Your Benefits · Act. A paper copy is also availablecontact the Payroll . Please Department to ......

Effective November 1, 2019 Through December 31, 2019

Your Benefits

SEBB Open Enrollment will be Oct 1 - Nov 15, 2019 for benefit

coverage beginning Jan 1, 2020. More information will be

provided by SEBB in late Sept 2019.

Prepared by Gallagher for the Employees of South Kitsap School District 1

WELCOME TO YOUR BENEFITS!

South Kitsap School District is proud to offer a robust benefits package to our employees and their families! Our benefits package is designed around choice, flexibility and value.

To learn about the available plans and choose which ones are right for your lifestyle and budget, take a look at this Benefits Guide. Highlights of all the plans and some additional decision-making tools are available online too. If you have general questions on your benefits or how to enroll, reach out to the Payroll Department—their contact info is toward the back of this Guide under “Your Benefits Contacts.”

In addition, a Summary of Benefits and Coverage (SBC) is available at www.skschools.org (Staff Resources/Benefit Information) to help you make your healthcare coverage choices. The SBC summarizes information about your medical plan options and is in a standard format required by the Affordable Care Act. A paper copy is also available. Please contact the Payroll Department to request a copy.

When Open Enrollment is finalized, we’ll make detailed carrier booklets available to you. But for now, please refer to this guide and online resources.

WHAT’S INSIDE

New Hire Enrollment Overview ................................................................................................................................................................... 2 Open Enrollment Overview ......................................................................................................................................................................... 3 2019-2020 Plan Design Changes ............................................................................................................................................................... 4 Eligibility ..................................................................................................................................................................................................... 5 Cost: What Does the Pooling Cover & How Much Can I Expect to Pay? ................................................................................................... 6 Premiums for 2019-2020 Plan Year ........................................................................................................................................................... 7 Cost Worksheet for 2019-2020 Plan Year .................................................................................................................................................. 8 Medical Benefits Overview ......................................................................................................................................................................... 9 Medical Benefits – Plan Highlights ........................................................................................................................................................... 10 Medical Benefits – Resources .................................................................................................................................................................. 14 Prescription Drug Benefits ........................................................................................................................................................................ 15 Health Savings Account (HSA) ................................................................................................................................................................. 16 Important Information Regarding Your Medical Benefits – Premera Blue Cross ...................................................................................... 17 Important Information Regarding Your Medical Benefits – Kaiser Permanente ........................................................................................ 19 Dental Benefits ......................................................................................................................................................................................... 21 Vision Benefits .......................................................................................................................................................................................... 22 Life & Disability Benefits ........................................................................................................................................................................... 23 Voluntary Life/AD&D Benefits ................................................................................................................................................................... 24 Voluntary Short-Term Disability Benefits .................................................................................................................................................. 25 Flexible Spending Accounts (FSA) ........................................................................................................................................................... 26 Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) .................................................................. 28 Certificate of Creditable Prescription Drug Coverage ............................................................................................................................... 30 Your Benefits Contacts ............................................................................................................................................................................. 32 Key Terms ................................................................................................................................................................................................ 33

IMPORTANT: If you (and/or your dependents) have Medicare or will become eligible for Medicare in the next 12 months, federal law gives you more choices about your prescription drug coverage. Please see page 30 for more details.


NEW HIRE ENROLLMENT OVERVIEW

For newly eligible employees. Please follow the steps below to choose your benefits and enroll.

BENEFIT PLANS

• Choice of eight medical plans including a prescription drug benefit:o Premera Blue Cross Plan 2 PPOo Premera Blue Cross Plan 3 PPOo Premera Blue Cross Plan 5 PPOo Premera Blue Cross Plan QHDHP PPOo Premera Blue Cross EasyChoice A PPOo Premera Blue Cross EasyChoice B PPOo Premera Blue Cross Basic PPOo Kaiser Permanente HMO

• Choice of two dental plans:o Ameritas Low Plano Ameritas High Plan

• Vision plan through Northwest Benefit Network (NBN)• Life/AD&D insurance through Symetra if enrolled in a Premera Blue Cross medical plan• Life/AD&D, Long-Term Disability, Voluntary Life/AD&D, and Voluntary Short-Term Disability insurance through LifeMap• Health Savings Account with WageWorks• Employee Assistance Program

1. PREPARE EVERYTHING YOU WILL NEED

• Social Security numbers for you and any family members whom you want to cover• Dates of birth for your family members

2. CHOOSE YOUR BENEFITS

Take the time to review the benefit outlines in this Guide and the Summary of Benefits and Coverage from the insurance company. This will help you understand the plans and how they will fit your lifestyle and budget. To make sure your family doctor and dentist are covered by the plans you have chosen, check the Provider Directory online or call customer service (see “Your Benefits Contacts” toward the back of this Guide).

3. FILL OUT YOUR ENROLLMENT FORM(S)/COMPLETE ONLINE ENROLLMENTComplete online enrollment or waiver through Skyward for all coverages (except voluntary and HSA).

4. YOU ARE DONE!Please complete your online enrollment (even if you are waiving medical coverage) and return any completed forms for optional HSA or voluntary benefits enrollment to the Payroll Department within 30 days of your hire date.

IMPORTANT

Enrollment timeline may vary in certain situations. See

“Special Enrollment Rights” on page 18 and 20.

OPEN ENROLLMENT OVERVIEW

For employees already enrolled.

Open Enrollment is September 1 through September 30, 2019. This is your only opportunity to make changes to your benefits for the coverage period November 1 - December 31, 2019 unless you have specific qualified life events, including:

Birth or adoption of a child You, your spouse or a dependent loses coverage under another group plan Change in marital status Relocation out of the service area You, your spouse or dependent become eligible for or lose other group coverage

including loss of eligibility for Medicaid, including becoming eligible for Medicaid or achild reaches age 26.

Open Enrollment through your spouse’s employer

ATTEND THE BENEFITS CARES FAIR – WEDNESDAY, OCTOBER 9TH

• This year's Cares fair will be geared toward our upcoming SEBB benefit open enrollment period Oct 1 - Nov 15 for benefitsbeginning Jan 1, 2020.

• The Benefits Fair is your chance to learn more about the benefit plans available to you. Come for expert advice about the planchoices, or to get help calculating your premium costs. Enter for a chance to win door prizes! Pick up plan summaries and costsheets.

• The fair will be held on Wednesday, October 9th from 3:00 pm to 6:00 pm at the South Kitsap High School.

MEDICAL/DENTAL/VISION BENEFITS – GO ONLINE TO COMPLETE YOUR ENROLLMENT

Login to the Skyward online enrollment system to review your benefit elections and verify your dependents (spouse and/or children) are accurately reflected. You must login to verify the demographic and enrollment information is correctly displayed for each dependent you wish to cover under any/all of the benefit plans.

To enroll in voluntary benefits, complete the appropriate enrollment form available at www.skschools.org (Staff Resources/Benefit Information).

Note: Dental and Vision coverage for family members is not automatic, so be sure to enroll them if you have not already done so.

VOLUNTARY BENEFITS

Your voluntary benefit elections carry forward year to year. If you want to make any changes to your election or enroll for the first time, you must complete an enrollment form and submit to the Payroll Department by the Open Enrollment deadline.


IMPORTANT

Enrollment timeline may vary in certain situations. See

“Special Enrollment Rights” on page 18 and 20.


2019-2020 PLAN DESIGN CHANGES

These changes are effective November 1, 2019, unless otherwise noted.

• The benefits outlined in this booklet are effective through Dec 31, 2019. Any changes made during this openenrollment period (Sept 1 - 30, 2019) will be effective Nov 1 - Dec 31, 2019 only.

