,
designated someone who is now deceased or designated someone that you no longer wish to be a
beneficiary.
After updating your personal information, click “CURRENT BENEFITS.” A summary of the benefits
you are currently enrolled in will appear.
After reviewing your current benefits, click “ENROLLMENT.” Depending on the benefits you are
currently enrolled in, the screen will look something like this:
You are now in a position to change your current benefits and add any benefits you are currently not
enrolled in. Available benefits appear on the right side of the page under a header that looks like this:
You will need to click “SELECT PLAN” under the Available
Benefit Types header and at the bottom right of the page you will
be asked to “DECLINE” or “ADD TO CART.” Continue this
process until you have either accepted or declined all remaining
benefits.
If you have questions, please don’t hesitate to ask your local
Benefit Administrator.
8
New Hire Enrollment Instructions
Please complete the enclosed enrollment forms and return to your local Benefits administrator within
31 days of your hire date – or the first day you are actively at work. For teachers or school
administration under contract, your hire date is the first day of your contract period.
Employee Benefits Enrollment Change Form
 Please be sure to print legibly
 Complete 1st page with your (and your dependents to be covered) information
 Be sure to check the appropriate “Coverage Selected” box for each person to be
covered under your Employer’s benefits.
 Health, Dental and Voluntary Vision – On page 2, select the Archdiocese benefits you wish to
participate in by checking the appropriate box (Employee Only or Family Coverage). If not
electing coverage, please check the WAIVE box.
 Flexible Spending Account / Pre-tax Premium Deductions – Check the box for the account you
would like to participate in (or WAIVE).
 If enrolling in either the Health Care or Dependent Care account, please indicate both
your annual election and per pay period amounts.
 Check the appropriate payroll frequency box.
 If enrolling, please complete the beneficiary designation section.
 If electing pre-tax premium deductions, premiums will continue to be deducted on a pretax basis in subsequent years unless you change this election during Open Enrollment.
 Basic Life and Disability Package – Select Employee Only or Family coverage or check the
WAIVE box.
 If enrolling, please complete the beneficiary designation section.
 If enrolling, completion of the Premium Calculation worksheet located on page 3 of the
enrollment form is required.
 If enrolling, please be sure to complete the beneficiary designation section.
 Voluntary Supplemental Life – Check the box next to the benefit you are electing and indicate
the amount of life insurance for yourself, your spouse and eligible dependent children (or
check WAIVE).
 You must be enrolled in the Basic Life package to purchase Voluntary Supplemental
Life.
 If enrolling, completion of the Premium Calculation worksheet is required.
 If enrolling, please be sure to complete the beneficiary designation section.
Humana Voluntary Benefits (issued through Kanawha Insurance Company)

These plans are only available for enrollment during the annual Open Enrollment
period. You will have an opportunity to enroll at our next Open Enrollment period in
October 2014.
 Voluntary Accident Insurance
 Voluntary Whole Life (Secure Life)
 Voluntary Critical Illness
9
Your One-Stop BENEFITS, HEALTH &
WELLNESS, AND HR RESOURCE
The Archdiocese is pleased to continue to provide our employees with an online Communications Portal.
Our Communications Portal is your one-stop benefits, health and wellness and HR resource that is
available 24 hours a day, 7 days a week. You have online access to the information and tools you need
to save time and effort – and make better informed benefits, health, and wellness decisions. Information
will be updated frequently so you’ll want to visit the Communications Portal often.
The Communications Portal includes four centers working together:
Benefits Center
 Get detailed benefit plan information and use the decision support
tools, such as multimedia presentations about our benefits plans,
tips on how to use our plan, and a plan comparison tool
 Check out the financial calculators, life event checklists, and
informative articles on a wide range of benefits topics
Health & Wellness Center
 Helps you and your family assess health problems, prevent and
manage conditions, and live healthier lives
 Award-winning content includes articles, images, videos, checklists,
health risk assessments, calculators, and interactive modelers
 All of the information provided is reviewed by teams of unbiased
medical professionals
Human Resources Center
 Find relevant and timely company news and communications
My Info Center
 Create a personal health record to keep track of your doctors,
immunizations, tests and more
 Subscribe to receive Synergy, our exclusive health and wellness enewsletter
We hope this makes it easier for you to get to the information you are
looking for. (our goal is to provide you with the information you need
without the hassle… )Check it out today!
Go to http://archkck.benergy.com
User ID: ArchKCKLayEEs
Password: benefits
OR
Visit the Human Resources page on the Archdiocese
website at www.archkck.org
10
Your Benefit Choices
The Archdiocese provides a wide
variety of benefits. Some are
provided automatically at no cost
to you. Check the list to the right
and select the benefits that best
meet your personal needs.
Benefit
Who Pays the Cost?
Medical/RX Coverage
Employer & Employee
Employee
Dental Coverage
Employer & Employee
Voluntary Vision
Employee
Basic Life & Disability Package
Employer & Employee
Voluntary Supplemental Life
Employee
Voluntary Whole Life
Employee
Employee
Health Care Reimbursement
Dependent Care Reimbursement
Pre-Tax Premium Deductions
Employee
Employee
Employee
Cost to participate
2014 Premium Deductions
The premiums for the Health plan are increasing 2% and Dental and Vision plans will not change for
2014. Your employer will pay 60% of your cost to participate in the Health and Dental plans. The chart
below shows your share of the 2014 monthly cost compared to the total cost. The Vision plan is a
voluntary plan; therefore you are 100% responsible for the cost to participate.
Monthly Rates
Health Plan (Includes RX)
Single
Family
Dental Plan
Single
Family
Voluntary Vision Plan
Single
Family
2014 Employee
Contribution
2014 Employer
Contribution
Total Cost
$251.12
$529.84
$376.67
$794.77
$627.79
$1,324.61
$16.98
$40.13
$25.47
$60.20
$42.45
$100.33
$8.99
$24.81
n.a.
n.a.
$8.99
$24.81
For Married Couples Both Working for Participating Agencies within the Archdiocese
Married couples, of which both parties are employed by a participating agency of the Archdiocese Health
and Dental Plan, will have the premium costs paid in full by the participating agency(ies). If one employer
employs both parties of the married couple, that agency will pay the entire premium. If two agencies are
involved, the full premium should be divided evenly between the two employing agencies. This policy
pertains to all participating agencies, except those who have been given a “special exception” to the
employer/employee premium ratio. Those exempted agencies will not be required to pay full premiums if
both spouses work for the exempted institution, but will be required to share equally in the cost of the
premium when one party of the couple works for some non-exempted participating agency of the Plan.
11
Health Benefits
You have the flexibility to seek care from an in-network or out-of-network provider. It is important to note that with the new
enhanced benefits you receive the maximum benefits from the plan when you seek services from Catholic hospitals.
The Blue Cross and Blue Shield networks offer the best national access to providers through the BlueCard PPO Program
in which all Blue Cross Blue Shield Plans participate. To learn more about the BlueCard Program, or if your physician
participates in the PPO network, please visit their website at www.MyHealthToolkitKC.com. Please note: St. Joseph
Medical Center and St. Mary’s Medical Center will not appear in the Kansas City area online provider directory, however
claims incurred at these facilities will be paid as in the PPO network and at the higher “Catholic Hospital” benefit level.
You may also direct your questions to the Customer Service number located on the back of your identification card.
The only changes being made for the 2014 plan year are those required by the Affordable Care Act. We will remove prest
existing condition limitations for all members effective January 1 as well as the $2 million annual benefit maximum. A
comprehensive summary of benefits can be found on the Summary of Benefits and Coverage.
BENEFIT
COMBINED IN-NETWORK AND OUT-OF-NETWORK PROVIDERS
Calendar Year Deductible
$475 Individual / $950 Family
Catholic Hospitals
In-Network Providers
Out-of-Network Providers
$1,800
$3,600
$1,800
$3,600
$2,300
$4,100
Wellness Benefits – Routine Care
Not Applicable
100% up to $500 per person, then
Plan pays 80% after Deductible
100% up to $500 per person,
then Plan pays 60% after
Deductible
Physician Visit
Not Applicable
$30 Copay
Plan pays 60% after
Deductible
Inpatient Hospital Services
100%, no Deductible
$120 Copay, then Plan pays 80%
after Deductible
$120 Copay, then Plan pays
60% after Deductible
Emergency Room
$90 Copay, then Plan
pays 100%, no
Deductible
after Deductible
Inpatient Hospice Care Services
100%, no Deductible
after Deductible
Chiropractic Care
Limit of 20 visits per calendar year
combined with Out-of-Network
Not Applicable
after Deductible
Plan pays 60% after
Deductible
100%, no Deductible
100%, no Deductible
Plan pays 60% after
Deductible
(facility charges only)
Out-of-Pocket Max
- Individual
- Family
Lab Services
This is a brief summary only. Certain restrictions and exclusions apply.
For exact terms and conditions, please refer to your summary plan description.
Natural Family Planning
The Archdiocese will continue to provide benefits for Natural Planning Services. This benefit includes the office visits
and materials and is available through programs approved by the Archdiocese. The following programs are
considered to be approved: the Creighton Model, and Couple to Couple. The Archdiocese will cover up to 60% of the
allowable charge up to a maximum of $400 per year. Please contact the Archdiocese Human Resource office in order
to submit a claim for benefits.
12
MedTrak is an independent prescription benefit management company, free of ownership ties to drug
manufacturers, mail pharmacies, retail pharmacies and insurance companies. MedTrak is a local company founded
in 1999 and is best known for its stellar customer service throughout the organization. At MedTrak, every individual
that calls into their Customer Service department will speak with a live person, not an automated voicemail system.
Your plan includes a list of prescription drugs that are preferred by the plan because they help control rising
prescription drug costs. This list, sometimes called a formulary, has a wide selection of generic and brand-name
medications. We recommend taking a copy of the plan’s preferred medications with you to each doctor visit to
discuss whether a drug on the list is right for you. A copy of this list may be obtained on MedTrak’s website at
www.medtrakservices.com.
In order to control future prescription drug costs we will be implementing several new programs in our Plan.
