2016-Employee-Benefit-Guide - Archdiocese of Kansas City in Kansas

Transcription

Archdiocese of Kansas City
Employee Benefits Enrollment Guide
Plan Year: 2016
Section
Page
2016 Guide to Benefits
2
Effects of Health Care Reform
4
What’s Changing for 2016?
5
Enrollment Instructions
6
Archdiocese Online Benefits Portal
9
Cost to Participate
10
Health Benefits
11
Prescription Drug Benefits
12
Medication Management – Tria Health
13
Alere Oncology Case Management
15
Naturally Slim
16
Telemedicine through Teledoc
17
Dental Insurance
18
Vision Insurance
19
Life/Disability Benefits
20
Hartford Value Added Services
22
Voluntary Supplemental Life Insurance
24
Voluntary Whole Life Insurance
25
Voluntary Accident Insurance
26
Voluntary Critical Illness
27
Flexible Spending Accounts
28
Contact Information
30
Legal Notices
31
Summary of Benefits and Coverage (Health Plan)
36
Enrollment/Application Forms
Archdiocese Enrollment Form
45
1
Welcome to the Archdiocese of Kansas City
in Kansas’ 2016 guide to employee benefits!
2016 Open Enrollment Information
This year OPEN ENROLLMENT begins on October 19th and ends on October 31st. Elections
you make during open enrollment will become effective January 1, 2016.
2016 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 2016. Please read it carefully for important
information you will need in order to make decisions about your benefit elections.
2
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
calendar 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 6.
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 19th and ends October 31st,
2015. During this period you may elect, change or waive coverage in the
health, dental or vision plans. Open Enrollment is the only opportunity you
have to enroll in the Humana voluntary worksite plans. All employees are
encouraged 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.
Employees who elect to pay for their benefits on a post-tax basis, may
discontinue their elections at anytime. Should you choose to re-enroll, you
may be subject to HIPAA Special Enrollment guidelines or furnish Evidence of
Insurability.
3
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 36 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.
4
What’s Changing for
2016?
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 and their families. 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. And we hope you are pleased
with the generous benefits package the Archdiocese continues to provide to your total
compensation. Below is a brief description of the changes taking place:
 Employee Premiums – No changes to employee contributions for 2016 on the Medical,
Dental or Vision plans.
 Medical and Prescription Drug Plan – The plan will renew with BlueKC with no benefit
plan changes for 2016. We are pleased to announce the addition of a number of
benefits available to those employees enrolled in the medical plan. Naturally Slim, Alere
Oncology Case Management and Teledoc. These are available at no additional cost.
More details can be found on pages 15-17 of this benefit guide.
 Dental Plan – The plan will renew with Delta Dental with no benefit plan changes for
2016.
 Vision Plan – The plan will renew with VSP with no benefit plan changes for 2016.
 Life and Disability – The Basic Life and Long Term Disability insurance will continue as
a shared voluntary plan paid 50% by the employee and 50% by the employer, but the
plan will have a slight reduction in premium and it will be for Basic Life/AD&D, Basic
Dependent Life and Long Term Disability insurance only.
 Short Term Disability – Short term disability insurance will be provided to all
Archdiocesan employees who are eligible for benefits at NO COST to the employee.
The cost of this insurance will be shared by the employer and the Archdiocese
5
Open Enrollment Instructions
You will be passively enrolled for 2016 in your current benefits with the exception of the Flexible Spending Accounts.
It is recommended that you login to review your 2016 elections but it is not required for the 2016 plan year if you are
not planning on making any benefit changes. There are instances where we recommend that you login. These are:
a. You would like to enroll in either the Health Care or Dependent Care Flexible Spending Account for the 2016
calendar year
b. You would like to update your beneficiary designations for either the Basic Life/AD&D or Voluntary
Supplemental Life
c. You would like to add, change or drop a benefit plan for 2016.
There are two ways to start the enrollment process:
1. 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.
2. Or you can go directly to HBC via https://www.devpb.com/demo
The OPEN ENROLLMENT tab or the above HBC link will direct you to the HBC login page that looks like
this:
Note: Be sure the Compatibility
icon is blue if using Microsoft
Internet 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:
6
Open Enrollment Instructions (cont’d)
Start by clicking the green “Start” button.
This will take you through the steps to update your personal information. 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.
Continue through the enrollment system by clicking the green arrows. Pay close attention to your beneficiary
designations. 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 the green arrow to continue. A summary of the benefits you are
currently enrolled in will appear.
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 will appear one-by-one as you go through the enrollment system. You will be asked to
“DECLINE COVERAGE” 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 or call Bill Defoor at Primebyte
directly at 913-406-2101.
7
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 Long Term 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. Your next opportunity to enroll will be at the Open Enrollment period in October
2016.
Voluntary Whole Life (Secure Life)
8
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
Human Resources Center
•
Find relevant and timely company news and communications
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
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
9
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
Short Term Disability
Archdiocese & Employer
Basic Life & Long Term 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
2016 Premium Deductions
The premiums for the Health, Dental and Vision plans will remain unchanged for 2016. Your employer will
pay 60% of your cost to participate in the Health and Dental plans. The chart below shows your share of
the 2016 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
2016 Employee
Contribution
2016 Employer
Contribution
Total Cost
$263.68
$556.36
$395.53
$834.54
$659.21
$1,390.90
$16.98
$40.13
$25.47
$60.20
$42.45
$100.33
$9.26
$25.56
n.a.
n.a.
$9.26
$25.56
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 and are eligible for benefits, 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.
10
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.