FLEXIBLE SPENDING ACCOUNT (FSA)

• Medical and Dependent care FSA's are ending September 30, 2019. Current participants must spend their full18-19 election amount by Sept 30, 2019 and claim any remaining funds no later than Dec 31, 2019

HEALTH SAVINGS ACCOUNT (HSA)

• The IRS maximum contribution for the 2019 calendar year is $3,500 for an individual and $7,000 for a family.Those age 55+ will continue to be able to contribute an additional $1,000 in “catch-up” contributions.

SEBB Open Enrollment will be Oct 1 - Nov 15, 2019 for benefit coverage beginning Jan 1, 2020. More information will be

provided by SEBB in late Sept 2019.


ELIGIBILITY

Regular employees who work a minimum of 17.5 or more hours per week are eligible for mandatory benefits (dental, vision, life insurance and long-term disability). Eligibility for medical insurance is determined by your union collective bargaining agreement or the Non-Rep Policies and Procedures guide available on your district website at www.skschools.org. You have 30 days to select and submit enrollment forms from the first day of the following event:

Date of hire for a new employee Date of qualified change in status Increase in your hours such that the new total number of hours worked is 17.5 or more hours per week

If an employee is hired on or before the 15th of the month and has completed the online open enrollment by the 15th, the effective date of coverage for the newly eligible employee will be the 1st of the following month. If you are hired or the enrollment process is submitted after the 15th of the month, then the effective date of coverage will be the 1st of the next month following 30 days (see example below).

Example: If an employee is hired on September 2nd, submits an enrollment form by September 15th, coverage will be effective October 1st. If an employee is hired on September 2nd and submits an enrollment form on September 16th, coverage will be effective on November 1st.

If your hours vary from week to week, confirm your eligibility with the Payroll Department.

You may enroll your eligible dependents for medical, dental, and vision. They are also eligible to receive Employee Assistance Program (EAP) services. Your eligible dependents include:

Your legal spouse or state-registered domestic partner Your children up to age 26 Any dependent child who is incapable of self-support because of a physical or mental disability

South Kitsap School District extends benefits to employees’ state-registered domestic partners. However, the value of these benefits must be included in the employee’s gross income and is subject to federal income tax and FICA tax (unless the state-registered domestic partner is the employee’s tax dependent). This means a portion of your benefit contribution (the difference between the cost to cover you plus your state-registered domestic partner and the cost to cover just you) is deducted from your pay after taxes have been applied (referred to as “post-tax”). It also means the premium your employer is paying on your behalf when you choose to cover your state-registered domestic partner is added to your taxable income. For more information, please contact the Payroll Department.

MAKING CHANGES TO YOUR BENEFITS

You may make changes to your benefits during Open Enrollment Sept 1-30. All benefits you select will be effective Nov 1 - Dec 31, 2019, unless you have a “qualified change in status” or are no longer eligible under the plan (e.g., leave employment). Because many of your benefits are available on a pre-tax basis, the IRS requires you to have a qualified change in status in order to make changes to your benefit elections outside of open enrollment.

If you have a qualified change in status, you can make changes to your benefits by contacting the Payroll Department within 30 days of the change. The change to your benefits must be consistent with the qualified change in status. For example, if you have a new baby, you can enroll the child as a dependent under your current health plan, but you may not remove another dependent who is already covered. To determine if your situation allows you to make changes to your benefits, please contact the Payroll Department.

QUALIFIED CHANGE IN STATUS EXAMPLES

Birth or adoption of a child Loss of your or a

dependent’s coverage underanother plan

Change in marital status

COST: WHAT DOES THE POOLING COVER & HOW MUCH CAN I EXPECT TO PAY?

STATE FUNDING AND POOLING

The District provides a benefit allotment to help pay for mandatory benefits (dental, vision, Life/AD&D, and LTD) and voluntary medical for you and your family members. The beginning allotment for a full-time employee for these benefits is $973.00 per month. This amount is before pooling and will be prorated for employees who work less than full time employment.

If you do not use your entire benefit allotment, the remaining amount is put into a “pool” for your employee group, and distributed based on the ratio of full time employees to members in your group who have elected medical coverage.

Note: The benefit allotment and pooling are available for use toward state-registered domestic partner coverage as well as legal spouses and dependent children. Please see the “Dependents” section on page 5 for information regarding the taxation of state-registered domestic partner premiums.

WHEN CAN I EXPECT PREMIUMS TO BE DEDUCTED FROM MY PAYCHECK?

A payroll deduction will occur if the monthly premiums for your mandatory benefits and voluntary medical are greater than your benefit allotment and pooling distribution. You will also incur a payroll deduction for the other voluntary benefits you select.

Deductions for medical insurance premiums are taken, pre-tax, from the current month’s pay warrant (last working day of the month) to pay for the next month’s coverage. You are automatically enrolled in the Premium Conversion Plan, allowing the premium for your medical coverage to be deducted before taxes which reduces your taxable income resulting in more take-home pay.

Because your medical insurance premiums are taken from your paycheck on a pre-tax basis, the IRS requires you to have a qualified change in status in order to make changes to your benefit elections during the year. Without an approved status change, your payroll deduction amount will remain in effect through November 30, 2019. Post-tax payroll deductions allow you to drop medical coverage only without a qualifying event. The District automatically takes your medical deductions on a pre-tax basis. If you would like to opt out of pre-tax deductions, contact the Payroll Department by the enrollment deadline.

An approved status change is always required if you have pre-tax deductions. If you have post-tax deductions, an approved status change is always required to add a dependent or modify your benefit selection.

If you are currently participating in the Healthcare or Dependent Care portion of the Flexible Spending Account (FSA), September 30, 2019 will be the last deduction of your annual amount for the 18-19 plan year. You must spend any remaining funds by September 30, 2019 and claim reimbursement by Dec 31, 2019.



PREMIUMS FOR COVERAGE THROUGH DEC 31, 2019

MONTHLY EMPLOYEE BENEFIT RATES

The District provides a benefit allotment to help pay for the premiums for you and your family members. This table shows the monthly rates and may be helpful as you decide which plan is best for you and your family.

Medical Premera Premera Premera Premera Premera Premera Kaiser

PLAN 2 PLAN 3 PLAN 5 QHDHP Basic EasyChoice

A & B HMO

Employee $900.05 $822.84 $1,040.88 $474.63 $489.08 $605.93 $927.02

Employee & Spouse/Partner $1,647.72 $1,506.57 $2,000.62 $861.60 $888.02 $1,101.07 $1,529.59

Employee & Child(ren) $1,201.86 $1,098.85 $1,420.34 $629.41 $648.66 $803.95 $1,237.41

Employee, Spouse/Partner & Child(ren)

$1,975.50 $1,806.42 $2,410.17 $1,018.13 $1,063.86 $1,319.38 $1,854.04

Dental Ameritas Dental Ameritas Dental

(Mandatory Benefit) Low Plan High Plan

Employee Only $63.32 $79.12

Employee & Spouse $96.24 $120.88

Employee & Child(ren) $102.44 $120.96

Employee, Spouse & Child(ren)

$155.32 $187.20

Vision Costs NBN Vision

(Mandatory Benefit)

Single or Family Coverage (Family members are NOT

automatically enrolled) $23.43

Life and AD&D Insurance (Mandatory Benefit)

Employee Group Benefit Amount Premium

All Benefits Eligible Employees $50,000 $6.65

Long-Term Disability (Mandatory Benefit)

Employee Group Premium

All Benefits Eligible Employees $9.50


COST WORKSHEET FOR COVERAGE THROUGH DEC 31, 2019

PAYROLL DEDUCTION WORKSHEET

Each eligible employee receives a benefit allocation based on his/her assigned annual hours. The benefit allocation will first be used to pay for dental, vision, life insurance and long-term disability, then the balance can be used to help pay for medical insurance. The beginning allotment for dental, vision, life insurance, long-term disability and medical for a full time employee before pooling is $973.00 per month. If you do not use all of your benefit allocation, the balance will go into a pool for your employee group. If you spend more than your benefit allocation, you may receive dollars from that pool to reduce your payroll deductions. Pre-tax dollars will be used to pay for medical payroll deductions, unless you have requested post-tax deductions.