MedTrak will notify eligible members over the next several months directly. We encourage you to discuss the
proposed options with your physician and consider taking advantage of any potential cost savings to both you and
the Plan.
You will want to use a participating retail pharmacy for short-term prescriptions (such as antibiotics to treat
infections). Be sure to show your MedTrak prescription benefit card to the pharmacist and pay your retail
copayment for each prescription.
Long-term medications (those taken for three (3) months or more) may be filled through the new Performance 90
retail network. Now you can fill your long-term medications at a local retail pharmacy like Walgreens, Target, WalMart and many Kansas City grocery stores. MedTrak also offers a mail order pharmacy option through Walgreens
Mail.
To find a participating retail pharmacy near you, contact MedTrak’s Customer Service department at 800-771-4648
or log on to www.medtrakservices.com.
Hours of Operation:
 Monday through Friday – 8:00 a.m. to 9:00 p.m.
 Saturday – 9:00 a.m. to 6:00 p.m.
Prescription Drugs
Retail (30-day Supply)
Generic
Brand
Formulary
Non-Formulary
Benefit
Lesser of $7 or actual cost
After $60 Annual Deductible per covered person
25% of discounted cost or $25 min
40% of discounted cost or $40 min
Mail Order (90-day supply)
Generic
Brand Formulary
Brand Non-Formulary
$20 Copay
$60 Copay
$100 Copay
This is a brief summary only. Certain restrictions and exclusions apply. For exact
terms and conditions, please refer to your summary plan description.
13
Medication Management Program
Helping You Manage Your Medications & Reduce Your Health Care Costs!
The Tria Health Program is provided at no additional cost to you through your insurance plan with Archdiocese
of Kansas City in Kansas. This confidential program is designed to improve your health, reduce your
healthcare costs and ensure you’re receiving the best care from your medications.
Tria Health’s programs offer you clinical guidance through the complexities of health care. Our pharmacists act
as your personal medication experts and work with you and your physician to achieve 3 primary goals:
1. Your medications are safe
2. You can afford the medications you’re prescribed
3. Your medications effectively treat your conditions
Pharmacy Advocate (PA) Program:
What is it?
The PA program offers one-on-one confidential counseling with a Tria Health Pharmacist to discuss how
effective your medications are in treating your conditions. Your Tria Pharmacist will work with you and your
physicians to reduce the risk of medication-related problems.
Examples of medication-related problems include:
You can enroll by…
- Nausea or other uncomfortable side effects
Mail
- Your prescription is too expensive to fill every
Eligible individuals will receive an
month
enrollment packet in the mail. This will
- The medication dosage is too low or too high and
include an enrollment form and
isn’t effectively treating your condition
envelope for you to send back to Tria
Health.
Who participates?
Individuals who have one or more chronic conditions and take
multiple medications. Active participants in the PA Program will be
eligible to receive 50% off brand copays and free generic copays
for 6 months on medications that are used primarily to treat chronic
conditions.
Online
You may enroll online by visiting our
website at
www.triahealth.com/patients.aspx
Programs for All Plan Members:
The programs below are designed to help all plan members receive the best results from their medications and
reduce the risk of medication-related problems.
Program:
Details:
Saves you and money by identifying less expensive, effective alternatives for
Affordable Med
your brand medications.
Med Safety
Alerts
Prevents the risks associated with taking medications that cause an adverse
reaction together.
Tria Clinical
Alerts
Identifies when taking an additional medication in conjunction with your current
treatment can improve your condition.
Forget to take your medications? Do side effects cause you to skip your meds?
Compliance Alerts help find solutions to help you take your medications as
prescribed.
Your complete and confidential resource anytime you have a medicationrelated question. Call us toll-free at 1.888.799.TRIA (8742).
Compliance
Alerts
Tria Help Desk
14
Medication Management Program (cont’d)
Tria Health FAQs:
What services does Tria Health provide?
Pharmacy Advocate Program
This program is designed specifically for individuals who have chronic conditions and are taking multiple
medications to control their conditions. Tria offers participating members the opportunity to speak one-on-one with a
Clinical Pharmacist to review their current medications. During this personalized counseling session, the Clinical
Pharmacist will answer any questions or concerns the member may have regarding their medications and work to
ensure that all of their health goals are achieved.
Tria Help Desk
The Tria Help Desk is a toll-free resource where all members can speak directly with a Tria Health Clinical
Pharmacist to receive information ranging from less expensive drug therapies to learning more about potential drug
to drug interactions. Members can access the Tria Help Desk at 1.888.799.TRIA Monday - Friday from 8am to 9pm
and Saturday from 9am to 8pm.
On-going Ancillary Programs (See previous page for program descriptions)
Program Name:
Frequency:
Recipient:
Communication Form:
Compliance Alerts Twice a Year
Plan Members
Letter Campaign
Med Safety Alerts
Plan Members & Prescribing Physicians
Letter & Call Campaign
Tria Clinical Alerts Quarterly
Letter Campaign
Affordable Med
Letter & Call Campaign
Weekly
Twice a Year
By participating in Tria Health, do members need to change where they get their prescriptions filled? Does
this change the relationship with their physicians?
No, participation in Tria Health will not require members to change where their prescriptions are filled. After a
member has enrolled in the Pharmacy Advocate Program, the Tria Clinical Pharmacist will notify the member’s
physician to inform them about the program. After a member has an appointment with their Tria Pharmacist, their
physician will receive a summary of the discussion. Tria Health Clinical Pharmacists work with the members’
physicians in order to ensure all members are receiving the best medical and prescription care possible!
How often do members speak with a Tria Health Clinical Pharmacist?
Pharmacists will keep in touch with each member approximately 2 or 3 times throughout the year, depending on
each member’s personal care plan which is discussed during their initial consultation. All members, however, have
unlimited access to the Tria Help Desk where they can speak with a Tria Health Clinical Pharmacist
regarding any medication issue.
How long does an initial consultation take?
The initial consultation can last anywhere from 20 to 45 minutes depending upon the complexity
of your medical care.
Is this like insurance?
Tria Health is an enhancement to your benefit insurance that is designed to reduce your
medical costs and keep you healthy.
How do I check eligibility for myself and my dependents?
Any plan member can check eligibility for themselves and/or dependents by calling
1.888.799.TRIA. Or take Tria Health’s online Medication Risk Quiz. Eligible members have one or more chronic
conditions and take multiple medications.
www.triahealth.com | 1.888.799.8742
15
NavigateCancer Foundation
A cancer diagnosis can be an overwhelming experience filled with a range of emotions, complex issues
and confusing questions. The Archdiocese has partnered with the NavigateCancer Foundation (NCF) to
improve cancer care for our employees and their family members through Cancer Advocacy. Cancer
Advocacy Services are available to all employees of The Archdiocese, at no additional cost and is
completely confidential.The mission of the NCF is to provide the tools and services all patients and their
families need to become expert patients and advocates. Through personalized, professional and expert
guidance from oncology nurses, the NCF will help to clarify disease and treatment options and ensure that
patients receive the highest quality of cancer care possible – every step of the way.
Here are some of the ways NCF can help:
 Personalized education on specific diagnosis
 Translating unfamiliar medical terminology
 Reviewing pathology, lab and scan reports
 Preparing for doctor’s visits
 Obtaining second opinions
 Teaching patients how to advocate for themselves
 Resource identification
 Recommendations to support groups and clinical trials
 Creating a treatment decision framework
NavigateCancer Foundation
www.navigatecancerfoundation.org/hope
Call 866.391.1121
16
Dental
Maintaining good dental health by getting regular checkups may prevent you from having major
expenses later. Archdiocese of Kansas City in Kansas’ Dental plan covers routine checkups and
comprehensive coverage for other types of dental work you might need. Our plan also offers you the
flexibility to seek treatment from any Provider. As with our Health Plan, you will maximize your dental
benefits if you use a Delta Dental provider due to the agreements Delta has in place with their
contracted dentists. Should you decide to use a non-participating dentist, please be advised that
your provider may balance bill you for any amount over the Delta Dental Maximum Plan Allowance.
Even though you are not required to use a Delta Dental provider, you have access to the largest
dental network in the state of Kansas. To learn more about the Delta Dental network, if your dentist
participates in the network, or for more information regarding our Dental plan provider please visit
their website at www.deltadentalks.com. Please click on the “Dentist Search” link located halfway
down the home page under the section titled “Searching for a Dentist.” In the “Dentist Search”
section, you may choose either the “Delta Dental Premier” or Delta Dental PPO” providers. You can
search for providers by name, city and state or zip code. Inquiries may also be made by calling
Customer Service at (800) 234-3375 (this number can also be found on your identification card).
Several enhancements will be made to our dental benefits for the upcoming plan year Jan 1 to Dec
31, 2014. The following chart provides you with a comparison of the enhancements for 2014. All
plan changes are highlighted in blue. A complete copy of the Dental Summary Plan Description can
be found on the Benergy website. See page 10 of this booklet for login instructions.
Services
Description
Benefit Amount
Type I Procedures
Exams, cleanings, fluoride treatments (2
per year)
Plan pays 100% of the Maximum Plan
Allowance. This benefit does not apply
towards the Annual Maximum
Type II Procedures
Regular fillings (amalgam or composite),
extractions, non-surgical root canals
After deductible, plan pays 80% of the
Maximum Plan Allowance
Type III Procedures
Inlays, crowns, dentures, implants
Maximum Plan Allowance
Type IV Procedures
Orthodontia services
For each eligible dependent, treatment
must begin prior to age 19
Maximum Plan Allowance up to a Lifetime
Maximum Benefit of $2,500
Annual Deductible
Applies to Type II, Type III and Type IV
Procedures
$25 per person
Annual Maximum
Per covered person
$2,500
This is a brief summary only. Certain restrictions and exclusions apply. For exact terms and conditions, please refer
to your summary plan description.
17
Issued through Kanawha I nsurance Company (a Humana Company)
Humana’s Accident Plus provides off-the-job coverage for accidental injuries, ambulance, hospital
care and includes an accidental death benefit. Benefits are payable for the actual expenses up to the
coverage amount selected. Accident Plus pays regardless of any other coverage you may have,
including the Archdiocese Health Plan.