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, Couple to Couple and Marquette Method. The Archdiocese will
cover 100% up to a maximum of $400 per year. Please contact the Archdiocese Human Resource office in order to
submit a claim for benefits.
11
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 manage prescription drug costs in the future, we will continue to offer
cost-saving programs in our Plan. MedTrak will continue to notify eligible
members 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 Performance 90 retail
network. You may fill your long-term medications at a local retail pharmacy like Walgreens, Target, Wal-Mart 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
Mail Order (90-day supply)
Generic
Brand Formulary
Brand 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
$20 Copay
$60 Copay
$100 Copay
For exact terms and conditions, please refer to the Medtrak summary available online
through Benergy.
12
Medication Management Program
Available to all health plan participants.
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
-
month
The medication dosage is too low or too high and
isn’t effectively treating your condition
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
on medications that are used primarily to treat chronic conditions.
Eligible individuals will receive an
enrollment packet in the mail. This will
include an enrollment form and
envelope for you to send back to Tria
Health.
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:
Affordable Med
Details:
Saves you and money by identifying less expensive, effective alternatives for
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
13
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
14
Support for cancer patients and their caregivers
Did you know that in the United States a cancer diagnosis is made every 23 seconds? A diagnosis of
cancer often brings feelings of fear and uncertainty. Many difficult decisions need to be made and it can
be overwhelming. Knowing what to expect physically and emotionally during the course of treatment helps
cancer patients and their caregivers cope during a difficult
time.
For those enrolled in the Archdiocese Health Plan, the
Alere Oncology Case Management program gives you
access to specially trained nurses in the specific area of
cancer care you need. Alere is an independent company
that provides cancer advocacy services on behalf of your
health plan.
The program’s expert nursing staff will provide support
and assistance that can help you:
•
•
•
•
•
•
Learn about your specific diagnosis
Learn more about the treatment plan your doctor has prescribed
Learn to control or minimize the side effects of treatments
Prepare for visits to the doctor
Receive help in identifying and connecting to support services
Get help with navigating the health care system.
If you or a family member have been diagnosed with cancer, get connected to the resources of the
oncology case management program.
1.855.814.5077
15
Lose Weight the Right Way
with Naturally Slim®
There are many possible paths to weight loss, but they don’t all lead to a healthier life. There’s the crash
diet before swimsuit season. There’s the starvation diet before your high school reunion. There are
complicated regimens of weigh-ins and calorie-counting. Naturally Slim is a different kind of program.
Naturally Slim Inc. is an independent company that provides a wellness program on behalf of your health
plan.
It involves mindful eating — which lets you enjoy foods, think about why you’re hungry, and focus more on
how you eat than what you eat. Most importantly, it has helped many people reduce their risk for an
increasingly common condition called metabolic syndrome.
Do you already have metabolic syndrome?
You might, if you have at least three of these risk factors:
• High blood pressure
• Low HDL (good cholesterol)
• High triglycerides
• High blood sugar
• Large waist circumference
With metabolic syndrome, you are:
•
•
•
700 percent more likely to get diabetes
300 percent more likely to get heart disease
200 percent more likely to have a stroke
With 10 hour-long, self-paced videos, Naturally Slim is an online program that helps people lose weight for
the right reasons: to avoid the costs of these serious diseases and live healthier, happier lives. Some 87
percent of participants lose weight, with an average 10-week loss of 10.1 pounds. The program teaches
mindful eating and behavior modification techniques that can reduce health risks, take pounds off and
keep them off.
Do you think you might qualify for the Naturally Slim program? Contact the Archdiocese Human
Resources department to learn more.
16
Telemedicine
For those enrolled in the Health Plan, the Archdiocese of Kansas City
in Kansas is providing you and your enrolled dependents with an
added medical benefit beginning January 1, 2016. Teladoc allows
you to talk to a doctor anytime, anywhere by phone consult. It’s an
affordable, convenient option for treating many medical conditions.
There’s no need to wait for your Teladoc ID card. On January 1st,
you can set up your account and request a consult. Once you
are set up, a Teledoc doctor is always just a call or click away.
Set up your account (after January 1st)
Request a consult
1. Visit Teledoc.com and click “Set up
account”
Once your account is set up, a doctor is
always just a call or click away
2. Select “No” when asked for username.
Then provide your name and date of
birth
1. Visit the Teledoc website and click
“Request a consult”
3. Follow the directions online to
complete account set-up and to
provide your medical history
2. Select the type of consult you want
3. Talk to a doctor within an hour *
* With your consent, Teledoc will provide information about your consult to your primary care physician.
WHEN CAN I USE TELEDOC?
GET THE CARE YOU NEED
Teledoc does not replace your
primary care physician. It is a
convenient and affordable
option for quality care.
Teledoc doctors can treat
many medical conditions,
including:
•
•
•
•
When you need care now
If you are considering the
ER or urgent care center
for a non-emergency issue
On vacation, on a
business trip, or away from
home
For short-term prescription
refills
•
•
•
•
•
•
•
Cold & flu symptoms
Allergies
Bronchitis
Urinary tract infection
Respiratory infection
Sinus problems
And more!
MEET OUR DOCTORS
Teledoc is simply a new way
to access qualified doctors.
All Teledoc doctors:
•
•
•
•
Are practicing PCPs,
pediatricians, and family
medicine physicians
Average 15 years
experience
Are U.S. board-certified
and licensed in your state
Are credentialed every
three years meeting
NCQA standards
17
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).
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
For exact terms and conditions, please refer to your summary plan description.