DENTAL, VISION, LIFE INSURANCE, LONG-TERM DISABILITY AND MEDICAL WORKSHEET

Your total payroll deduction will be equal to the estimate in the above worksheet plus the amount of any voluntary benefits AND optional benefits for which you have enrolled.

IMPORTANT REMINDER ABOUT PREMIUMS

Please see the announcement regarding the District Benefits Allocation to determine the contribution for your bargaining group. Use the Monthly Cost Worksheet online or in Payroll to calculate your premium share, if any. Note: Because of the District Benefits Allocation, health coverage offered meets the affordability guidelines under the Affordable Care Act, and might preclude you and family members from obtaining subsidized coverage through the Washington HealthPlanFinder (the Health Insurance “Exchange”).

Enter District Allocation 1. $

Enter Dental Premium 2. $

Enter Vision Premium 3. $23.43

Enter Life/AD&D Premium 4. $6.65

Enter Long-Term Disability Premium 5. $9.50

Total cost of mandatory benefits - lines 2+3+4+5 6. $

Subtract line 6 from line 1 (this is the amount of the allocation left over for medical)

7. $

Enter Medical Premium 8. $

Subtract Line 8 from line 7 (If negative, this is your payroll deduction amount for

medical coverage) 9. $


MEDICAL BENEFITS OVERVIEW

Comprehensive and preventive health care coverage is important in protecting you and your family from the financial risks of unexpected illness and injury. South Kitsap School District offers you a choice of seven plans through Premera Blue Cross and one plan through Kaiser Permanente. All eight plans cover most of the same in-network benefits, but your out-of-pocket expenses and network physicians vary with some of the plans. All plans provide excellent coverage of preventive services, such as routine physical exams and immunizations which are very important to you and your family’s health. Prescription drug coverage is also included with all medical plan options.

Please read the descriptions of the plans below; then review the highlights of what each plan covers on the following pages.

PREMERA BLUE CROSS PPO PLANS

Please see the plan highlights on the pages to follow for the difference in coverage between in-network and out-of-network providers. If you choose an in-network provider, your cost will be less. You can find Premera Blue Cross providers online, by mobile app, or by phone – please see the information in “Your Benefits Contacts” at the end of this Guide.

Premera Blue Cross has multiple provider networks. All plans use the Heritage Plus Network. Use the Find a Doctor tool available at www.premera.com to confirm your providers are in the plan’s network.

QUALIFIED HIGH DEDUCTIBLE HEALTH PLAN

The Qualified High Deductible Health Plan (QHDHP) works in a similar manner as the Premera PPO plans described above. The main differences are that the deductible is higher for the QHDHP and apply for most services (with the exception of preventive care and certain preventive medications). However, the premium is lower and this plan is compatible with a Health Savings Account (HSA) which allows you to set aside funds pre-tax to pay for future healthcare needs. These funds are yours and any unused amounts will roll-over every year.

KAISER PERMANENTE MANAGED CARE PLAN

With this plan, there are low out-of-pocket expenses and you must seek services from a Kaiser Permanente provider. You will need to select a Primary Care Physician (PCP) who will coordinate care with your other providers. Please note that out-of-network services will not be covered. You can find providers online, by mobile app, or by phone – please see the information in “Your Benefits Contacts” in the end of this Guide.

CALENDAR YEAR DEDUCTIBLE

This is the amount you pay before your plan begins covering expenses. The family deductible applies if you have family members enrolled in your plan along with you. The deductible starts over each January 1.

COPAY & COINSURANCE

A copay is a flat dollar amount you pay for a medical service. Coinsurance is when you pay a percentage of the cost.

OUT-OF-POCKET MAXIMUM

The out-of-pocket maximum is the most you pay in a calendar year for covered medical services. Once the out-of-pocket maximum is met, the plan will pay 100% of the allowed amount for the remainder of the calendar year for covered services. The out-of-pocket maximum starts over each January 1.

OUT-OF-NETWORK ALLOWABLE

When you use out-of-network services, your plan will only pay a percentage of the allowable

amount. If you enroll in the Kaiser Permanente plan and

use out-of-network services, you will be responsible for the full cost; however, Emergency

and Urgent Care services are covered when traveling outside of the Kaiser Permanente

service area.


MEDICAL BENEFITS – PLAN HIGHLIGHTS

Limitations: This benefit outline is for illustrative purposes only. Actual claims paid are subject to maximum allowable charge, frequencies, age limitations, terms and conditions of the contract.

Premera Blue CrossPlan 2



PCY = Per Calendar Year (January 1-December 31)

In-Network Out-of-

Network In-Network Out-of-Network In-Network

Out-of-Network

Annual Deductible $300/$900 $500/$1,500 $200/$600

$350 per member (Individual/Family)

What You Pay 20% 40% 20% 40% 10% 30%

Annual Out-of-Pocket Maximum $2,000/$6,000 $3,400/$10,200 $3,000/$9,000 $5,900/$17,700 $1,000/$3,000 No limit (Individual/Family) Preventive Care

Exams/Immunizations No charge 20% No charge 20% No charge Not covered

Preventative Screenings No charge 20% No charge 20% No charge Not covered

Outpatient Services

Office Visit $25 per visit $30 per visit $30 per visit $40 per visit $20 per visit 30% after deductible

Specialist Visit $35 per visit $40 per visit $40 per visit $50 per visit $30 per visit 30% after deductible

Diagnostic Lab & X-Ray 20% after deductible

40% after deductible





Surgery $100 copay +


$100 copay + 40% after deductible





Rehabilitation $35 per visit $40 per visit $40 per visit $50 per visit $30 per visit 30% after deductible

45 visits combined PCY 45 visits combined PCY 45 visits combined PCY

Physical Therapy 20% after deductible



40% after deductible See outpatient rehabilitation

Unlimited visits combined PCY Unlimited visits combined PCY

Other Services

Chiropractic Care $25 per visit $30 per visit $30 per visit $40 per visit $20 per visit 30% after deductible

Unlimited visits combined PCY Unlimited visits combined PCY Unlimited visits combined PCY

Acupuncture $25 per visit $30 per visit $30 per visit $40 per visit $20 per visit 30% after deductible

12 visits combined PCY 12 visits combined PCY Unlimited visits combined PCY

Emergency Room (copay waived if admitted)

$75 copay + 20% after deductible $100 copay + 20% after deductible $50 copay + 10% after deductible

Inpatient Hospitalization

$150 per day to $450 max PCY +











Rehabilitation limitation 120 days combined PCY 30 days combined PCY 30 days combined PCY

Life/AD&D Plan (underwritten by Symetra)

Employee Benefit $25,000 $25,000 $25,000


PLAN HIGHLIGHTS (CONTINUED)


Premera Blue CrossEasyChoice A

Premera Blue CrossEasyChoice B


In-Network Out-of-Network In-Network Out-of-Network

Annual Deductible $1,250/$3,750 $2,000/$6,000 $750/$2,250 $1,500/$4,500

(Individual/Family)