After an accident, you may have expenses you’ve never thought about before. It’s reassuring to
know that an accident insurance policy can be there for you through the many stages of care, from
the initial emergency treatment or hospitalization, to follow up treatments or physical therapy.
Accident Plus Benefits
Level 2
Level 4
$1,000
$2,000
Accident Medical Expense
Pays the actual expenses up to the amount selected
for diagnosis or treatment by a Physician or in an
Emergency Room. Emergency Room service is
subject to a $50 deductible.
Ambulance Benefit
Pays actual charges up to the amount selected if injury
requires ground or air ambulance transportation.
$500
$1,000
Hospital Indemnity
Pays a benefit equal to amount selected if injury
requires inpatient hospital confinement, includes room
charge, and starts within 30 days after accident.
Benefit is limited to 30 days per accident.
$150
$300
Accidental Death & Dismemberment
$10,000
$20,000
Bone Fracture and
Dislocation
(Optional Benefit)
Pays a benefit when a covered person suffers one of
the fractures or dislocations listed in the policy
$1,500
$1,500
Hospital Intensive Care Unit
(Optional Benefit Rider)
Pays a daily benefit when a covered person is
confined to a Hospital Intensive Care Unit as a result
of injuries suffered in a covered accident. The benefit
is payable for a maximum of 30 days for any one
accident
$300
$300
Plan Features






No waiting period
No pre-existing condition limitation
Unisex rates for ages 18 to 67
Provides benefits beginning with the first day
Coverage is fully portable


If you have family coverage, newborn children are
covered from birth provided they are added to the
policy within 31 days
Benefits are paid directly to the insured
All children are covered for one rate
This is a brief summary only. Certain restrictions and exclusions apply. For exact terms and conditions, please refer to
your summary plan description.
Rates are age banded and based on the l evel of benefi t el ected.
Benefit
Level 2
Level 4
Employee
18-50
51-67
$15.15
$17.05
$19.20
$21.10
Employee & Spouse
18-50
51-67
$30.30
$34.10
$38.40
$42.20
18
Employee & Children
18-50
51-67
$34.85
$36.75
$46.50
$48.40
Family
18-50
51-67
$50.00
$53.80
$65.70
$69.50
Vision
The Archdiocese partners with VSP for your vision benefits. Our Voluntary Vision program provides
comprehensive coverage for all of your routine vision needs. You pay the full cost of coverage
through pre-tax payroll deductions.
For more information, please refer to the benefit summary below.
Services
VSP Provider
Out-of-Network Provider
$15 copay
Up to $50
Exam (Every 12 months)
Prescription Glasses
Lenses and Covered Lens Options
(every 12 months)
Frame (every 24 months)
$35 copay
Single Vision, Lined Bifocals, Lined
Trifocals, Lenticular, photochromic
lenses, polycarbonate lenses for
dependent children, scratch
resistant coating, UV coating $130
allowance, 20% discount on
overage cost
Single Vision Up to $50
Bifocal: Up to $75
Trifocal: Up to $100
Lenticular: Up to $125
No allowance for lens options
Frame: Up to $70
Non Covered Lens Options
Fixed discounted copays. Saving
on average 35-40%.
n.a.
Contacts
(in lieu of glasses and every 12 months)
Contact Lens Fitting Exam
Contacts
Up to $60 maximum copay $130
allowance towards materials
Up to $105 towards fitting
exam and materials
20% discount on additional pair of
prescription glasses and nonprescription sunglasses
n.a.
Additional Discounts
Glasses
Corrective Laser Surgery
Discounts average 15% through a
VSP contracted laser surgery
center.
For more information contact VSP.
n.a.
This is a brief summary only. Certain restrictions and Exclusions apply. For exact terms and conditions please refer
to your VSP certificate of coverage.
Life & Disability Insurance
The Archdiocese offers Basic Life and Disability Income benefits as a package through Hartford Life.
This includes employee Life insurance and Accidental Death and Dismemberment (AD&D), spouse
and child(ren) Life Insurance and Short and Long Term Disability. These benefits must be purchased
as a package and are not available separately. The monthly cost for this package is based on your
salary as of January each year. You and your Employer share equally in the cost of the coverage. To
determine your cost for this package of benefits, complete the Basic Life and Disability worksheet on
page 19.
You are eligible for Life and Disability benefits if you are an active employee working a minimum of 30
hours per week, per school or calendar year (whichever is appropriate). Your spouse and dependent
children (from 15 days old to the end of the calendar year they turn 26) are eligible for Dependent Life
coverage. If you enroll within 31 days of your eligibility date, coverage is guarantee issue.
19
Life & Disability Insurance (cont’d)
Coverage is effective the date the enrollment form is signed
and dated by the employee during the eligibility period.
The Life & Disability package is not a part of the Archdiocese
Open Enrollment period; therefore if you waived participation
during your initial eligibility period, you must provide evidence
of insurability by completing a Personal Health Statement.
Basic Package
Benefit
Employee
Pays 50%
Employer
Pays 50%
Total Cost
Employee Life *
AD&D *
$20,000
$20,000
$0.90
$0.20
$0.90
$0.20
$1.80
$0.40
Dependent Life
Spouse
Child(ren)
$4,000
$2,000
$0.60
$0.60
$1.20
Short Term Disability
Benefit is 67% of weekly
income to a maximum benefit
th
of $500. Benefits begin the 7
day after sickness or accident
and are payable up to 13
weeks.
To calculate your monthly cost: Annual salary divided
by 52 = $______________ (weekly income not to
exceed $746.27) x 67% divided by 10 x $0.20 =
$_________ (total cost). Divide in half to determine
your cost. One-half is paid by your employer and onehalf is paid by you.
Long Term Disability
Benefit is 50% of monthly
income to a maximum benefit
of $3,000. Benefits begin after
13 weeks.
To calculate your monthly cost: Annual salary divided
by 12 = $______________ (monthly income not to
exceed $6,000) divided by 100 x $0.263 = $_________
(total cost). Divide in half to determine your cost. Onehalf is paid by your employer and one-half is paid by
you.
This is a brief summary only. Certain restrictions and Exclusions apply. For exact terms and conditions please refer to
Voluntary Supplemental Life Insurance
The Archdiocese offers a Voluntary Supplemental Life Insurance benefit that can be purchased at
your expense for you and your dependents. You will receive group rates and the premium is
conveniently deducted from your payroll. The cost is determined by the age of the employee and
spouse as of January of each calendar year or date of hire for a new employee. For benefit and rate
information, please see the table on page 20.
You are eligible to purchase additional life insurance if you participate in the Basic Life and Disability
package. If you enroll within 31 days of your date of hire no evidence of insurability is required.
Also, during our annual enrollment period you will be able to enroll or increase your enrollment by
$10,000 without having to provide evidence of insurability. Any amounts over the $10,000 will be
subject to approval by Hartford Life.
20
Voluntary Supplemental Life Insurance (cont’d)
Coverage
Employee Paid Benefit
Employee
$10,000 increments to $150,000 maximum
Spouse
$5,000 increments to $75,000 maximum, cannot exceed 50% of employee’s benefit
Children
Option 1 - $5,000 on each child; Option 2 - $10,000 on each child
Monthly Cost for Each $1,000 of Employee & Spouse Life Insurance Coverage
Age
<30
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75 +
Life
$0.06
$0.08
$0.10
$0.14
$0.23
$0.36
$0.56
$0.71
$1.27
$2.10
$3.70
Children
All children are covered for one monthly cost.
Option 1: $5,000 - $0.35; Option 2: $10,000 - $0.70
Issued through Kanawha I nsurance Company (a Humana Company)
Humana’s Secure Life Select is a voluntary individual non-participating whole life policy with
premiums payable to age 99. Secure Life Select provides guaranteed renewable protection that
cannot be reduced. The policy builds cash value which can be withdrawn at the policy’s surrender,
borrowed against as a loan, annuitized or used to purchase extended or reduced paid-up insurance.
Standalone policies for employees, spouse
and children (or grandchildren) may be
purchased. Employee purchase is not
required to purchase life insurance for your
spouse, child or grandchild. Secure Life
Select also provides a Facility Care
Acceleration Benefit. This is a monthly
benefit for nursing home, assisted living or
adult day care services.
Rates are age specific and will be calculated
at time of enrollment. For additional
information during open enrollment, please
contact Cool Creek at 913-745-4803.
21
Issued through Kanawha I nsurance Company (a Humana
Company)
Humana’s Voluntary Critical Illness is voluntary coverage that helps protect you, your family, and your
assets in the event of a critical illness. It offers specialized benefits to supplement other health
insurance when you and your family may be most vulnerable: during the working years. Benefit
payments can assist in covering a variety of expenses associated with a critical illness: out-of-pocket
medical care costs, home health care, travel to and from treatment facilities, rehabilitation, and other
expenses. Rates are age specific and will be calculated at time of enrollment.
Coverage Type
Voluntary Critical Illness is a group policy that includes coverage for
heart/stroke, cancer and other critical illnesses
Benefit Amount
Benefit amounts are available at various levels. You can choose:
 $5,000 to $50,000 for employees
You can also add coverage for your dependents:
 Spouse: $2,500 to $25,000. Spouse coverage benefit is equal to exactly half
of the employee’s coverage
 Child: $2,500 to $5,000 for each eligible child
Coverage for Vascular Conditions
Percent of benefit amount paid at initial diagnosis:
 Heart Attack
 Transplant as a result of heart failure
 Stroke
 Coronary artery bypass surgery as a result of coronary
artery disease
Coverage for Cancer Conditions
Percent of benefit amount paid at initial diagnosis:
 First diagnosis of internal cancer or malignant
melanoma
 Carcinoma in situ
100%
100%
100%
25%
100%
25%
Coverage for Other Critical
Illnesses
Percent benefit amount paid at initial diagnosis:
 Transplant other than heart
 End stage renal failure
 Loss of sight, speech, or hearing
 Coma
 Severe burns
 Permanent paralysis due to an accident
 Occupational HIV
Additional Included Benefits
Waiver of premium for disability: This waives an employee’s premium if he or
she becomes totally disabled for at least 180 days after the effective date of
coverage. For employees ages 18-55.