18
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
Exam (Every 12 months)
Prescription Glasses
Lenses and Covered Lens Options
(every 12 months)
Frame (every 24 months)
VSP Provider
Out-of-Network Provider
$15 copay
Up to $50
$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.
19
New Employer-paid Benefit
Short Term Disability
A disability can occur at any time. If the disability is severe
enough, it will prevent the person from being able to work and
provide for their family. Food, mortgage payments, and other
monthly bills cannot be paid without a steady income. Disability
insurance provides some income replacement should you
become disabled and unable to work due to a non-work related
injury or illness.
The Archdiocese and your employer provide short term disability
insurance at no cost to you and eligible employees are
automatically enrolled.
Maternity leave (though not a sickness) does qualify for short term disability benefits.
Please contact your local benefit administrator for more information on filing a claim.
Company Paid Short Term Disability
Premiums are paid by
The Archdiocese and your employer
Elimination Period
Accidents: You must be unable to work for 7 days due to a qualified disability in
order to be eligible for benefits. Benefits may begin on the eighth day of
disability
Sickness: You must be unable to work for 7 days due to a qualified disability in
order to be eligible for benefits. Benefits may begin on the eighth day of
disability
Benefit Amount Payout
The benefit amount is 67% of your pre-disability earnings up to a maximum of
$500 per week.
Taxable Benefit
Yes
Benefit Duration
Benefits may be payable for up to 13 weeks.
For exact terms and conditions please refer to your summary plan description.
20
Life & Long Term Disability Insurance
The Archdiocese offers Basic Life and Long Term 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 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 Long
Term Disability worksheet below.
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.
Coverage is effective the date the enrollment form is signed
and dated by the employee during the eligibility period.
If you waived participation in the Basic Life and Long Term
Disability package during your initial eligibility period, you
must provide evidence of insurability by completing a
Personal Health Statement and be approved by the Hartford
for coverage.
Basic Package
Benefit
Employee
Pays 50%
Employer
Pays 50%
Total Cost
Employee Life *
AD&D *
$20,000
$20,000
$0.88
$0.10
$0.88
$0.10
$1.76
$0.20
Dependent Life
Spouse
Child(ren)
$4,000
$2,000
$0.588
$0.588
$1.176
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
$0.241 = $_________ (total cost). Divide in half to
determine your cost. One-half is paid by your
employer and one-half is paid by you.
For exact terms and conditions please refer to your summary plan description.
21
Hartford Life Value-Added Services
These services are available for those employees participating in the Basic Life and Long Term Disability
package.
Ability Assist Counseling Services
Available Services
Emotional or work-life
counseling
Helps address stress, relationship or other personal issues you or your family
members may face. It’s staffed by GuidanceExperts℠ – highly trained master’s
and doctoral level clinicians – who listen to concerns and quickly make referrals to
in-person counseling or other valuable resources. Situations may include:
• Job pressures
• Relationship/marital conflicts
• Stress, anxiety and depression • Work/school disagreements
• Substance abuse
• Child and elder care referral services
Financial information
and resources
Provides support for the complicated financial decisions you or your family
members may face. Speak by phone with a Certified Public Accountant and
Certified Financial Planners on a wide range of financial issues. Topics may
include:
• Managing a budget • Retirement
• Saving for college
• Getting out of debt • Tax questions
Legal support and
resources
Offers assistance if legal uncertainties arise. Talk to an attorney by phone about
the issues that are important to you or your family members. If you require
representation, you’ll be referred to a qualified attorney in your area with a 25%
reduction in customary legal fees thereafter. Topics may include:
• Debt and bankruptcy • Guardianship
• Divorce
HealthChampion Health care support service
If you become disabled from an accident or are diagnosed with a critical illness, your first priority should be
focusing on your treatment and recovery. What you don’t need is more stress about your care options, medical
benefits, co-pays and other expenses.
To help, there’s ComPsych® HealthChampion℠ – a
service that helps take some of the burden off your
shoulders. No matter what kind of health plan you have
- whether a self-funded plan or a public or private health
care exchange - the HealthChampion program can:
•
•
•
Guide you through health care options
Connect you with the right resources
Advocate for timely and fair resolution of issues
How does it work? HealthChampion specialists walk
you through all aspects of your health care issue.
Helping to ensure that you’re fully supported with employee
assistance programs and/or work-life services.
22
Hartford Life Value-Added Services (cont’d)
Travel Assistance and ID Theft Protection Services
The best laid travel plans can go awry, leaving you vulnerable and, possibly, unable to communicate
your needs. When the unexpected happens far from home, it’s important to know whom to call for
assistance.
If you are covered under a Hartford Group Policy, you and your
family have access to Travel Assistance Services provided by
Europ Assistance USA. With a local presence in 200 countries
and territories around the world, and numerous 24/7 assistance
centers, they are available to help you anytime, anywhere.
Identity theft, America’s fast growing crime, victimizes almost 10
million American consumers each year. Europ Assistance USA
helps protect you and your family from its consequences 24/7, at
home and when you travel.
In addition to prevention education, this service provides advice
and help with administrative tasks resulting from identity theft.
Estate Guidance Will Services
As a covered employee under a Hartford Group Life insurance policy, you have access to
EstateGuidance® Will Services provided by ComPsych®. It helps you create a simple, legally binding
will quickly and conveniently online, saving you the time and expense of a private legal consultation.
Other advantages include:
• Online assistance from licensed attorneys should you have questions.
• The ability to save drafts for up to six months. During this period, you can revise your will at no
cost, as long as you haven’t already printed or downloaded it.