What You Pay 20% 50% 25% 50%

Annual Out-of-Pocket Maximum $4,000/$8,000 No limit $3,500/$7,000 No limit

(Individual/Family) Preventive Care

Exams/Immunizations No charge Not covered No charge Not covered

Preventative Screenings No charge Not covered No charge Not covered

Outpatient Services

Office Visit $25 per visit 50% after deductible $30 per visit 50% after deductible

Specialist Visit $35 per visit 50% after deductible $40 per visit 50% after deductible

Diagnostic Lab & X-Ray First $1,000 PCY: no

charge then 20% after deductible

First $1,000 PCY: no charge then 50% after

deductible 25% after deductible 50% after deductible

Surgery 20% after deductible 50% after deductible 25% after deductible 50% after deductible

Rehabilitation $35 per visit 50% after deductible $40 per visit 50% after deductible

30 visits combined PCY 45 visits combined PCY

Physical Therapy See outpatient rehabilitation See outpatient rehabilitation

Other Services

Chiropractic Care $25 per visit 50% after deductible $30 per visit 50% after deductible


Acupuncture $25 per visit 50% after deductible $30 per visit 50% after deductible



$100 copay + 20% after deductible $150 copay + 25% after deductible

Inpatient Hospitalization 20% after deductible 50% after deductible 25% after deductible 50% after deductible

Rehabilitation limitation 30 days combined PCY 45 days combined PCY


Employee Benefit $25,000 $25,000




*QHDHP Plan – When two or more members are enrolled in this plan, the family deductible must be met before benefits are paid out.

IMPORTANT! Premera Blue Cross requires prior authorization to receive coverage for certain planned services. If prior authorization is not obtained for a required service, you will be subject to additional cost shares not outlined here. A complete list of services requiring prior authorization is available at www.premera.com.

Premera Blue Cross Basic

Premera Blue Cross QHDHP


In-Network Out-of-Network In Network Out-of-Network

Annual Deductible (Individual/Family)

$2,100/$4,200 $2,500/$5,000 $1,750/$3,500* $3,000/$6,000*

What You Pay 30% 50% 20% 50%

Annual Out-of-Pocket Maximum (Individual/Family)*

$6,600/$13,200 No limit $5,000/$10,000 No limit

Preventive Care

Exams/Immunizations No charge Not covered No charge Not covered

Preventative Screenings No charge Not covered No charge Not covered

Outpatient Services

Office Visit $35 per visit 50% after deductible 20% after deductible 50% after deductible

Specialist Visit $50 per visit 50% after deductible 20% after deductible 50% after deductible

Diagnostic Lab & X-Ray 30% after deductible 50% after deductible 20% after deductible 50% after deductible

Surgery 30% after deductible 50% after deductible 20% after deductible 50% after deductible

Rehabilitation $50 per visit 50% after deductible 20% after deductible 50% after deductible 30 visits combined PCY 15 visits combined PCY

Physical Therapy See outpatient rehabilitation See outpatient rehabilitation

Other Services

Chiropractic Care $35 per visit 50% after deductible 20% after deductible 50% after deductible


Acupuncture $35 per visit 50% after deductible 20% after deductible 50% after deductible



$200 copay + 30% after deductible 20% after deductible

Inpatient Hospitalization 30% after deductible 50% after deductible 20% after deductible 50% after deductible

Rehabilitation limitation 30 days combined PCY 30 days combined PCY


Employee Benefit $25,000 $25,000




Kaiser Permanente PCY = Per Calendar Year (January 1-December 31)

In-Network Only

Annual Deductible $200/$600

(Individual/Family)

Annual Out-of-Pocket Maximum $2,000/$6,000 (Individual/Family)

Preventive Care No charge

Outpatient Services

Office Visit $15 per visit after deductible

Diagnostic Lab & X-Ray No charge after deductible

Surgery $15 per visit after deductible

Rehabilitation $15 per visit after deductible Up to 45 visits PCY

Other Services

Chiropractic Care $15 per visit after deductible

10 visits PCY

Acupuncture $15 per visit after deductible

12 visits PCY


$100 per visit after deductible

Inpatient Hospitalization Rehabilitation

$100 after deductible, per day up to 3 days per admit 30 days PCY

Retail Pharmacy (30-day supply)

Generic $15

Preferred Brand Name $30

Mail Order (90-day supply) 2 x retail copay


MEDICAL BENEFITS – RESOURCES

PREMERA.COM

You’re on the go—and so is your health plan. Log in at premera.com to:

Track your care and your spending, including your deductible Find in-network doctors, hospitals, and pharmacies Refill prescriptions and get dose reminders Find the forms you need Learn more about your benefits

Getting started is easy. Go to premera.com, click Log In and then select Member. Follow the prompts to create your account. You’ll need your member ID number, which is on your Premera ID card.

PREMERA MOBILE

Download the Premera Mobile app and be ready when you need it.

Show proof of coverage – no card required! Find doctors and other providers Check benefits and find out on the spot whether it’s covered Monitor claims Contact the 24-Hour NurseLine

NURSELINE*

It’s after hours, and you have a fever that won’t go down. Who can help you decide what to do?

Call the free and confidential NurseLine to get advice from a registered nurse anytime. The nurse can help you decide whether you should be on your way to the ER or urgent care, call your doctor in the morning, or how to care for the problem yourself. Call 800.841.8343, available 24-hours (the number is also on the back of your Premera card).

TELADOC®**

We all have times when we need to see a provider, but it’s inconvenient. You and your eligible dependents can use Teladoc to get treated by doctors by phone or online video, so you have immediate and convenient access to care whenever and wherever you need it.

Common conditions a Teladoc physician can help you handle include sinus problems, allergies, cold and flu symptoms and many other non-emergency illnesses. Virtual doctor office visits are available via video or phone – at no cost share to the member (except QHDHP members for whom the deductible applies).

Visit the Teladoc website at www.teladoc.com/premera, click “Set Up Account”, and provide the required information in the “My Medical History” tab. You can also call Teladoc at 855.332.4059. After you set up your account, a Teladoc doctor is just a call or click away anytime you need medical care.

On the go? Download the Teladoc mobile app to request a visit anytime.

*Always call 911 or your local emergency number if you are having a medical emergency. NurseLine gives general information, but does not diagnose or prescribe. NurseLine cannot advise you about what is covered by your plan.

**Teladoc® is an independent company that provides virtual medical care services on behalf of Premera Blue Cross. Teladoc operates subject to state regulation and may not be available in certain states. Teladoc does not guarantee that a prescription will be written. Teladoc does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs that may be harmful because of their potential for abuse. Teladoc physicians reserve the right to deny care for potential misuse of services.


PRESCRIPTION DRUG BENEFITS

Your medical insurance includes comprehensive prescription drug coverage. The level of coverage depends on whether the drug is generic or brand name, and whether it is on the Premera formulary, or preferred drug list. Your out-of-pocket cost is lowest when you buy generic drugs, and highest when you buy brand name drugs that are not on the formulary. To find out if your medication is on the formulary, please check the online list at www.premera.com.

When filling a prescription, present your Premera member ID card at any participating pharmacy. If using an out-of-network pharmacy, you will need to pay the drug cost out-of-pocket and then submit a claim form to Premera to be reimbursed for the amount of coverage.

Review the Kaiser medical benefit summary on page 13 for information regarding the Kaiser prescription drug coverage.

RESOURCES

Premera provides tools on premera.com and the Express Scripts® mobile app, which let you manage your pharmacy care anytime, anywhere.*

View current medications, set dosing time, and refill reminders Look up potential lower-cost options available under your plan and

discuss them with your doctor – while you’re still in the doctor’s office! Request, manage, and track home delivery of ongoing maintenance

medications Use your phone to show your virtual ID card at the pharmacy Receive personalized alerts of possible health risks related to

medications Locate in-network retail pharmacies

*Express Scripts® is an independent company that provides pharmacy benefit services on behalf of Premera Blue Cross.