Benefit Recurrence: This provides an additional benefit for the same condition
if a covered participant is treatment-free for at least 12 months.
Health Screening: Benefit pays $150 per calendar year for covered health
screenings. There are 18 covered tests including mammograms, colonoscopies,
and stress tests.
100%
100%
100%
100%
100%
100%
100%
This is a brief summary only. Certain restrictions and exclusions apply. For exact terms and conditions, please refer to
22
Health Care and Dependent Care Flexible
Spending Accounts
What is a Flexible Spending Account (FSA)?
A Flexible Spending Account (FSA) is an account in which you set aside pre-tax dollars to pay for eligible
health care or dependent care expenses not covered by insurance. The annual amount you elect to
contribute to each account will be divided into equal amounts and deducted
from your paycheck pre-tax. You are eligible to participate in both the
Health Care Reimbursement account and the Dependent Care
Reimbursement Account if you work a minimum of 20 hours per week.
Health Care Accoun t: You may elect an amount up to $2,500 per plan
year to be used for medical, prescription drug, dental and vision expenses
for you and eligible dependents. Some eligible expenses include (but are
not limited to) the following:
Dependent Care Acco unt: You may elect an amount up to $5,000 per
plan year ($2,500 maximum per year if married and filing a separate tax
return) to be used for child day care or elder day care expenses for your
eligible dependents. Some eligible expenses include (but are not limited to)
the following:
Why Should I Participate?
By setting aside pre-tax dollars to pay for out-of-pocket expenses you would normally pay for using aftertax dollars, you are reducing your “taxable income” because it reduces the amount of federal, state and
FICA taxes you pay. This means more take-home pay for you!
How Does an FSA Work?
Your contributions are taken pre-tax and divided equally among your pay periods. Funds can be used for
expenses incurred from January 1st through March15th of the following year (a total of 14.5 months).
Federal tax laws require that your FSA operate on a “use it or lose it” basis meaning any unused funds in
the account at the end of the calendar year will be forfeited. You have until March 31st following the close
of the plan year to submit your claims and receipts for reimbursements from the prior plan year.
Additionally, the IRS imposes some rules and restrictions on the way you can use FSAs. Unused funds
left in the account(s) from the previous year that are not used to reimburse expenses incurred by the end
of the plan year are subject to the use-it-or-lose-it rule and are forfeited. For additional rules and
restrictions, please see Human Resources.
Can Orthodontia be reimbursed through your FSA ?
Orthodontia expenses can be reimbursed through your Flexible Spending Account (FSA), but the
reimbursement process governed by the Internal Revenue Service can be challenging to understand. In
short, your FSA reimbursement aligns with the payment/treatment schedule set up with your
orthodontist/dentist. Reimbursement can span as much as two years if the treatment time is that long.
Even if you pay for orthodontia in full prior to treatment, your reimbursement schedule will align with the
treatment months. Additional detailed information can be found on the Archdiocese Benergy site or you
may contact NueSynergy FSA Customer Service at 1-855-890-7238 or email at
[email protected].
23
Spending
Accounts
(cont’d)
Spending Accounts
(cont’d)
REIMBURSEMENTS – 2 OPTIONS


File a claim – complete the Claim for Reimbursement form and submit it with itemized receipts to our FSA
administrator, NueSynergy. Reimbursement for your expenses may be paid to you via check or direct
deposit.
Debit Card –Allows you to pay directly from your flexible spending account at the point of service,
eliminating the hassles associated with having to “pay twice.”
 By electing to use the debit card, you agree to save all invoices and receipts related to any
expense paid with the debit card. Upon request you must submit these documents for review
by NueSynergy. Failure to submit the requested documents will cause the expense to be
treated as a non-qualified expense and you will be required to remit payment to your employer.
 Note debit cards may no longer be used to purchase OTC medicines and drugs. You will need
to use another form of payment and file a claim for reimbursement.
Tips & Reminders
 Estimate your expenses and plan carefully so that you don’t leave a balance in your account at the end
of the year because the user-it-or-lose-it rule does apply to both the Health Care and Dependent Care
FSAs.
 Keep your receipts! Even if you use the debit card successfully, you may still be asked to submit a
receipt in order to comply with IRS regulations.
 Most over-the-counter medications are not eligible expenses. You can find a full list of eligible
expenses on NueSynergy website.
 Debit card will be mailed to your home in a plain white envelope labeled “Important Benefit Information”.
 You can’t use funds in your Health Care FSA to pay for Dependent Care expenses, and vice versa.
 You can use your Health Care FSA to purchase over-the-counter (OTC) medications as long as you
have a prescription.
 Some OTC items do not require prescriptions like insulin, diabetic supplies, band aids, and contact lens
solution.
PRE-TAX PREMIUM DEDUCTIONS
Premium deductions for the Archdiocese Health, Dental, Voluntary
Vision and Voluntary Accident plans may be deducted from your
paycheck on a pre-tax basis. By electing to participate in the Pre-Tax
Premium plan you may take advantage of tax savings. Please note
that your social security benefits may be affected due to the pre-tax
reduction in your salary. Benefits elected to be paid with pre-tax
premium may not be changed mid-year unless you experience a family
status change.
NueSynergy gives you access to your account status 24 hours a day, seven days a week, through an interactive voice
response system. Call (855) 890-7238, email [email protected] or visit the website at
www.NueSynergy.com
24
Contact Information
Archdiocese of Kansas City in Kansas, in partnership with the following vendors, strives to meet your
benefit needs. If you have any questions regarding your benefits, please visit
http://archkck.benergy.com and follow the login information below (Benergy can also be accessed
through the Human Resources page on the Archdiocese website at www.archkck.org) or contact
the corresponding vendor listed below. If you still have questions, please contact your local Benefits
Coordinator or the Human Resources office of the Archdiocese.
Benefit
Vendor Name
Customer Service
Health Care Plan
Blue Cross Blue Shield of Kansas
City
Medtrak Services
Medication Management
Tria Health
& Voluntary Critical Illness
Humana Specialty Benefits
Dental Plan
Delta Dental of Kansas
Vision Plan
VSP
Humana Specialty Benefits
NueSynergy
(855) 890-7238 or
[email protected]
www.NueSynergy.com
Benefits Enrollment
Assistance
Cool Creek
(913) 745-4803
(888) 495-9340 / (913) 642-4276
www.MyHealthToolkitKC.com
(800) 771-4648
www.medtrakservices.com
(888) 799-8742
www.triahealth.com
(877) 378-1505
www.humanaworkplacevoluntary.com/members
(800) 234-3375 / (316) 264-4511
www.deltadentalks.com
(800) 877-7195
www.vsp.com
(877) 378-1505
www.humanaworkplacevoluntary.com/members
The information in this Enrollment Guide is presented for illustrative purposes and is based on information
provided by the employer. The text contained in this Guide was taken from various summary plan descriptions
and benefit information. While every effort was taken to accurately report your benefits, discrepancies or errors
are always possible. In case of discrepancy between the Guide and the actual plan documents the actual plan
documents will prevail. All information is confidential, pursuant to the Health Insurance Portability and
Accountability Act of 1996. If you have any questions about your Guide, contact Human Resources.
25
Legal Notices
The Archdiocese of Kansas City in Kansas Benefit Program qualifies as a “church plan” as defined under IRS
Code 414(e). By meeting this definition, the Archdiocese Benefit Program is permanently exempt from
meeting certain requirements including, but not limited to, the Employee Retirement Income Security Act
(ERISA) and Consolidated Omnibus Budget Reconciliation Act (COBRA) regulations.
The Archdiocese offers continuation of benefits for employees either who terminate their employment or
otherwise lose eligibility for benefits. All members enrolled in the benefit plan who lose eligibility (employees,
spouses and dependent children) are eligible to receive benefits under the continuation provision.
Women’s Health and Cancer Rights Act
If you had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s
Health and Cancer Rights of 1998. For individuals receiving mastectomy-related benefits, coverage will be
provided in a manner determined in consultation with attending physician and the patient, for:
1. All stages of reconstruction of the breast on which the mastectomy was performed.
2. Surgery and reconstruction of the other breast to produce a symmetrical appearance;
3. Prostheses; and
4. Treatment of physical complications during all stages of the mastectomy, including lymphedemas.
These benefits will be provided subject to the same deductible, copays, and coinsurance applicable to other
medical and surgical benefits under the plan.
Mothers & Newborn Act
Group health plans and health insurance issuers generally may not, under Federal Law, restrict benefits for
any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours
following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law
generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from
discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans
and issuers may not, under Federal law require that a provider obtain authorization from the plan or the
insurance issuer for prescribing a length of stay not in excess of 48 hours or (96 hours).
26
Legal Notices
Medicaid and the Children’s Health Insurance Program (CHIP)
Offer Free or Low-Cost Health Coverage to Children and Families
If you or your children are eligible for Medicaid or CHIP and you are eligible for health coverage from your
employer, your State may have a premium assistance program that can help pay for coverage. These States
use funds from their Medicaid or CHIP programs to help people who are eligible for these programs, but also
have access to health insurance through their employer. If you or your children are not eligible for Medicaid or
CHIP, you will not be eligible for these premium assistance programs.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, you
can contact your State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your
dependents might be eligible for either of these programs, you can contact your State Medicaid or CHIP office
or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, you can ask the
State if it has a program that might help you pay the premiums for an employer-sponsored plan.
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or
CHIP, as well as eligible under your employer plan, your employer must permit you to enroll in your employer
plan if you are not already enrolled. This is called a “special enrollment” opportunity, and you must request
coverage within 60 days of being determined eligible for premium assistance. If you have questions
about enrolling in your employer plan, you can contact the Department of Labor electronically at
www.askebsa.dol.gov or by calling toll-free 1-866-444-EBSA (3272).