• Additional estate planning services are also available for purchase, including the creation of
living wills and trusts, guidance about divorce
Beneficiary Assist Counseling Services
Beneficiary Assist provides you, your eligible beneficiaries and immediate family members with
unlimited 24/7 phone access to help related to the death of yourself or a loved one. That includes:
• Legal advice, financial planning and emotional counseling for up to one year from the date the
claim is filed.
• Up to five face-to-face sessions or equivalent professional time for one service or a
combination.
Funeral Planning and Concierge Services
The death of a loved one is one of life’s most stressful situations. Quick, often costly decisions must
be made while emotions are at their peak. Yet, how many people know how to plan a funeral?
That’s why your employer offers a funeral planning and concierge service through The Hartford’s
Group Life insurance program— provided by Everest the first to offer this service nationwide.
23
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 below.
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 and your spouse’s by $5,000 without having to provide evidence of insurability. Any
amounts over the $10,000 will be subject to approval by Hartford Life.
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
24
Available During Open Enrollment Only
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.
25
I ss ued t h r o ugh K an a w h a I n su ran c e C o m p an y (a H u man a C o mp an y )
Humana’s Accident Plus provides off-the-job coverage for accidental injuries, ambulance, and 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
For exact terms and conditions, please refer to your benefit booklet from Humana
Rates are age banded and based on the level of benefit elected.
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
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
26
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%
For exact terms and conditions, please refer to your benefit booklet from Humana
27
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:
• Medical or Dental Deductibles and Coinsurance
• Office Visit and Prescription Drug Copays
• Eyeglasses and Contact Lenses
• Hearing Aides
Dependent Care A ccount: 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:
• Adult Day Care for Seniors
• Child Daycare
• Before and/or After School Care
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 March 15th 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.
28
Health
and
Dependent
Care
Flexible
HealthCare
Care
and
Dependent
Care
Flexible
Spending
SpendingAccounts
Accounts(cont’d)
(cont’d)
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 (855) 890-7239 or email at [email protected].
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.
A debit card fee of $12 per year will be deducted from your account at the beginning of the calendar year.
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) 890-7239, email [email protected] or visit the website at
www.NueSynergy.com
29
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
Health Care Plan
Blue Cross Blue Shield of Kansas
City
Medtrak Services
Medication Management
Tria Health
Cancer Care Advocacy
Alere Oncology Management
Telemedicine
Teledoc
Dental Plan
Delta Dental of Kansas
Vision Plan
VSP
Hartford Life Value Added
Services
Hartford Life
Voluntary Accident Insurance &
Humana Specialty Benefits
NueSynergy
Enrollment Assistance
(only available during Open
Enrollment)
Primebyte
Archdiocese Human Resources
Customer Service
(888) 495-9340
www.MyHealthToolkitKC.com
(800) 771-4648
www.medtrakservices.com
(888) 799-8742
www.triahealth.com
(855) 814-5077
(800) TELADOC (835-2362)
www.teladoc.com
(800) 234-3375 / (316) 264-4511
www.deltadentalks.com
(800) 877-7195
www.vsp.com
(800) 96-HELPS
www.thehartford.com/employeebenefits
(877) 378-1505
www.humanaworkplacevoluntary.com/members
(855) 890-7239 or
[email protected]
www.NueSynergy.com
Bill Defoor
(913) 406-2101
Mark Defoor
(913) 832-0072
Art Walsh
[email protected]
(913) 647-0362
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.
30
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).
HIPAA Privacy Notice
The Archdiocese of Kansas City in Kansas Health Care Plan is required by law to take reasonable steps to
ensure the privacy of your personally identifiable health information and to inform you about the uses of
protected health information (PHI) and your privacy rights. PHI use and disclosure by the Archdiocese Health
Care Plan is regulated by federal law known as HIPAA (the Health Insurance Portability and Accountability
Act). A copy of this notice will be included in the Blue Cross Blue Shield of Kansas City Health Care Summary
Plan Description.