Plan 2 Plan 3 Plan 5 QHDHPAnnual Deductible None None None Shared with medical

Annual Out-of-pocket Maximum

Shared with medical Shared with medical Shared with medical Shared with medical

Retail Pharmacy (34-day supply) (34-day supply) (30-day supply) (30-day supply) Generic $10 $15 $10 20% after deductible Preferred Brand $20 $25 $15 20% after deductible Non-Preferred Brand $35 $40 $30 20% after deductible Specialty $50 (30-day supply) $60 (30-day supply) $50 20% after deductible

Mail Order Pharmacy (100-day supply) (100-day supply) (90-day supply) (90-day supply) Generic $20 $30 $20 20% after deductible Preferred Brand $40 $50 $30 20% after deductible Non-Preferred Brand $65 $70 $60 20% after deductible

EasyChoice A EasyChoice B Basic

Annual Deductible $500 per person PCY (waived for generics)

$250 per person PCY (waived for generics)

$750 per person/$1,500 per family

Annual Out-of-pocket Maximum

Shared with medical Shared with medical Shared with medical

Retail Pharmacy (30-day supply) (30-day supply) (30-day supply) Generic $10 $5 $15 after deductible Preferred Brand 30% after deductible $30 after deductible $30 after deductible Non-Preferred Brand 30% after deductible $45 after deductible $50 after deductible Specialty 30% after deductible 30% after deductible 30% after deductible

Mail Order Pharmacy (90-day supply) (90-day supply) (90-day supply) Generic $20 $10 $30 after deductible Preferred Brand 30% after deductible $75 after deductible $60 after deductible Non-Preferred Brand 30% after deductible $112 after deductible $100 after deductible

IMPORTANT

Specialty drugs are only available through a specialty

pharmacy. You will be notified of the refill procedure if you are

taking one of these drugs.


HEALTH SAVINGS ACCOUNT (HSA)

WHAT IS AN HSA?

If you enroll in South Kitsap School District’s High Deductible Health Plan (HDHP), then you may be eligible to open an HSA. An HSA is a bank account where you can set aside money to pay for expenses that your health plan does not cover. The money in your HSA is not considered income, so it is not subject to taxes.

HOW DOES AN HSA WORK?

You can use the money in your HSA at any time to pay for eligible medical expenses. When you visit a provider, no copay is required at the time of service. The provider will submit a claim to Premera for the services you received.

Premera will then send you an Explanation of Benefits (EOB) outlining the negotiated/allowed charges. The provider will then send you an invoice reflecting the allowed charges. Make sure the amount matches the EOB sent to you by Premera.

You can then pay the invoice with money from your HSA (either your HSA debit card or as a reimbursement to you). Remember to keep your receipts, in case the IRS requests them.

WHO CAN OPEN AN HSA?

You are eligible to open and contribute to an HSA if you meet the following requirements:

You must be covered by a qualified high-deductible health plan. You must not be enrolled in or covered by Medicare or Tricare. You must not be covered by your own or a spouse’s non-limited purpose

Flexible Spending Account (FSA), Health Reimbursement Arrangement(HRA) or any other non HSA-qualified health plan.

You must not be claimed as a tax dependent on another person’s taxes. You have not received any Veteran’s Administration health benefits for a non-

service connected disability in the last three months. You have not used Indian Health Services coverage in the last three months.

RESOURCES

Log in to www.premera.com to access information on your health plan and www.wageworks.com your HSA information. You can also download the WageWorks mobile app (EZ Receipts) to access your HSA while you’re out and about.

View account balance, account alerts, claims and transaction history Submit a new claim Upload claim documentation

The intent of this information is to provide general information about HSA regulations. It is not intended to address specific situations or provide tax advice. Questions regarding specific issues should be discussed with a tax advisor.

CONTRIBUTIONS

The maximums are $3,500/Individual or $7,000/Family in 2019.

For individuals age 55 or older, an additional $1,000 in “catch-up” contributions are allowed for 2019.

Your money rolls over every year. There is no “use it or lose it” rule.

Your Contributions

Your Health Savings

Account (HSA)

Use money for healthcare today

Save for healthcare needs tomorrow

OR

$

$$

$$

$

$$

$

$

$

HSA AND DOMESTIC PARTNERS

Domestic partners are eligible to be enrolled in an HDHP plan, however distributions from the HSA are only

allowed if your domestic partner is an IRS qualified tax dependent. Consult

your tax advisor for details.


IMPORTANT INFORMATION REGARDING YOUR MEDICAL BENEFITS – PREMERA BLUE CROSS

NON-NETWORK COSTS

The amount the plan pays for covered services provided by non-network providers is based on a maximum allowable amount for the specific service rendered. Although your plan stipulates an out-of-pocket maximum for out-of-network services, please note the maximum allowed amount for an eligible procedure may not be equal to the amount charged by your out-of-network provider. Your out-of-network provider may bill you for the difference between the amount charged and the maximum allowed amount. This is called balance billing and the amount billed to you can be substantial. The out-of-pocket maximum outlined in your policy will not include amounts in excess of the allowable charge and other non-covered expenses as defined by your plan. The maximum reimbursable amount for non-network providers can be based on a number of schedules such as a percentage of reasonable and customary or a percentage of Medicare. Contact your claims payer or insurer for more information. The plan document or carrier’s master policy is the controlling document, and this Benefit Highlight does not include all of the terms, coverage, exclusions, limitations, and conditions of the actual plan language.

ORGAN TRANSPLANT

There is no pre-existing condition limitations for this health plan. Organ and bone marrow transplants have a $7,500 travel and lodging maximum. Please see your plan contract booklet for further details.

WOMEN’S HEALTH AND CANCER RIGHTS ACT

The Women's Health and Cancer Rights Act of 1998 requires group health plans that provide medical and surgical coverage for mastectomies also provide coverage for reconstructive surgery following such mastectomies in a manner determined in consultation with the attending physician and the patient.

Coverage must include:

All stages of reconstruction of the breast on which the mastectomy has been performed, Surgery and reconstruction of the other breast to produce a symmetrical appearance, and Prostheses and treatment of physical complications of all stages of mastectomy, including lymphedema.

Benefits for the above coverage are payable on the same basis as any other physical condition covered under the plan, including any applicable deductible and/or copays and co-insurance amounts.

OUT-OF-AREA BENEFITS

Like all Blue Cross and/or Blue Shield Licensees, Premera Blue Cross participates in a program called "BlueCard." Whenever enrollees access health care services outside their program's service area, the claim for those services may be processed through BlueCard and presented to Premera Blue Cross for payment. Blue Cross/Blue Shield Licensees outside the service area may charge certain fees, which will be passed to you. The access fee may be charged only if that Licensee's arrangement with the provider prohibits billing enrollees for amounts in excess of the discounted rate. However, providers may still bill for deductibles, coinsurance, amounts in excess of stated benefit maximums, and charges for excluded services.

COBRA

Federal COBRA is a U.S. law that applies to employers who employ 20 or more individuals and sponsor a group health plan. Under Federal COBRA you may be eligible to continue your same group health insurance for up to 18 months if your job ends or your hours are reduced. You are responsible for COBRA premium payments.


IMPORTANT INFORMATION REGARDING YOUR MEDICAL BENEFITS – PREMERA BLUE CROSS (CONTINUED)

SPECIAL ENROLLMENT RIGHTS

If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents’ other coverage). However, you must request enrollment within 60 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).