If you live in one of the following States, you may be eligible for assistance paying your employer
health plan premiums. The following list of States is current as of July 31, 2012. You should contact
your State for further information on eligibility –
Kansas – Medicaid
Missouri - Medicaid
Website: www.kdheks.gov/hcf/
Website: www.dss.mo.gov/mhd/participants/pages/hipp.htm
Phone: (800) 792-4884
Phone: (573) 751-2005
To see if any more States have added a premium assistance program since July 31, 2012, or for more
information on special enrollment rights, you can contact either:
U.S. Department of Labor
Employee Benefits Security Administration
www.dol.gov/ebsa
U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services
www.cms.hhs.gov
(866) 444-EBSA (3272)
(877) 264-2323, Ext. 61565
27
Legal Notices
Important Notice from Archdiocese of Kansas City in Kansas
About Your Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find it. This notice has information about your
current prescription drug coverage with Archdiocese of Kansas City in Kansas and about your options under
Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a
Medicare drug plan. If you are considering joining, you should compare your current coverage, including
which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription
drug coverage in your area. Information about where you can get help to make decisions about your
prescription drug coverage is at the end of this notice.
There are two important things you need to know about your current coverage and Medicare’s prescription
drug coverage:
1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this
coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or
PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of
coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.
2. Archdiocese of Kansas City in Kansas has determined that the prescription drug coverage offered by the
Archdiocese of Kansas City in Kansas Employee Health Care Plan is, on average for all plan participants,
expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore
considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this
coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.
__________________________________________________________________________
When Can You Join A Medicare Drug Plan?
th
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15 through
th
December 7 .
However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be
eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.
What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?
If you decide to join a Medicare drug plan, your current coverage with Archdiocese of Kansas City in Kansas will not be
affected. Archdiocese of Kansas City in Kansas Employee Health Care Plan will coordinate benefits with Part D
coverage. Please be advised that our group medical plan will be primary and the Medicare Part D plan will be secondary.
If you do decide to join a Medicare drug plan and drop your current Archdiocese of Kansas City in Kansas coverage, be
aware that you and your dependents may not be able to get this coverage back.
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?
You should also know that if you drop or lose your current coverage with Archdiocese of Kansas City in Kansas and don’t
join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a
penalty) to join a Medicare drug plan later.
If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by
at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For
example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher
than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have
Medicare prescription drug coverage. In addition, you may have to wait until the following November to join.
28
Legal Notices
For More Information About This Notice Or Your Current Prescription Drug Coverage…
Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will also get it before
the next period you can join a Medicare drug plan, and if this coverage through Archdiocese of Kansas City in Kansas
changes. You also may request a copy of this notice at any time.
For More Information About Your Options Under Medicare Prescription Drug Coverage…
More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You”
handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly
by Medicare drug plans.
For more information about Medicare prescription drug coverage:
 Visit www.medicare.gov
 Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare
& You” handbook for their telephone number) for personalized help
 Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For
information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-7721213 (TTY 1-800-325-0778).
Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare
drug plans, you may be required to provide a copy of this notice when you join to show
whether or not you have maintained creditable coverage and, therefore, whether or not you
are required to pay a higher premium (a penalty).
Name of Entity/Sender:
Contact--Position/Office:
Address:
Phone Number:
Archdiocese of Kansas City in Kansas
Kathleen Thomas
12615 Parallel Parkway
Kansas City KS 66109
913.647.0328
29
Legal Notices
The Archdiocese of Kansas City in Kansas Health Plan
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
Our Company’s Pledge to You
This notice is intended to inform you of the privacy practices followed by the Archdiocese of Kansas City in
Kansas Health Plan(the Plan) and the Plan’s legal obligations regarding your protected health information
under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The notice also explains the
privacy rights you and your family members have as participants of the Plan. It is effective on September 23,
2013.
The Plan often needs access to your protected health information in order to provide payment for health
services and perform plan administrative functions. We want to assure the participants covered under the Plan
that we comply with federal privacy laws and respect your right to privacy. The Archdiocese requires all
members of our workforce and third parties that are provided access to protected health information to comply
with the privacy practices outlined below.
Protected Health Information
Your protected health information is protected by the HIPAA Privacy Rule. Generally, protected health
information is information that identifies an individual created or received by a health care provider, health plan
or an employer on behalf of a group health plan that relates to physical or mental health conditions, provision
of health care, or payment for health care, whether past, present or future.
How We May Use Your Protected Health Information
Under the HIPAA Privacy Rule, we may use or disclose your protected health information for certain purposes
without your permission. This section describes the ways we can use and disclose your protected health
information.
Payment. We use or disclose your protected health information without your written authorization in order to
determine eligibility for benefits, seek reimbursement from a third party, or coordinate benefits with another
health plan under which you are covered. For example, a health care provider that provided treatment to you
will provide us with your health information. We use that information in order to determine whether those
services are eligible for payment under our group health plan.
Health Care Operations. We use and disclose your protected health information in order to perform plan
administration functions such as quality assurance activities, resolution of internal grievances, and evaluating
plan performance. For example, we review claims experience in order to understand participant utilization and
to make plan design changes that are intended to control health care costs.
However, we are prohibited from using or disclosing protected health information that is genetic information for
our underwriting purposes.
Treatment. Although the law allows use and disclosure of your protected health information for purposes of
treatment, as a health plan we generally do not need to disclose your information for treatment purposes.
30
Legal Notices
Your physician or health care provider is required to provide you with an explanation of how they use and
share your health information for purposes of treatment, payment, and health care operations.
As permitted or required by law. We may also use or disclose your protected health information without your
written authorization for other reasons as permitted by law. We are permitted by law to share information,
subject to certain requirements, in order to communicate information on health-related benefits or services that
may be of interest to you, respond to a court order, or provide information to further public health activities
(e.g., preventing the spread of disease) without your written authorization. We are also permitted to share
protected health information during a corporate restructuring such as a merger, sale, or acquisition. We will
also disclose health information about you when required by law, for example, in order to prevent serious harm
to you or others.
Pursuant to your Authorization. When required by law, we will ask for your written authorization before using
or disclosing your protected health information. Uses and disclosures not described in this notice will only be
made with your written authorization. Subject to some limited exceptions, your written authorization is required
for the sale of protected health information and for the use or disclosure of protected health information for
marketing purposes. If you choose to sign an authorization to disclose information, you can later revoke that
authorization to prevent any future uses or disclosures.
To Business Associates. We may enter into contracts with entities known as Business Associates that
provide services to or perform functions on behalf of the Plan. We may disclose protected health information to
Business Associates once they have agreed in writing to safeguard the protected health information. For
example, we may disclose your protected health information to a Business Associate to administer claims.
Business Associates are also required by law to protect protected health information.
To the Plan Sponsor. We may disclose protected health information to certain employees of the Archdiocese
for the purpose of administering the Plan. These employees will use or disclose the protected health
information only as necessary to perform plan administration functions or as otherwise required by HIPAA,
unless you have authorized additional disclosures. Your protected health information cannot be used for
employment purposes without your specific authorization.
Your Rights
Right to Inspect and Copy. In most cases, you have the right to inspect and copy the protected health
information we maintain about you. If you request copies, we will charge you a reasonable fee to cover the
costs of copying, mailing, or other expenses associated with your request. Your request to inspect or review
your health information must be submitted in writing to the person listed below. In some circumstances, we
may deny your request to inspect and copy your health information. To the extent your information is held in an
electronic health record, you may be able to receive the information in an electronic format.
Right to Amend. If you believe that information within your records is incorrect or if important information is
missing, you have the right to request that we correct the existing information or add the missing information.
Your request to amend your health information must be submitted in writing to the person listed below. In some
circumstances, we may deny your request to amend your health information. If we deny your request, you may
file a statement of disagreement with us for inclusion in any future disclosures of the disputed information.
Right to an Accounting of Disclosures. You have the right to receive an accounting of certain disclosures of
your protected health information. The accounting will not include disclosures that were made (1) for purposes
of treatment, payment or health care operations; (2) to you; (3) pursuant to your authorization; (4) to your
friends or family in your presence or because of an emergency; (5) for national security purposes; or (6)
incidental to otherwise permissible disclosures.
Your request to for an accounting must be submitted in writing to the person listed below. You may request
an accounting of disclosures made within the last six years. You may request one accounting free of charge
within a 12-month period.
31
Legal Notices
Right to Request Restrictions. You have the right to request that we not use or disclose information for
treatment, payment, or other administrative purposes except when specifically authorized by you, when
required by law, or in emergency circumstances. You also have the right to request that we limit the protected
health information that we disclose to someone involved in your care or the payment for your care, such as a
family member or friend. Your request for restrictions must be submitted in writing to the person listed below.
We will consider your request, but in most cases are not legally obligated to agree to those restrictions.
Right to Request Confidential Communications. You have the right to receive confidential communications
containing your health information. Your request for restrictions must be submitted in writing to the person
listed below. We are required to accommodate reasonable requests. For example, you may ask that we
contact you at your place of employment or send communications regarding treatment to an alternate address.
Right to be Notified of a Breach. You have the right to be notified in the event that we (or one of our
Business Associates) discover a breach of your unsecured protected health information. Notice of any such
breach will be made in accordance with federal requirements.
Right to Receive a Paper Copy of this Notice. If you have agreed to accept this notice electronically, you
also have a right to obtain a paper copy of this notice from us upon request. To obtain a paper copy of this
notice, please contact the person listed below.
Our Legal Responsibilities
We are required by law to maintain the privacy of your protected health information, provide you with this
notice about our legal duties and privacy practices with respect to protected health information and notify
affected individuals following a breach of unsecured protected health information.
We may change our policies at any time and reserve the right to make the change effective for all protective
health information that we maintain. In the event that we make a significant change in our policies, we will
provide you with a revised copy of this notice. You can also request a copy of our notice at any time. For more
information about our privacy practices, contact the person listed below.
If you have any questions or complaints, please contact:
Kathleen Thomas
The Archdiocese of Kansas City in Kansas
Kansas City, KS 66109
913.647.0328 or [email protected]
Complaints
If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about
access to your records, you may contact the person listed above. You also may send a written complaint to the
U.S. Department of Health and Human Services — Office of Civil Rights. The person listed above can provide
you with the appropriate address upon request or you may visit www.hhs.gov/ocr for further information. You
will not be penalized or retaliated against for filing a complaint with the Office of Civil Rights or with us.