31
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’re eligible for health coverage from your employer, your
state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP
programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance
programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more
information, visit www.healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, 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, 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, ask your state if it has a program that might help you
pay the premiums for an employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your
employer plan, your employer must allow you to enroll in your employer plan if you aren’t 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, contact the Department of Labor
at www.askebsa.dol.gov or call 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, 2015. Contact your State for more information on
eligibility –
ALABAMA – Medicaid
Website: www.myalhipp.com
Phone: 1-855-692-5447
ALASKA – Medicaid
Website: http://health.hss.state.ak.us/dpa/programs/medicaid/
Phone (Outside of Anchorage): 1-888-318-8890
Phone (Anchorage): 907-269-6529
COLORADO – Medicaid
Medicaid Website: http://www.colorado.gov/hcpf
Medicaid Customer Contact Center: 1-800-221-3943
FLORIDA – Medicaid
Website: https://www.flmedicaidtplrecovery.com/
Phone: 1-877-357-3268
KENTUCKY – Medicaid
Website: http://chfs.ky.gov/dms/default.htm
Phone: 1-800-635-2570
LOUISIANA – Medicaid
Website: http://www.lahipp.dhh.louisiana.gov
Phone: 1-888-695-2447
GEORGIA – Medicaid
Website: http://dch.georgia.gov/
- Click on Programs, then Medicaid, then Health Insurance Premium Payment
(HIPP)
Phone: 1-800-869-1150
INDIANA – Medicaid
Website: http://www.in.gov/fssa
Phone: 1-800-889-9949
IOWA – Medicaid
Website: www.dhs.state.ia.us/hipp/
Phone: 1-888-346-9562
KANSAS – Medicaid
Website: http://www.kdheks.gov/hcf/
Phone: 1-800-792-4884
NEW HAMPSHIRE – Medicaid
Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf
Phone: 603-271-5218
NEW JERSEY – Medicaid and CHIP
Medicaid Website:
http://www.state.nj.us/humanservices/dmahs/clients/medicaid/
Medicaid Phone: 609-631-2392
CHIP Website: http://www.njfamilycare.org/index.html
CHIP Phone: 1-800-701-0710
NEW YORK – Medicaid
MAINE – Medicaid
Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html
Phone: 1-800-977-6740
TTY 1-800-977-6741
MASSACHUSETTS – Medicaid and CHIP
Website: http://www.nyhealth.gov/health_care/medicaid/
Phone: 1-800-541-2831
Website: http://www.mass.gov/MassHealth
Phone: 1-800-462-1120
Website: http://www.ncdhhs.gov/dma
Phone: 919-855-4100
NORTH CAROLINA – Medicaid
32
Legal Notices
MINNESOTA – Medicaid
NORTH DAKOTA – Medicaid
Website: http://www.dhs.state.mn.us/id_006254
Click on Health Care, then Medical Assistance
Phone: 1-800-657-3739
Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/
Phone: 1-800-755-2604
MISSOURI – Medicaid
Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm
Phone: 573-751-2005
OKLAHOMA – Medicaid and CHIP
Website: http://www.insureoklahoma.org
Phone: 1-888-365-3742
MONTANA – Medicaid
OREGON – Medicaid
Website: http://www.oregonhealthykids.gov
http://www.hijossaludablesoregon.gov
Website: http://medicaid.mt.gov/member
Phone: 1-800-694-3084
Phone: 1-800-699-9075
NEBRASKA – Medicaid
Website: www.ACCESSNebraska.ne.gov
Phone: 1-855-632-7633
NEVADA – Medicaid
Medicaid Website: http://dwss.nv.gov/
Medicaid Phone: 1-800-992-0900
SOUTH CAROLINA – Medicaid
PENNSYLVANIA – Medicaid
Website: http://www.dpw.state.pa.us/hipp
Phone: 1-800-692-7462
RHODE ISLAND – Medicaid
Website: www.ohhs.ri.gov
Phone: 401-462-5300
VIRGINIA – Medicaid and CHIP
Medicaid
Website: http://www.coverva.org/programs_premium_assistance.cfm
Medicaid Phone: 1-800-432-5924
CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm
CHIP Phone: 1-855-242-8282
WASHINGTON – Medicaid
Website: http://www.scdhhs.gov
Phone: 1-888-549-0820
SOUTH DAKOTA - Medicaid
Website: http://dss.sd.gov
Phone: 1-888-828-0059
TEXAS – Medicaid
Website: http://www.hca.wa.gov/medicaid/premiumpymt/pages/ index.aspx
Phone: 1-800-562-3022 ext. 15473
WEST VIRGINIA – Medicaid
Website: https://www.gethipptexas.com/
Phone: 1-800-440-0493
Website: www.dhhr.wv.gov/bms/
Phone: 1-877-598-5820, HMS Third Party Liability
UTAH – Medicaid and CHIP
WISCONSIN – Medicaid and CHIP
Website:
https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm
Phone: 1-800-362-3002
Website: Medicaid: http://health.utah.gov/medicaid
CHIP: http://health.utah.gov/chip
Phone: 1-866-435-7414
VERMONT– Medicaid
WYOMING – Medicaid
Website: http://www.greenmountaincare.org/
Phone: 1-800-250-8427
Website: http://health.wyo.gov/healthcarefin/equalitycare
Phone: 307-777-7531
To see if any other states have added a premium assistance program since July 31, 2015, or for more information
on special enrollment rights, contact either:
U.S. Department of Labor
Employee Benefits Security Administration
www.dol.gov/ebsa
1-866-444-EBSA (3272)
U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services
www.cms.hhs.gov
1-877-267-2323, Menu Option 4, Ext. 61565
OMB Control Number 1210-0137 (expires 10/31/2016)
33
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.
34
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).
Date:
Name of Entity/Sender:
Contact--Position/Office:
Address:
Phone Number:
October 1, 2015
Archdiocese of Kansas City in Kansas
Kathleen Thomas
12615 Parallel Parkway
Kansas City KS 66109
913.647.0328
35
Archdiocese of Kansas City in Kansas: PPO Plan
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2016 - 12/31/2016
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.com or by calling 1-888-495-9340 (for prescription drug coverage questions, contact MedTrak at 1-800-771-4648)
Important Questions Answers
What is the overall
deductible?
Tier 1 $475 person/$950 family. In-Network $475
person/$950 family. Out-of-Network $475
person/$950 family. Doesn't apply to preventive
care.
Are there
other deductibles for
specific services?
Is there an out–of–
pocket limit on my
expenses?
What is not included in
the out-of-pocket limit?
No.
Yes. Tier 1 $1,800 person/$3,600 family. InNetwork $1,800 person/$3,600 family.
Out-of-Network $2,300 person/$4,100 family.
Per Admission Copayment, Per Occurrence
Copayment, Premiums, balance-billed charges and
health care this plan doesn't cover.
No.
Why this Matters:
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
when the deductible starts over (usually, but not always, January 1st). See the
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.
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.
Is there an overall
annual limit on what the
plan pays?
Does this plan use
Yes. See www.MyHealthToolkitKC.com or call
a network of providers? 1-800-810-BLUE (2583) for a list of participating
medical providers. To find a participating
pharmacy near you, log on
to www.medtrakservices.com or call 1-800-7714648.