You may also be able to enroll yourself or your dependents in the future if you or your dependents lose health coverage under Medicaid or your state Children's Health Insurance Program, or become eligible for state premium assistance for purchasing coverage under a group health plan, provided that you request enrollment within 60 days after that coverage ends or after you become eligible for premium assistance.

In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 60 days after the marriage, birth, adoption, or placement for adoption. To request special enrollment or obtain more information, contact the Payroll Department. Refer to your benefit booklet for details.

HIPAA NOTICE OF PRIVACY PRACTICES REMINDER

HIPAA requires South Kitsap School District to notify its employees that a privacy notice is available from the Payroll Department. To request a copy of South Kitsap School District’s Privacy Notice or for additional information, please contact the Payroll Department.

HEALTHCARE REFORM & YOUR BENEFITS

The Affordable Care Act requires most Americans to have health insurance (unless you meet certain exceptions). If you do not have health insurance you may pay a tax penalty. South Kitsap School District offers a medical plan option that provide valuable comprehensive coverage that meets the requirements of the healthcare reform law and is intended to be affordable as defined by the law. Also note, it’s unlikely that you are eligible for financial help from the government to help you pay for insurance purchased through a Marketplace because you have access to an employer plan that complies with the affordability standard.

PREVENTIVE CARE

Certain preventive care services must be provided by non-grandfathered group health plans without member cost-sharing (such as deductibles or copays) when these services are provided by a network provider. Please refer to your insurance company for more information. Contact information is listed under “Your Benefits Contacts” in the back of this Guide.


IMPORTANT INFORMATION REGARDING YOUR MEDICAL BENEFITS – KAISER PERMANENTE

NON-NETWORK COSTS

This plan does not provide non-network benefits except in the case of emergency services.

ORGAN TRANSPLANT

Prior Authorization is required from the Health Plan. Kaiser Permanente Washington’s Review Services Department reviews the medical information provided by the physician. If a Member is approved into the transplant program, the specific transplant center manages the patient and will be the point of contact for information regarding the transplant process.

WOMEN’S HEALTH AND CANCER RIGHTS ACT

The Women's Health and Cancer Rights Act of 1998 requires group health plans that provide medical and surgical coverage for mastectomies also provide coverage for reconstructive surgery following such mastectomies in a manner determined in consultation with the attending physician and the patient.

Coverage must include:

All stages of reconstruction of the breast on which the mastectomy has been performed, Surgery and reconstruction of the other breast to produce a symmetrical appearance, and Prostheses and treatment of physical complications of all stages of mastectomy, including lymphedema.

Benefits for the above coverage are payable on the same basis as any other physical condition covered under the plan, including any applicable deductible and/or copays and co-insurance amounts.

OUT-OF-AREA BENEFITS

If you are traveling in another Kaiser region, you may receive services at those Kaiser facilities after contacting your home plan to have a visiting membership set up. Emergency care is covered at the closest Emergency Facility. If you receive Emergency care or are

admitted into a hospital, you must notify us within 24 hours or as soon as reasonably possible at 1‐888‐457‐9516. Urgent care is

covered at any licensed Urgent Care facility when you are travelling outside of the service area. If you are within the service area, Urgent Care is covered at Kaiser Permanente Urgent Care facilities and contracted Urgent Care facilities. Urgent/Emergency care is covered when you are out of the country. If you have any questions please call the number on the back of your ID card (206-630-4636 or 1-888-901-4636). If you would like to speak to a Consulting Nurse, please call the Consulting Nurse Service line on the back of your ID card (1-800-297-6877).

COBRA

Federal COBRA is a U.S. law that applies to employers who employ 20 or more individuals and sponsor a group health plan. Under Federal COBRA you may be eligible to continue your same group health insurance for up to 18 months if your job ends or your hours are reduced. You are responsible for COBRA premium payments.


IMPORTANT INFORMATION REGARDING YOUR MEDICAL BENEFITS – KAISER PERMANENTE (CONTINUED)

SPECIAL ENROLLMENT RIGHTS

If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents’ other coverage). However, you must request enrollment within 31 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).

You may also be able to enroll yourself or your dependents in the future if you or your dependents lose health coverage under Medicaid or your state Children’s Health Insurance Program, or become eligible for state premium assistance for purchasing coverage under a group health plan, provided that you request enrollment within 60 days after that coverage ends or after you become eligible for premium assistance.

In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 31 days after the marriage and 60 days after the birth, adoption, or placement for adoption. To request special enrollment or obtain more information, contact the Payroll Department. Refer to your benefit booklet for details.

HIPAA NOTICE OF PRIVACY PRACTICES REMINDER

HIPAA requires South Kitsap School District to notify its employees that a privacy notice is available from the Payroll Department. To request a copy of South Kitsap School District’s Privacy Notice or for additional information, please contact the Payroll Department.

HEALTHCARE REFORM & YOUR BENEFITS

The Affordable Care Act requires most Americans to have health insurance (unless you meet certain exceptions). If you do not have health insurance you may pay a tax penalty. South Kitsap School District offers a medical plan option that provide valuable comprehensive coverage that meets the requirements of the healthcare reform law and is intended to be affordable as defined by the law. Also note, it’s unlikely that you are eligible for financial help from the government to help you pay for insurance purchased through a Marketplace because you have access to an employer plan that complies with the affordability standard.

PATIENT PROTECTION DISCLOSURE NOTICE

Kaiser Permanente generally allows the designation of a primary care provider. You have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members. Until you make this designation, Kaiser Permanente may designate one for you. For information on how to select a primary care provider, and for a list of the participating primary care providers, contact the number listed under “Your Benefits Contacts” in the back of this Guide.

For children, you may designate a pediatrician as the primary care provider.

You may not need prior authorization from Kaiser Permanente or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a healthcare professional in our network who specializes in obstetrics or gynecology. The healthcare professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating healthcare professionals who specialize in obstetrics or gynecology, contact the number listed under “Your Benefits Contacts” in the back of this Guide.

PREVENTIVE CARE

Certain preventive care services must be provided by non-grandfathered group health plans without member cost-sharing (such as deductibles or copays) when these services are provided by a network provider. Please refer to your insurance company for more information. Contact information is listed under “Your Benefits Contacts” in the back of this Guide.


DENTAL BENEFITS

Going to the dentist isn’t on anyone’s list of favorite things to do, but South Kitsap School District’s dental benefits make it as painless as possible with comprehensive coverage through Ameritas. You can access services from any licensed dentist you wish. However, your costs will typically be lower if you choose an Ameritas dentist. You can find Ameritas PPO providers online. Please see the information in “Your Benefits Contacts” toward the back of this Guide.

BEFORE TREATMENT BEGINS

You should have your dentist’s office contact Ameritas if you expect the charges to be more than $300. Your dentist’s office will coordinate with Ameritas to determine how much of the cost will be covered under the plan, and how much will be your responsibility.

DISCOUNTS

Ameritas members have access to hearing aid and prescription drug discounts!

iHear is a unique hearing aid device and you don’t need to visit an audiologist. Simply order your iHearTest kit online for $69, take the test from the convenience of your home, and order your hearing aid online. Please note that you will also order a Programming Kit for $129 to adjust settings on your device. Order your iHear device today at www.ameritas.com/listen. Enter the code “AmeritasF&F” at checkout and receive free shipping.

Save on prescription medications at over 60,000 pharmacies across the nation including CVS, Walgreens, Rite Aid, and Walmart. This Rx discount is offered at no additional cost, and it is not insurance. Sign in to www.ameritas.com to access your Rx savings card.