32
Archdiocese of Kansas City in Kansas : PPO Plan
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Why this Matters:
Coverage Period: 01/01/2014 - 12/31/2014
Coverage for: Individual | Plan Type: 3 Tier PPO
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at
www.MyHealthToolkitKC.co m or by calling 1-888-495-9340.
Important Questions Answers
What is the overall
deductible?
The chart starting on page 2 describes any limits on what the plan will pay for
specific covered services, such as office visits.
The out-of-pocket limit is the most you could pay during a coverage period
(usually one year) for your share of the cost of covered services. This limit helps
you plan for health care expenses.
Even though you pay these expenses, they don’t count toward the
out-of-pocket limit.
Tier 1 $475 person/$950 family. In-Network $475 You must pay all the costs up to the deductible amount before this plan begins
to pay for covered services you use. Check your policy or plan document to see
person/$950 family. Out-of-Network $475
when the deductible starts over (usually, but not always, January 1st). See the
person/$950 family.
chart starting on page 2 for how much you pay for covered services after you
meet the deductible.
You don't have to meet deductibles for specific services, but see the chart
starting on page 2 for other costs for services this plan covers.
Are there other
No.
deductibles for specific
services?
Yes. Tier 1 $1,800 person/$3,600 family.
Is there an
In-Network $1,800 person/$3,600 family.
out– of– pocket limit
Out-of-Network $2,300 person/$4,100 family.
on my expenses?
What is not included in Per Admission Copayment, Per Occurrence
the out-of-pocket limit? Copayment, Premiums, balance-billed charges and
health care this plan doesn't cover.
Is there an overall
No.
annual limit on what the
plan pays?
Does this plan use a
network of
providers?
Do I need a referral to
see a specialist?
Yes.
No.
You can see the specialist you choose without permission from this plan.
Yes. See www.MyHealthToolkitKC.com or call If you use an in-network doctor or other health care provider, this plan will pay
1-800-810-BLUE (2583) for a list of participating some or all of the costs of covered services. Be aware, your in-network doctor
or hospital may use an out-of-network provider for some services. Plans use
providers.
the term in-network, preferred, or participating for providers in their network.
See the chart starting on page 2 for how this plan pays different kinds of
providers.
Are there services this
plan doesn’t cover?
Some of the services this plan doesn’t cover are listed in the Excluded Services
and Other Covered Services section. See your policy or plan document for
additional information about excluded services.
Questions: Call 1-888-495-9340 or visit us at www.MyHealthToolkitKC.com. If you aren’t clear about any of the bolded terms used in this form, see
the Glossary. You can view the Glossary at www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-888-495-9340 to request a copy.
NA AB20130925114916311842
Blue Cross and Blue Shield of Kansas City is an independent licensee of the Blue Cross and Blue Shield Association.
Page 1 of 10
33
Not Covered
Not Covered
Not Covered
Catholic
Hospitals
Your cost if you use
In-Network
Provider
$30 Copay per visit
40% Coinsurance
40% Coinsurance
$25 Copay per visit then 40% Coinsurance
20% Coinsurance
$30 Copay per visit
Out-of-Network
Provider
Chiropractic services are limited to
20 visits per benefit year.
Allergy injections, dialysis, x-rays,
surgeries and second surgical opinions
are covered with 20% Coinsurance in
an in-network physicians office. Tier 1
and in-network labs are covered with
No Charge.
Allergy injections, dialysis, x-rays,
surgeries and second surgical opinions
are covered with 20% Coinsurance in
an in-network physicians office. Tier 1
and in-network labs are covered with
No Charge.
Limitations & Exceptions
• Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
• Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the
plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you
haven’t met your deductible.
• The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed
amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed
amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
• This plan may encourage you to use in-network providers by charging you lower deductibles , copayments and coinsurance amounts.
Primary care visit to
treat an injury or illness
Common
Medical Event Services You May
Need
If you visit a
health care
provider’s office
or clinic
Specialist visit
Other practitioner office
visit
Page 2 of 10
34
Common
Need
Preventive care/
screening/immunization
Catholic
Hospitals
No Charge
No Charge
If you have a test Diagnostic test (x-ray, blood No Charge
work)
Imaging (CT/PET scans,
MRIs)
In-Network
Provider
No Charge
20% Coinsurance
20% Coinsurance
No Charge
Services are covered at No Charge to a
$500 max. Mammograms and
colonoscopies are not subject to the
max. After the max has been met tier 1
is covered at No Charge, tier 2 is
covered at 20% Coinsurance and outof-network is covered at 40%
Coinsurance. Some services not
available at tier 1. Labs are
covered at 40% Coinsurance for
out-of-network. Mammograms are
covered for age 40 and up.
Mammograms, PSAs, Paps and
colonoscopies covered annually.
40% Coinsurance
Tier 1 and in-network labs are
covered with No Charge.
Out-of-Network
Provider
40% Coinsurance
Pre-authorization is required.
Penalty for not obtaining
pre-authorization is denial of all
charges.
Page 3 of 10
35
Not Covered
Catholic
Hospitals
If you need drugs Generic drugs
to treat your
illness or
condition
Not Covered
Common
Need
More information Preferred brand drugs
about prescription
drug coverage is
available at
www.medtrakservic
es.com
Non-preferred brand drugs Not Covered
In-Network
Provider
Out-of-Network
Provider
No Charge
$90 Copay per visit then $90 Copay per visit then Copayment will be waived if
20% Coinsurance
40% Coinsurance
admitted.
20% Coinsurance
$50 Copay per visit then $50 Copay per visit then
20% Coinsurance
40% Coinsurance
––––––––––none–––––––––––
$7 copay per prescription $7 copay per prescription Prior authorization on select
(up to a 30-day supply); (up to a 30-day supply)
medications; formulary drug list.
$20 copay per
plus balance bill; $20
prescription (up to a 90- copay per prescription (up
day supply)
to a 90-day supply) plus
balance bill
The greater of $25 copay The greater of $25 copay Prior authorization on select
or 25% coinsurance per or 25% coinsurance per medications; formulary drug list.
prescription (30-day
supply); $60 copay per supply) plus balance bill;
prescription (up to 90-day $60 copay per prescription
supply)
(up to 90-day supply) plus
balance bill
The greater of $40 copay The greater of $40 copay Prior authorization on select
or 40% coinsurance per or 40% coinsurance per medications; formulary drug list.
supply); $100 copay per supply) plus balance bill;
prescription (up to 90-day $100 copay per
supply)
prescription (up to 90-day
supply) plus balance bill
20%
Coinsurance
20% Coinsurance
––––––––––none–––––––––––
If you need
Emergency room services
immediate
medical attention
––––––––––none–––––––––––
––––––––––none–––––––––––
$90 Copay per
visit
20% Coinsurance
40% Coinsurance
If you have
Facility fee (e.g.,
outpatient surgery ambulatory surgery center)
20%
Coinsurance
$30 Copay per visit
40% Coinsurance
Emergency medical
transportation
Not Covered
Physician/surgeon fees
Urgent care
Page 4 of 10
36
$120 Copay per admission Emergency admissions require a prethen 40% Coinsurance authorization within 48 hours of
admission. Pre-authorization is
required. Penalty for not
obtaining pre-authorization is a
$200 reduction.
$120 Copay per
admission then
20% Coinsurance
40% Coinsurance
Out-of-Network
Provider
20% Coinsurance
40% Coinsurance
In-Network
Provider
20%
Coinsurance
20% Coinsurance
Services that are rendered in an innetwork physicians office are covered
with a $30 Copay.
Catholic
Hospitals
No Charge
$120 Copay per
admission then
20% Coinsurance
Mental/Behavioral
health inpatient
services
No Charge
No Charge
20% Coinsurance
Common
Need
If you have a
hospital stay
No Charge
Facility fee (e.g., hospital
room)
Substance use
disorder outpatient
services
No Charge
$120 Copay per
admission then
20% Coinsurance
$120 Copay per admission Pre-authorization is required.
then 40% Coinsurance Penalty for not obtaining
pre-authorization is a $200
reduction.
––––––––––none–––––––––––
Substance use disorder
inpatient services
$30 Copay per visit
Physician/surgeon fee
Prenatal and postnatal care Not Covered
No Charge
reduction.
40% Coinsurance
Services that are rendered in an innetwork physicians office are covered
with a $30 Copay.
reduction.
40% Coinsurance
No additional copayment for
ongoing routine care.
If you have mental Mental/Behavioral
health, behavioral health outpatient
health, or
services
substance abuse
needs
If you are
pregnant
Delivery and all inpatient
services
$120 Copay per
admission then
20% Coinsurance
Page 5 of 10
37
Common
Need
20% Coinsurance
In-Network
Provider
Not Covered
20% Coinsurance
Catholic
Hospitals
No Charge
20% Coinsurance
If you need help Home health care
recovering or
have other special
health needs
Rehabilitation services
No Charge
No Charge
Out-of-Network
Provider
20% Coinsurance
40% Coinsurance
40% Coinsurance
––––––––––none–––––––––––
40% Coinsurance
pre-authorization is denial of all
charges.
The physicians charges for tier 1 and
40% Coinsurance
in-network providers are covered
with a $25 Copay and 20%
Coinsurance. Out-of-network
providers will be covered with 40%
Coinsurance.
The physicians charges for tier 1 and
40% Coinsurance
in-network providers are covered
with a $25 Copay and 20%
Coinsurance. Out-of-network
providers will be covered with 40%
Coinsurance.
$120 Copay per admission Skilled Nursing Care services are
then 40% Coinsurance limited to $50,000 per benefit year.
Pre-authorization is required. Penalty
for not obtaining pre-authorization is
a $200 reduction.
20% Coinsurance
$120 Copay per
admission then
20% Coinsurance
Habilitation services
Skilled nursing care
No Charge
Durable medical equipment Not Covered
Hospice service
pre-authorization for tier 1 inpatient
services and in-network inpatient
services is a $200 reduction. Penalty
for not obtaining pre-authorization
for out-of-network inpatient and all
outpatient services is denial of all
charges.