Do I need a referral to
No.
see a specialist?
The chart starting on page 2 describes any limits on what the plan will pay for
specific covered services, such as office visits.
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.
Yes.
If you use an in-network doctor or other health care provider, this plan will pay
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
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.
You can see the specialist you choose without permission from this plan.
Questions: Call BlueKC 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.
Blue Cross and Blue Shield of Kansas City is an independent licensee of the Blue Cross and Blue Shield Association.
NA AR20141117103613682778
Page 1 of 9
• 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.
Common
Medical Event Services You May Need
If you visit a
health care
provider’s office
or clinic
Your cost if you use
Tier 1
In-Network
Provider
Out-of-Network Limitations & Exceptions
Provider
Primary care visit to treat an injury or
illness
Not Covered
$30 Copay per visit 40% Coinsurance
Allergy injections, dialysis,
surgeries, x-rays, and second
surgical opinions are covered
with 20% Coinsurance
In-Network. Tier 1 and
In-Network labs are covered at
No Charge. Tier 1 x-rays are not
covered.
Specialist visit
Not Covered
Allergy injections, dialysis,
surgeries, x-rays, and second
surgical opinions are covered
with 20% Coinsurance
In-Network. Tier 1 and
No Charge. Tier 1 x-rays are not
covered.
Other practitioner office visit
Not Covered
then 20%
Coinsurance
Chiropractic services are limited
to 20 visits per benefit year.
Page 2 of 9
Common
Tier 1
Preventive care/screening/immunization No Charge
If you have a test Diagnostic test (x-ray, blood work)
Imaging (CT/PET scans, MRIs)
If you need drugs Generic drugs (Retail)
to treat your
illness or
condition
Generic drugs (Mail Order)
More information
about prescription
drug coverage is
Preferred brand drugs (Retail)
available at
www.medtrakservic
es.com
In-Network
Provider
Provider
No Charge
No Charge
Preventive care services are
limited to $500 per benefit year,
excluding mammograms and
colonoscopies. Once the $500 is
met, services are covered at No
Charge Tier 1, 20% Coinsurance
In-Network, and 40%
Coinsurance Out-of-Network.
Mammograms and colonoscopies
are covered at No Charge and are
each limited to one per benefit
year.
No Charge
20% Coinsurance
40% Coinsurance
No Charge.
No Charge
No Charge
40% Coinsurance
Pre-authorization is required.
Penalty for not obtaining
pre-authorization is denial of all
charges.
Not Covered
$7 Copay per
$7 Copay per
Prior authorizations on select
prescription (up to prescription (up to a medications; formulary drug list
30-day supply) plus
a 30-day supply)
balance bill
Not Covered
$20 Copay per
$20 Copay per
prescription up to a prescription up to a
90-day supply)
90-day supply) plus
balance bill
The greater of $25 The greater of $25
copay or 25%
copay or 25%
coinsurance per
coinsurance per
prescription (30prescription (30-day
day supply)
supply) plus balance
bill
Not Covered
medications; formulary drug list
Page 3 of 9
Common
Tier 1
Preferred brand drugs (Mail Order)
Not Covered
Non-preferred brand drugs (Retail)
Not Covered
Non-preferred brand drugs (Mail Order) Not Covered
Specialty drugs
If you have
Facility fee (e.g., ambulatory surgery
outpatient surgery center)
Physician/surgeon fees
If you need
Emergency room services
immediate
medical attention
If you have a
hospital stay
In-Network
Provider
Provider
$60 copay per
$60 copay per
prescription (up to prescription (up to medications; formulary drug list
90-day supply)
90-day supply) plus
balance bill
The greater of $40 The greater of $40 Prior authorizations on select
copay or 40%
copay or 40%
coinsurance per
coinsurance per
prescription (30prescription (30-day
day supply)
supply) plus balance
bill
$100 copay per
$100 copay per
prescription (up to prescription (up to
90-day supply)
90-day supply) plus
balance bill
Not Covered
Coverage based on Coverage based on
tier level above
tier level above
No Charge
$50 Copay per visit $50 Copay per visit ––––––––––none–––––––––––
then 20%
then 40%
Coinsurance
Coinsurance
20% Coinsurance
20% Coinsurance
40% Coinsurance
––––––––––none–––––––––––
$90 Copay per visit $90 Copay per visit $90 Copay per visit Copayment will be waived if
then 20%
then 40%
admitted.
Coinsurance
Coinsurance
Emergency medical transportation
20% Coinsurance
20% Coinsurance
20% Coinsurance
––––––––––none–––––––––––
Urgent care
Not Covered
––––––––––none–––––––––––
Facility fee (e.g., hospital room)
No Charge
$120 Copay per
admission then
20% Coinsurance
$120 Copay per
admission then 40% Penalty for not obtaining preCoinsurance
authorization is $200.
Page 4 of 9
Common
Tier 1
In-Network
Provider
Provider
20% Coinsurance
20% Coinsurance
40% Coinsurance
––––––––––none–––––––––––
No Charge
20% Coinsurance
40% Coinsurance
In-Network office visits are
covered with a $30 Copay. Tier 1
office visits are not covered.
No Charge
$120 Copay per
admission then
20% Coinsurance
No Charge
20% Coinsurance
Substance use disorder inpatient services No Charge
$120 Copay per
admission then
20% Coinsurance
$120 Copay per
40% Coinsurance
In-Network office visits are
covered with a $30 Copay. Tier 1
office visits are not covered.