Ameritas-Low Plan Ameritas-High Plan

In-Network Out-of-Network In-Network Out-of-Network

Annual Deductible (waived for Preventive & Diagnostic)

$0 $50 person $0 $50 person

Annual Benefit Maximum $1,600 $2,000 $1,750

Waiting Period None None

Services

Preventive & Diagnostic No charge No charge No charge No charge

Basic 20% after deductible 20% after deductible 10% after deductible 10% after deductible

Major 50% after deductible 50% after deductible 50% after deductible 50% after deductible

Crowns 50% after deductible 50% after deductible 10% after deductible 40% after deductible

Periodontics Covered under basic Covered under basic

Endodontics Covered under basic Covered under basic

Implants Covered under major Covered under major

Orthodontia (Adult and Children to age 26)

Services 50% 50% 50% 50%

Lifetime Benefit Maximum $2,000 per person $2,000 per person


USUAL, CUSTOMARY & REASONABLE

Benefits are paid at the negotiated fee level for in-network providers. Benefits for services from out-of-network providers will be paid at the 90th percentile of the amount charged by the majority of dentists in the area.


VISION BENEFITS

To help you take care of your eyesight, South Kitsap School District provides vision care coverage through Northwest Benefit Network (NBN). You can access vision care services from any provider you wish. However, your costs will typically be lower if you choose a NBN network provider. You may obtain a NBN ID card from the website or phone app under ‘Forms and Documents.’ However, you do not need an ID card. You can simply let your provider know you are a NBN participant when you make your appointment. You can find NBN providers by using the NBN Vision Provider Locator on the website or the phone app. The website and phone app also allow you to check your claim and eligibility status, download your Plan brochure, explanation of benefits and a claim form if you need to submit an out-of-network provider claim. Please see the information in “Your Benefits Contacts” toward the back of this Guide.

In-Network Out-of-Network

Reimbursed

Routine Exam No charge Up to $50

Materials Copay N/A

LensesSingle Vision No charge* Up to $55 Lined Bifocals No charge* Up to $85 Lined Trifocals No charge* Up to $105

Lens Enhancements Standard & Premium Progressive

No charge Not covered

Frames No charge for covered frames Up to $45

Elective Contact Lenses (in lieu of all other hardware services)

Up to $350 allowance for contact lenses

Up to $100 for services and materials

Frequency (Exam/Lenses/Frames/Contacts)

12/12/12/12 Months (once every 365 consecutive days) Benefit frequency is tracked from service date to service date

*IMPORTANT

Basic single vision, lined bifocals, and lined trifocals are covered at no charge in-network.

Additional lens options may incur out-of-pocket cost. Discuss your lens options with your

provider to determine which are covered or not covered and whether or not you want to continue

with their recommendations for lens options based on your out-of-pocket cost.


LIFE & DISABILITY BENEFITS

BASIC LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D) INSURANCE

To help you protect your family, South Kitsap School District offers basic life and accident insurance that is fully paid for by South Kitsap School District.

Life/AD&D

Benefit Amount $50,000

Guaranteed Issue $50,000

Benefit Reduction To 65% at age 65, 45% at age 70, 30%

at age 75, 20% at age 80, to 15% at age 85, and 10% at age 90

LONG-TERM DISABILITY (LTD) COVERAGE

When you cannot work for an extended period of time due to an approved, non-work related illness or injury, an LTD plan can help cover a portion of your pre-disability earnings.

Long-Term Disability

Monthly Benefit Amount 60% of base monthly earnings

Maximum Monthly Benefit $7,000

Elimination Period 90 days

Definition of Disability Own occupation for 60 months,

then any occupation

Benefit Duration ADEA – 65 Reducing Benefit Duration

(See table below)

Age When Disability Begins Maximum Period of Payment

Less than age 60 To age 65, but not less than 5 years

Age 60 60 months

Age 61 48 months

Age 62 42 months

Age 63 36 months

Age 64 30 months

Age 65 24 months

Age 66 21 months

Age 67 18 months

Age 68 15 months

Age 69 and over 12 months

WHEN YOU FIRST ENROLL

When you first enroll in life insurance benefits, you will need to designate a beneficiary who would receive the benefits in the event of your death. You may change or update your beneficiary at any time.

IMPORTANT

Restrictions and limitations apply to these benefits. Please review the insurance booklet

or certificate for complete

Elimination Period: The time period that you must be ill or injured with a covered condition before collecting benefits.

Prepared by Gallagher for the Employees of South Kitsap School District

24

VOLUNTARY LIFE/AD&D BENEFITS

Additional life and accidental death and dismemberment (AD&D) insurance is available at group discounted rates for employees to purchase.

Benefit Outline Voluntary Life Voluntary AD&D

Benefit Options Employee Spouse Child(ren)

$10,000 increments $5,000 increments

$1,000, $5,000 or $10,000

$10,000 increments

50% of employee benefit* 15% of employee benefit*

*For spouse and child coverage

combined, benefit will reduce to 40% of employee benefit for spouse and 10% of employee benefit for child

Benefit Maximums Employee Spouse Children

$300,000

100% of employee benefit $10,000

$300,000


Guarantee Issue Employee Spouse Children

$40,000 $20,000 $10,000

$300,000


Additional Features Accelerated Benefit Benefits Begin to Reduce at Age Waiver of Premium

50% up to $100,000

70 Included

N/A 70 N/A

Voluntary Life – Monthly Cost Outline

Age Employee/Spouse Rates

Non-Tobacco (Per $10,000)

Employee/Spouse Rates Tobacco

(Per $10,000) < 25 $0.80 $1.50

25-29 $0.80 $1.50 30-34 $0.90 $1.60 35-39 $1.20 $2.20 40-44 $2.10 $3.60 45-49 $3.00 $6.60 50-54 $5.00 $10.80 55-59 $8.70 $19.40 60-64 $13.80 $23.80 65-69 $21.70 $38.20 70-74 $31.00 $50.10 75 + $44.30 $65.70

Child(ren) Rate $0.16 per $1,000 of benefit regardless of the number of

children in the family

Voluntary AD&D – Monthly Cost Outline

Benefit Rate

(Per $10,000)

Employee $0.50

Family $0.80


VOLUNTARY SHORT-TERM DISABILITY BENEFITS

Voluntary Short-Term Disability – Benefit Outline

Description This disability plan provides financial protection for employees by paying a portion of your income while disabled.

Weekly Benefit Percentage of Weekly Earnings

66.67%

Maximum Weekly Benefit $1,500

Minimum Weekly Benefit $25

Elimination Period 7 Days – Injury 7 Days - Sickness

Pre-Existing Condition Limitation 3/12

Maximum Benefit Period 12 Weeks

Voluntary Short-Term Disability – Monthly Cost Outline

Age Rate Per $10 of Weekly Benefit

< 25 $0.46 25-29 $0.4930-34 $0.5035-39 $0.4540-44 $0.4945-49 $0.6050-54 $0.7455-59 $0.9160-64 $1.07 65 +/ $1.29

Elimination Period: The time period that you must be ill or injured with a covered condition before collecting benefits.

Pre-Existing Condition Limitation: You may not be eligible for benefits if you have received treatment for a condition within 3 months prior to your effective date under this policy until you have been covered under the policy for 12 months.

FLEXIBLE SPENDING ACCOUNTS (FSA)

THE CURRENT FSA PLAN YEAR RUNS THROUGH 9/30/2019

CURRENT PARTICIPANTS MUST SPEND ANY REMAINING FUNDS BY SEPT 30, 2019 AND CLAIM ANY REMAINING FUNDS BY DEC 31, 2019

You may use money in your FSA to pay for eligible expenses incurred by you, your spouse, and your dependents. You and/or your dependents do not have to be enrolled in the medical plan to participate in the healthcare FSA.