Page 6 of 10
38
Common
Need
See your Employer for benefit
details.
Not Covered
details.
Out-of-Network
Provider
Not Covered
Not Covered
details.
In-Network
Provider
Not Covered
Not Covered
Not Covered
Catholic
Hospitals
Glasses
Not Covered
Not Covered
If your child needs Eye exam
dental or eye care
Dental check-up
Not Covered
Excluded Services & Other Covered Services:
• Hearing Aids
• Routine Eye Care (Adult)
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
• Acupuncture
• Routine Eye Care (Child)
• Routine Foot Care
• Infertility Treatment
• Long-Term Care
• Cosmetic Surgery
• Dental Care (Adult)

Contraceptives, drugs and devices, maybe covered if medically necessary
for purposes other than contraception; Prior authorization required.
• Dental Care (Child)
• Non-emergency care when traveling outside the
U.S.
• Private-Duty Nursing, if part of pre-authorized
home health care
• Weight Loss Programs
Other Covered Services. (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these
services.)
• Bariatric Surgery
• Chiropractic Care
• Most coverage provided outside the U.S. See
www.MyHealthToolkitKC.com
Page 7 of 10
39
Your Rights to Continue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health
coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while
covered under the plan. Other limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at 1-888-495-9340. You may also contact your state insurance department, the U.S.
Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 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 any or all of the following:
• 1-888-495-9340 or visit us at www.MyHealthToolkitKC.com
Language Access Services:
To obtain assistance in your specific language, call the customer service number shown on the first page of this notice.
Spanish: Para obtener asistencia en español, llame al número de atención al cliente que aparece en la primera página de esta notificación.
Tagalog: Upang makakuha ng tulong sa Tagalog, tawagan ang numero ng customer service na makikita sa unang pahina ng paunawang ito.
Chinese:
Navajo:
–––––––––––––––––––––– To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––
Page 8 of 10
40
About these Coverage
Examples:
These examples show how this plan might
cover medical care in given situations. Use
these examples to see, in general, how much
financial protection a sample patient might
get if they are covered under different plans.
This is
not a cost
estimator.
Don’t use these examples to
estimate your actual costs under
this plan. The actual care you
receive will be different from
these examples, and the cost of
that care will also be different.
See the next page for important
information about these examples.
Having a baby
Managing type 2 diabetes
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
Total
$480
$210
$210
$2,930
$3,830
$2,900
$1,300
$700
$300
$100
$100
$5,400
Sample care costs:
Amount owed to providers: $5,400
Plan pays $1,570
Patient pays $3,830
(routine maintenance of
a well-controlled condition)
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
(normal delivery)
Amount owed to providers: $7,540
Plan pays $6,700
Patient pays $840
Sample care costs:
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive
Total
Patient pays:
Deductibles
$480
Copays
$150
Coinsurance
$40
Limits or exclusions
$170
Total
$840
These numbers assume the patient has given
notice of her pregnancy to the plan. If you are
pregnant and have not given notice of your
pregnancy, your costs may be higher. For more
information, please contact: 1-888-495-9340.
Page 9 of 10
41
What does a Coverage Example
show?
 Yes. When you look at the Summary of
Benefits and Coverage for other plans, you’ll
find the same Coverage Examples. When you
compare plans, check the “Patient Pays” box
in each example. The smaller that number, the
more coverage the plan provides.
Can I use Coverage Examples to
compare plans?
Does the Coverage Example predict
my own care needs?
 No. Treatments shown are just examples.
The care you would receive for this condition
could be different based on your doctor’s
advice, your age, how serious your condition
is, and many other factors.
 Yes. An important cost is the premium you
pay. Generally, the lower your premium, the
more you’ll pay in out-of-pocket costs, such
as copayments, deductibles, and
coinsurance. You should also consider
contributions to accounts such as health
savings accounts (HSAs), flexible spending
arrangements (FSAs) or health reimbursement
accounts (HRAs) that help you pay
out-of-pocket expenses.
Are there other costs I should
consider when comparing
plans?
For each treatment situation, the Coverage
Example helps you see how deductibles,
copayments, and coinsurance can add up. It
also helps you see what expenses might be left up
to you to pay because the service or treatment
isn’t covered or payment is limited.
Questions and answers about the Coverage Examples:
What are some of the assumptions
behind the Coverage Examples?
—
—
—
—
—
—
—
Costs don't include premiums.
Sample care costs are based on national
averages supplied by the U.S. Department
of Health and Human Services, and aren’t
specific to a particular geographic area or
health plan.
The patient’s condition was not an
excluded or preexisting condition.
All services and treatments started and
ended in the same coverage period.
There are no other medical expenses for
any member covered under this plan.
Out-of-pocket expenses are based only on
treating the condition in the example.
The patient received all care from
in-network providers. If the patient had
received care from out-of-network
providers, costs would have been higher.
Does the Coverage Example predict
my future expenses?
 No. Coverage Examples are not cost
estimators. You can’t use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your own
costs will be different depending on the care
you receive, the prices your providers charge,
and the reimbursement your health plan
allows.
Page 10 of 10
Questions: Call 1-888-495-9340 or visit us at www.MyHealthToolkitKC.com. If you aren’t clear about any of the bolded terms used in this form, see
the Glossary. You can view the Glossary at www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-888-495-9340 to request a copy.
NA AB20130925114916311842
42
ENROLLMENT
CITY
(PLEASE PRINT)
EMAIL ADDRESS
STATE
-
-
ZIP CODE
STATUS CHANGE / CHANGE OF COVERAGE
(Proof must be provided with completed form in order to document changes)
 Birth
 Adoption / Placement  Marriage
 Divorce
 Death  Last Name / Address
 Beneficiary Change
 Loss of other Coverage
 Termination of Employment – PROVIDE DATE
/
/
LAST NAME
M.I
SOCIAL SECURITY #
CELL PHONE
 New Enrollment
 Open Enrollment
 Waiver
 ‘Change of Status’ Change
 Transfer
EMPLOYEE FIRST NAME
HOME PHONE
STREET ADDRESS
WAIVE ALL COVERAGES
ACTION
SELF
LAST, FIRST & M.I.
 Health
 Vol Vision
 Supplemental Life
 Health
 Vol Vision
 Health
 Vol Vision
 Health
 Vol Vision
 Health
 Vol Vision
 Dental
 Basic Life/Disability
 Flexible Spending Acct
 Decline ALL
 Dental
 Basic Life
 Decline ALL
 Dental
 Basic Life
 Decline ALL
 Dental
 Basic Life
 Decline ALL
 Dental
 Basic Life
 Decline ALL
SPOUSE
EMPLOYEE
LOCATION
/
TODAY’S DATE
EMPLOYEE BENEFITS
ENROLLMENT / CHANGE FORM
/
DATE OF BIRTH
GENDER
HIRE DATE
 MALE
/
/
/
/
 FEMALE
MARITAL STATUS
EFFECTIVE DATE OF COVERAGE
 Single
/
/
 Married
AVERAGE HOURS /WEEK
ANNUAL SALARY
DATE OF BIRTH
-
-
-
-
-
 Male
 Female
 Male
 Female
 Male
 Female
 Male
 Female
/
/
/
/
/
/
/
/
SEE ABOVE
-
-
SEE
ABOVE
-
SEE ABOVE
FAMILY INFORMATION - COMPLETE THE FOLLOWING INFORMATION FOR EACH FAMLY MEMBER TO BE COVERED BY THE PLAN.
IF ADDITIONAL SPACE IS NEEDED, PLEASE ATTACH A SEPARATE PAGE WITH THE ADDITIONAL INFORMATION.
COVERAGE ELECTED
RELATIONSHIP
SOCIAL SECURITY #
GENDER
 By checking the box, I elect to waive participation in ALL of the following Archdiocese’s Benefit Plans – Health, Dental, Voluntary Vision, Flexible Spending Account, Basic Life and Disability and Voluntary Supplemental Life. I understand that if I waive
participation at this time that I will not have another opportunity to enroll except during the Archdiocese Open Enrollment. I also understand if I later wish to enroll in the LIFE insurance I may be required to furnish evidence of insurability before my
coverage will become effective. (PLEASE BE SURE TO SIGN AND DATE LAST PAGE OF THIS FORM.)
 New
 Terminate
 Change
 New
 Terminate
 Change
 New
 Terminate
 Change
 New
 Terminate
 Change
 New
 Terminate
 Change
Termination Date:
Continued on next page
PREEXISTING CONDITIONS - PRIOR COVERAGE
Your Employer’s group contract imposes a preexisting condition waiting period for members age 19 or older. This exclusion applies to conditions for which medical advice, diagnosis, care or treatment was recommended or received within the six-month period
prior to enrolling in the health plan and the exclusion may last up to 12 months. The exclusion does not apply to pregnancy nor to a child who is enrolled in the Plan within 30 days after birth, adoption or placement for adoption. Your Employer’s group contract will
provide credit for preexisting conditions if you were previously covered under creditable coverage. The period of any preexisting condition exclusion that would otherwise apply to a person will be reduced by the number of days of creditable coverage the person
has as of the enrollment date. In order to receive credit towards the preexisting condition exclusion period, you must provide copies of the Certificates of the Creditable Coverage or other acceptable proof of coverage from the prior plan(s) or the following
information for the verification of prior creditable medical coverage you or any listed dependents currently have, or previously had, including continuation of coverage. Should you need additional information or assistance regarding any preexisting condition
exclusion, contact the Blue Cross Blue Shield of Kansas City Customer Services Department at (888) 495-9340 (for the Kansas City area (913) 642-4276).
Insurance Company Name:
Name as Listed on Policy:
Name(s) of Person Covered in Prior Plan:
Effective Date:
REVISED 10.01.2013 / Page 1
43
OTHER INSURANCE COVERAGE / MEDICARE
Are you, or any other person listed above, covered by any other MEDICAL, DENTAL OR MEDICARE plan?  NO  YES
Name and Address of Insurance Company:
Policy #:
Member Name:
DENTAL – Delta Dental of Kansas
(Employee & Employer share the Cost)
 EMPLOYEE ONLY
 FAMILY
 WAIVE – Do Not elect Coverage
VOLUNTARY VISION – VSP
(Employee pays 100% of Cost)
If YES,  Medical  Dental  Medicare AND complete the following:
HEALTH – Blue Cross Blue Shield of Kansas City & MedTrak
(Employee & Employer share the Cost)
 EMPLOYEE ONLY
 FAMILY
(First & M.I.)