$120 Copay per
admission then 40% Penalty for not obtaining preauthorization is $200.
Coinsurance
Prenatal and postnatal care
Not Covered
Delivery and all inpatient services
No Charge
$120 Copay per
admission then
20% Coinsurance
$120 Copay per
Not Covered
20% Coinsurance
40% Coinsurance
No Charge
20% Coinsurance
Habilitation services
No Charge
20% Coinsurance
Skilled nursing care
No Charge
Durable medical equipment
Not Covered
$120 Copay per
admission then
20% Coinsurance
20% Coinsurance
Physician/surgeon fee
If you have
Mental/Behavioral health outpatient
mental health,
services
behavioral health,
or substance
Mental/Behavioral health inpatient
abuse needs
services
Substance use disorder outpatient
services
If you are
pregnant
If you need help Home health care
recovering or
have other special
health needs
Rehabilitation services
No additional copayment for
ongoing routine care.
pre-authorization is denial of all
charges.
Tier 1 and In-Network office
40% Coinsurance
visits are covered with a $25
Copay then 20% Coinsurance.
Tier 1 and In-Network office
40% Coinsurance
visits are covered with a $25
Copay then 20% Coinsurance.
$120 Copay per
admission then 40% Penalty for not obtaining preauthorization is $200.
Coinsurance
40% Coinsurance
––––––––––none–––––––––––
Page 5 of 9
Common
Tier 1
Hospice service
In-Network
Provider
Provider
pre-authorization is $200 for
In-Network inpatient services
and denial of all charges for
In-Network outpatient and all
Out-of-Network services.
See your Employer for benefit
details.
No Charge
20% Coinsurance
40% Coinsurance
Not Covered
Not Covered
Not Covered
Glasses
Not Covered
Not Covered
Not Covered
details.
Dental check-up
Not Covered
Not Covered
Not Covered
details.
If your child needs Eye exam
dental or eye care
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
• Acupuncture
• Hearing Aids
• Routine Eye Care (Adult)
• Cosmetic Surgery
• Infertility Treatment
• Routine Eye Care (Child)
• Dental Care (Adult)
• Long-Term Care
• Routine Foot Care
• Dental Care (Child)
• Prescription Drugs
• 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
• Non-emergency care when traveling outside the
U.S.
• Private-Duty Nursing, if part of pre-authorized
home health care
Page 6 of 9
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 7 of 9
Managing type 2 diabetes
Having a baby
(normal delivery)
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.
Amount owed to providers:
Plan pays $6,740
Patient pays $800
(routine maintenance of
a well-controlled condition)
Amount owed to providers:
Plan pays $1,570
Patient pays $3,830
$7,540
Sample care costs:
Sample care costs:
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive
Total
$5,400
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
Patient pays:
Deductibles
$480
Copays
$150
Coinsurance
$0
Limits or exclusions
$170
Total
$800
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.
Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
Total
$2,900
$1,300
$700
$300
$100
$100
$5,400
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$480
$210
$210
$2,930
$3,830
Page 8 of 9
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.
What does a Coverage Example
show?
Can I use Coverage Examples to
compare 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.
P Yes. When you look at the Summary of
Does the Coverage Example predict
my own care needs?
No. Treatments shown are just examples.
OThe
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.
Does the Coverage Example predict
my future expenses?
O 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.
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.
Are there other costs I should
consider when comparing
plans?
P 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.
Questions: Call BlueKC 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.
Page 9 of 9
NA AR20141117103613682778
Page 10 of
(PLEASE PRINT)
ENROLLMENT
 New Enrollment
 Open Enrollment
 Waiver
 ‘Change of Status’ Change
 Transfer
EMPLOYEE FIRST NAME
HOME PHONE
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
STREET ADDRESS
-
EMAIL ADDRESS
CITY
STATE
ZIP CODE
LOCATION
EMPLOYEE BENEFITS
ENROLLMENT / CHANGE FORM
TODAY’S DATE
/
/
DATE OF BIRTH
GENDER
HIRE DATE
 MALE
/
/
 FEMALE
MARITAL STATUS
EFFECTIVE DATE OF COVERAGE
 Single
/
/
 Married
AVERAGE HOURS /WEEK
ANNUAL SALARY
/
/
WAIVE ALL COVERAGES
 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 Long Term 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.)
ACTION
 New
 Terminate
 Change
LAST, FIRST & M.I.
SELF
 New
 Terminate
 Change
 New
 Terminate
 Change
 New
 Terminate
 Change
 New
 Terminate
 Change
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
 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
EMPLOYEE
SPOUSE
SEE ABOVE
SEE
ABOVE
DATE OF BIRTH
SEE ABOVE
-
-
 Male
 Female
/
/
-
-
 Male
 Female
/
/
-
-
 Male
 Female
/
/
-
-
 Male
 Female
/
/
PREEXISTING CONDITIONS - PRIOR COVERAGE
Your Employer’s group contract imposes a preexisting condition waiting period for members age 19 and 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 09.18.2015/Page 1
Termination Date:
Continued on next page
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:
If YES,  Medical  Dental  Medicare AND complete the following:
Policy #:
Member Name:
Family Members Covered:
HEALTH – Blue Cross Blue Shield of Kansas City & MedTrak
(Employee & Employer share the Cost)
DENTAL – Delta Dental of Kansas
(Employee & Employer share the Cost)
VOLUNTARY VISION – VSP
(Employee pays 100% of Cost)
 EMPLOYEE ONLY
 FAMILY
 WAIVE – Do Not elect Coverage
 EMPLOYEE ONLY
 FAMILY
 EMPLOYEE ONLY
 FAMILY
FLEXIBLE SPENDING ACCOUNT / PRE-TAX PREMIUM DEDUCTIONS – NueSynergy (Employee pays 100% of Cost)
 HEALTH CARE ACCOUNT
 DEPENDENT CARE ACCOUNT
Debit Card Option
Direct Deposit
$____________________ Annual Election
$____________________ Annual Election  One card – Must
Authorization
 Enroll
Payroll Frequency
Payroll Frequency
provide email address
(Cost of $12 annually plus $2
Be sure to complete
 Monthly (12/year)
 Monthly (12/year)
setup fee for card)
the Direct Deposit
 Semi-monthly (24/year)
 Semi-monthly (24/year)
Authorization form.
 Bi-weekly (26/year)
 Bi-weekly (26/year)
 Additional Card
 Other: _______________________
 Other: _______________________
(Cost of $2 annually)
$____________________ Per Pay Period
$____________________ Per Pay Period
Name on card
____________________
(Last Name)
 WAIVE – Do NOT
elect Debit Card
 WAIVE – Do NOT
enroll in Direct
Deposit
 Pre-Tax Premium Deductions
By checking the box above, I elect to participate in the Archdiocese’s
Premium Only Plan for benefits made available under Section 125 of the
Internal Revenue Code. I hereby authorize the contributions for MEDICAL,
DENTAL, VOLUNTARY VISION, VOLUNTARY ACCIDENT and/or
FLEXIBLE SPENDINGACCOUNT(S) to be deducted from my paycheck for
the coverage selected including any additional deductions due to an
increase in a selected program’s cost during the plan year. I understand
that I may NOT change my elections during the plan year except as
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
plan any changes in eligibility of my dependents or myself.
 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.
(First & M.I.)
(Relationship)
(Address)
1.
BASIC LIFE and LONG TERM 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.
BASIC LIFE & AD&D BENEFIT
LONG TERM DISABILITY BENEFIT
 EMPLOYEE ONLY
Employee Basic Life - $20,000
Benefit is 50% of monthly income to a maximum benefit of $3,000. Benefits begin after 13 weeks.
 FAMILY
Employee Basic AD&D - $20,000
Spouse Life $4,000
Dependent Child $2,000
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
(Last Name)
1
2
(First & M.I.)
(Relationship)
(Address)
(Last Name)
1.
1.
2.
2.
(First & M.I.)
(Relationship)
(Address)
Please see page 3 for Basic Life and Long Term 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.
BASIC LIFE and LONG TERM DISABILITY PACKAGE (continued from page 2)
Premium Calculation: Basic Package (Includes BASIC LIFE & AD&D AND LONG TERM DISABILITY (Employee pays 50% of Cost)
Salary: Weekly $ _______________________________
Monthly $ _______________________________
(As of September 1 or Date of Hire for new employees) (Weekly salary is calculated by dividing your annual salary by 52)
(Monthly salary is calculated by dividing your annual salary by 12.)
Coverage
Cost per Unit
Monthly Cost
EMPLOYEE COST
(MONTHLY COST divided by 2)
EMPLOYEE BASIC LIFE
$20,000 x $0.088 / $1,000
$1.76
$0.88
EMPLOYEE BASIC AD&D
$20,000 x $0.01 / $1,000
$0.20
$0.10
SPOUSE and/or DEPENDENT CHILD LIFE
$1.176 per covered SPOUSE & ALL listed eligible dependent CHILDREN
$1.176
$0.588
LONG TERM DISABILITY
MONTHLY Salary $ __________________ (not to exceed $6,000)/ 100 x $0.241
$
$
Total Monthly Cost $
$
VOLUNTARY SUPPLEMENTAL LIFE – Hartford Life (Employee pays 100% of Cost) EMPLOYEE MUST ENROLL IN THE BASIC LIFE and LONG TERM DISABILITY PACKAGE IN ORDER TO ELECT VOLUNTARY LIFE
 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)
(Last Name)
(First & M.I.)
(Relationship)
(Address)
(Last Name)
1.
1.
2.
2.
Rates based on Age as
of Jan 1 of this year
Under 30
$0.06
30 – 34
$0.08
(First & M.I.)
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
(Relationship)
(Address)
65 – 69
$1.27
70 – 74
$2.10
Coverage
Cost per Unit
Monthly Cost
EMPLOYEE
$ _____________________ (Amount elected above) / $1,000 x $ ________ (Employee’s age rate as above)
$
SPOUSE
$ _____________________ (Amount elected above) / $1,000 x $ ________ (Spouse’s age rate as above)
$
DEPENDENT CHILD(REN)
Option 1 or 2 as elected above. Option 1 $0.35 or Option 2 $0.70
$
75 and over
$3.70
Total Monthly Payroll Deduction $
1
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.
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.
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
Date
EMPLOYER Signature
Print EMPLOYER Name
EMPLOYEE Instructions
Please be sure to complete the EMPLOYEE BENEFITS ENROLLMENT / CHANGE FORM in its entirety and return within the requested timeframe to your EMPLOYER. Also be sure to retain a copy for your personal files.
EMPLOYER Instructions
Please retain a copy for the EMPLOYEE’s personnel file. The original copy should be forwarded to the Archdiocese of Kansas City in Kansas Human Resource office.
End of form
Archdiocese of Kansas City in Kansas
12615 Parallel Parkway
Kansas City, KS 66109

2016-Employee-Benefit-Guide - Archdiocese of Kansas City in Kansas

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