(Relationship)
(Address)
(Relationship)
(Address)
LONG TERM DISABILITY BENEFIT
Benefit is 50% of monthly income to a maximum benefit of $3,000. Benefits begin after 13 weeks.
(Last Name)
1.
(First & M.I.)
1.
2.
(Last Name)
2.
(First & M.I.)
(Relationship)
Please see page 3 for Basic Life and Disability Package PREMIUM CALCULATION.
A beneficiary may be changed by completing this change request form. The beneficiary for life insurance on the lives of your spouse or children will automatically be you, if surviving, otherwise your estate, subject to the policy provisions.
(Address)
LIFE/AD&D BENEFICIARY APPLIES TO BASIC LIFE. BENEFICIARY DESIGNATIONS MUST BE COMPLETED. PROVIDE A COMPLETE ADDRESS IF DIFFERENT THAN EMPLOYEE’S. 2
PRIMARY BENEFICIARY
CONTINGENT BENEFICIARY
BASIC LIFE & AD&D BENEFIT
Employee Basic Life - $20,000
Employee Basic AD&D - $20,000
Spouse Life $4,000
Dependent Child $2,000
BASIC LIFE and DISABILITY PACKAGE - Hartford Life (Employee pays 50% of Cost) 1
By checking one of the boxes below, I elect to participate in the Archdiocese’s BASIC LIFE and DISABILITY Package. Below is an outline of the benefits provided through this package.
SHORT TERM DISABILITY BENEFIT
 EMPLOYEE ONLY
Benefit is 67% of weekly income to a maximum benefit of $500. Benefits begin the 8th day after sickness or accident and are payable for 13 weeks
 FAMILY
1.
(Last Name)
FLEXIBLE SPENDING ACCOUNT / PRE-TAX PREMIUM DEDUCTIONS – NueSynergy (Employee pays 100% of Cost)
 HEALTH CARE ACCOUNT
 DEPENDENT CARE ACCOUNT
 Debit Card Option
Direct Deposit
 Pre-Tax Premium Deductions
By checking the box above, I elect to participate in the Archdiocese’s
$____________________ Annual Election
$____________________ Annual Election
 One card – Must
Authorization
Premium Only Plan for benefits made available under Section 125 of the
Payroll Frequency
Payroll Frequency
provide email address
 Enroll
Internal Revenue Code. I hereby authorize the contributions for MEDICAL,
(Cost of $12 annually plus $2
Be sure to complete the
 Monthly (12/year)
 Monthly (12/year)
DENTAL, VOLUNTARY VISION, VOLUNTARY ACCIDENT and/or
setup fee for card)
Direct Deposit
 Semi-monthly (24/year)
 Semi-monthly (24/year)
FLEXIBLE SPENDINGACCOUNT(S) to be deducted from my paycheck for
Authorization form.
 Bi-weekly (26/year)
 Bi-weekly (26/year)
the coverage selected including any additional deductions due to an

Additional
Card
increase in a selected program’s cost during the plan year. I understand
 Other: _______________________
 Other: _______________________
(Cost of $2 annually)
that I may NOT change my elections during the plan year except as
$____________________ Per Pay Period
$____________________ Per Pay Period
Name on card
allowed by the plan for a “Change in Family Status”, following IRS
____________________
guidelines. I understand that by participating in the plan, my social security

benefits may be affected because certain elections will be deducted before
my salary is taxed. I understand that it is my responsibility to report to the
 WAIVE – Do NOT
 WAIVE – Do NOT
plan any changes in eligibility of my dependents or myself.
elect Debit Card
enroll in Direct
Deposit
 WAIVE – I do Not elect Pre-Tax Premium Deductions
BENEFICIARY DESIGNATION APPLIES TO THE FLEXIBLE SPENDING ACCOUNT. IF ELECTING TO PARTICIPATE, BENEFICIARY DESIGNATION MUST BE COMPLETED.
 EMPLOYEE ONLY
 FAMILY
Family Members Covered:
2
1
44
1
BASIC LIFE and DISABILITY PACKAGE (continued from page 2)
EMPLOYEE BASIC AD&D
EMPLOYEE BASIC LIFE
Coverage
$1.20 per covered SPOUSE & ALL listed dependent CHILDREN
$20,000 x $0.02 / $1,000
$20,000 x $0.09 / $1,000
Cost per Unit
$
$1.20
$0.40
$1.80
Monthly Cost
$
$
$0.60
$0.20
$0.90
EMPLOYEE COST
(MONTHLY COST divided by 2)
(Monthly salary is calculated by dividing your annual salary by 12.)
Premium Calculation: Basic Package (Includes BASIC LIFE & AD&D, SHORT TERM (WEEKLY) AND LONG TERM DISABILITY (Employee pays 50% of Cost)
Salary: Weekly $ _______________________________
Monthly $ _______________________________
SPOUSE and/or DEPENDENT CHILD LIFE
WEEKLY Salary $ ___________________(not to exceed $746.27) x .67 / 10 x $0.20
$
(As of September 1 or Date of Hire for new employees) (Weekly salary is calculated by dividing your annual salary by 52)
SHORT TERM (WEEKLY) DISABILITY
MONTHLY Salary $ __________________ (not to exceed $6,000)/ 100 x $0.263
$
LONG TERM DISABILITY
Total Monthly Cost $
VOLUNTARY SUPPLEMENTAL LIFE – Hartford Life (Employee pays 100% of Cost) EMPLOYEE MUST ENROLL IN THE BASIC LIFE and DISABILITY PACKAGE IN ORDER TO ELECT VOLUNTARY LIFE
(First & M.I.)
(Relationship)
(Address)
(Last Name)
(First & M.I.)
(Relationship)
(Address)
75 and over
$3.70
 EMPLOYEE LIFE $____________________ (available in $10,000 increments, $150,000 max)
 SPOUSE LIFE $ _____________________ (available in $5,000 increments, $75,000 max or 50% of EMPLOYEE’S amount whichever is less)
 DEPENDENT CHILD(REN) - Option 1 ($5,000 on each child) *
 DEPENDENT CHILD(REN) - Option 2 ($10,000 on each child) *
* May pick only ONE coverage option for ALL dependent children
LIFE/AD&D BENEFICIARY APPLIES TO VOLUNTARY LIFE. BENEFICIARY DESIGNATIONS MUST BE COMPLETED. PROVIDE A COMPLETE ADDRESS IF DIFFERENT THAN EMPLOYEE’S. 1
PRIMARY BENEFICIARY
CONTINGENT BENEFICIARY
 SAME AS BASIC LIFE & AD&D (if different, please complete sections below)
 SAME AS BASIC LIFE & AD&D (if different, please complete sections below)
1.
(Last Name)
1.
2.
Monthly Cost
70 – 74
$2.10
Cost per Unit
$
65 – 69
$1.27
Coverage
$ _____________________ (Amount elected above) / $1,000 x $ ________ (Employee’s age rate as above)
$
Premium Calculation: VOLUNTARY LIFE INSURANCE (Employee pays 100% of Cost)
35 – 39
40 – 44
45 – 49
50 – 54
55 – 59
60 – 64
$0.10
$0.14
$0.23
$0.36
$0.56
$0.71
2.
30 – 34
$0.08
EMPLOYEE
$ _____________________ (Amount elected above) / $1,000 x $ ________ (Spouse’s age rate as above)
$
Under 30
$0.06
SPOUSE
Option 1 or 2 as elected above. Option 1 $0.35 or Option 2 $0.70
Rates based on Age as
of Sep 1 of this year
DEPENDENT CHILD(REN)
Total Monthly Payroll Deduction $
A beneficiary may be changed by completing this change request form. The beneficiary for life insurance on the lives of your spouse or children will automatically be you, if surviving, otherwise your estate, subject to the policy provisions.
45
COVERAGE / CHANGE OF COVERAGE / AUTHORIZATION TO RELEASE INFORMATION
By signing this form, I am applying for covered services for which my family and I are eligible and I authorize my employer to deduct from my earnings any required contributions.
I agree on behalf of myself and those family members enrolled (“Dependents”), for whom I have the authority to enroll and to consent on their behalf (collectively my Dependents and I shall be referred to as my “Enrolled Family”),
that Archdiocese of Kansas City in Kansas or their authorized representatives (collectively referred to as “Health Plan”) may use or disclose to third parties the information contained on this enrollment form and individually identifiable
health information relating to my Enrolled Family for purposes of administering my insurance benefits, including for treatment, payment or health care operations, as those terms are explained in detail in Health Plan’s Notice of
Privacy Practices and to the extent permitted by law.
I understand, if I waive any of the LIFE insurance coverages offered to me, that if I desire to apply for these coverages at a later date, I may be required to furnish, at my own expense, medical evidence in support of insurability that
is satisfactory with the current insurance carrier, before my coverage will become effective.
Date
EMPLOYER Signature
Print EMPLOYER Name
End of form
I represent the information to be complete and accurate to the best of my knowledge. I understand that my answers will be used to determine my eligibility for coverage. I further understand that if any material is omitted or
misrepresented, it could provide a basis to refuse / rescind coverage and to refund any premiums paid as though coverage had never been in force.
EMPLOYEE Signature
Print EMPLOYEE Name
EMPLOYEE Instructions
Please be sure to complete the EMPLOYEE BENEFITS ENROLLMENT / CHANGE FORM in its entirety and return within the requested timeframe. Also be sure to retain a copy for your personal files.
EMPLOYER Instructions
Please retain one for the EMPLOYEE’s personnel file. The original copy should be forwarded to the Archdiocese of Kansas City in Kansas Human Resource office.
46
47
Archdiocese of Kansas City in Kansas
Kansas City, KS 66109

2014? - Archdiocese of Kansas City in Kansas

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