If you have an HSA, your healthcare FSA can only be used for eligible dental and vision expenses. Once you’ve met your deductible, you can use your healthcare FSA for eligible medical expenses. See the Limited Purpose FSA section on the next page for more information.

REIMBURSEMENTS

You can use your FSA debit card pay for healthcare expenses at the point of purchase at pharmacies and many other authorized retailers and providers. The debit card lets you to pay for eligible expenses directly from your healthcare FSA so you do not have to wait for reimbursement.

Keep your receipts! In the event WageWorks requires documentation for a purchase made with the benefits debit card, it is your responsibility to provide the detailed copy of your store receipt (not just a credit slip stating dollar amount).

If you do not use the debit card, you will need to submit a claim form and proper documentation. A claim form may be found at www.wageworks.com.

WAGEWORKS EZ RECEIPTS MOBILE APP

The WageWorks EZ Receipts mobile app is a mobile platform that allows you to manage your benefits from the palm of your hand. Available for iPhone, Android, or Blackberry devices, the app is a free-to-download and free-to-use tool for any WageWorks participant with an active FSA. The app includes access to real-time account balances, account alerts, and claim submissions.

Flexible Spending Accounts (FSA)

Flexible Spending Account enrollment for the 2019-2020 School year will not be available until we transition to SEBB on Jan 1, 2020. The SEBB open enrollment period will be Oct 1 - Nov 15, 2019 and the SEBB Benefit Booklet will be available in late September.

**IMPORTANT NOTICE For current 2018-2019 Flex Plan Participants: There will be no rollover available with the transition to SEBB**

If you were a 2018-2019 Flex Plan participant with WageWorks you must spend your account balance by Sept 30, 2019 and claim reimbursement by Dec 31, 2019.


Prepared by Gallagher for the employees of South Kitsap School District26


FLEXIBLE SPENDING ACCOUNTS (FSA) (CONTINUED)

HEALTHCARE FSA

This plan allows you to pay for eligible medical, dental, and vision out-of-pocket expenses with non-taxed dollars. The amount you designate will be deducted from your paycheck in equal amounts throughout the plan year. Once you incur an eligible expense, you can request reimbursement from your account. Note: You may request reimbursement of up to your entire annual election, even though the money has not yet been placed into your account.

Examples of eligible healthcare expenses

Copays for doctor visits and prescription drugs Coinsurance for your medical, dental, and vision plans Deductible amounts for your medical, dental, and vision plans Over-the-counter medicines, except insulin, require a prescription in order to be eligible for reimbursement

Is enrollment in the Healthcare FSA tied to the medical plan?

No. You and/or your dependents do not have to be enrolled in the medical plan to participate in the healthcare FSA.

LIMITED PURPOSE HEALTHCARE FSA – FOR QHDHP PARTICIPANTS

This plan allows you to pay for eligible dental and vision out-of-pocket expenses with non-taxed dollars.

Examples of eligible healthcare expenses

Coinsurance for your dental and vision plans Deductible amounts for your dental and vision plans Over-the-counter medicines, except insulin, require a prescription in order to be eligible for reimbursement

DEPENDENT CARE FSA

This plan allows you to pay for daycare expenses on a pre-tax basis so you and your spouse can go to work or school. You can use this account for children up to the age of 13 (other individuals may qualify if they are incapable of self-care and are considered taxable dependents).

The amount you designate will be deducted from your paycheck in equal amounts throughout the plan year. You are eligible to be reimbursed as the account is funded. Reimbursements cannot exceed the account balance. The IRS will not allow you to claim a dependent care credit on your Federal Tax Return for reimbursed expenses from the dependent care reimbursement account. Consult your professional tax advisor to determine whether you should enroll in this plan.

Examples of qualified daycare providers

Daycare centers Before and after school providers In-home daycare providers Day camp (not overnight)

Does my daycare provider need to be licensed?

No. Your provider must be over the age of 18 and cannot be a qualified dependent living in your household. Your provider’s Social Security number must be provided at the time of claim. The amount you pay this provider will be reported on your Federal Tax Return and the amount paid should be claimed as income on your provider’s Federal Tax Return.

For additional information on FSA plans, including a full list of eligible expenses, please refer to www.wageworks.com.

CARRY OVER

You may carry over up to $500 in unused healthcare FSA money

from one year to the next. Unused amounts in your Dependent Care FSA cannot be carried over and

will be forfeited.


PREMIUM ASSISTANCE UNDER MEDICAID AND THE CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) 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, 2018. Contact your State for more information on eligibility.

ALABAMA – Medicaid Website: http://myalhipp.com/ Phone: 1.855.692.5447

ALASKA – Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1.866.251.4861 Email: [email protected] Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

ARKANSAS – Medicaid Website: http://myarhipp.com/ Phone: 1.855.MyARHIPP (855.692.7447)

COLORADO – Health First Colorado (Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+) Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1.800.221.3943/ State Relay 711 CHP+: Colorado.gov/HCPF/Child-Health-Plan-Plus CHP+ Customer Service: 1.800.359.1991/State Relay 711

FLORIDA – Medicaid Website: http://flmedicaidtplrecovery.com/hipp/ Phone: 1.877.357.3268

GEORGIA – Medicaid Website: http://dch.georgia.gov/medicaid Click on Health Insurance Premium Payment (HIPP) Phone: 404.656.4507

INDIANA – Medicaid Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/ Phone: 1.877.438.4479 All other Medicaid Website: http://www.indianamedicaid.com Phone 1.800.403.0864

IOWA – Medicaid Website: https://dhs.iowa.gov/hawk-i Phone: 1.800.257.8563

KANSAS – Medicaid Website: http://www.kdheks.gov/hcf/ Phone: 1.785.296.3512

KENTUCKY – Medicaid Website: https://chfs.ky.gov Phone: 1.800.635.2570

LOUISIANA – Medicaid Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 1.888.695.2447

MAINE – Medicaid Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1.800.442.6003 TTY: Maine relay 711

MASSACHUSETTS – Medicaid and CHIP Website: http://www.mass.gov/eohhs/gov/departments/masshealth/ Phone: 1.800.862.4840

MINNESOTA – Medicaid Website: https://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-programs/programs-and-services/other-insurance.jsp Phone: 1.800.657.3739

MISSOURI – Medicaid Website: https://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573.751.2005

MONTANA – Medicaid Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1.800.694.3084

NEBRASKA – Medicaid Website: http://www.ACCESSNebraska.ne.gov Phone: 855.632.7633 Lincoln: 402.473.7000 Omaha: 402.595.1178


CHIP (CONTINUED) NEVADA – Medicaid Medicaid Website: https://dhcfp.nv.gov Medicaid Phone: 1.800.992.0900

NEW HAMPSHIRE – Medicaid Website: https://www.dhhs.nh.gov/ombp/nhhpp/ Phone: 603.271.5218 Hotline: NH Medicaid Service Center at 1.888.901.4999

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 Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1.800.541.2831

NORTH CAROLINA – Medicaid Website: https://dma.ncdhhs.gov/ Phone: 919.855.4100

NORTH DAKOTA – Medicaid Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1.844.854.4825

OKLAHOMA – Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1.888.365.3742

OREGON – Medicaid Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1.800.699.9075

PENNSYLVANIA – Medicaid Website: http://www.dhs.pa.gov/provider/medicalassistance/healthinsurancepremiumpaymenthippprogram/index.htm Phone: 1.800.692.7462

RHODE ISLAND – Medicaid Website: http://www.eohhs.ri.gov/ Phone: 855.697.4347

SOUTH CAROLINA – Medicaid Website: https://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://gethipptexas.com/ Phone: 1.800.440.0493

UTAH – Medicaid and CHIP Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1.877.543.7669

VERMONT– Medicaid Website: http://www.greenmountaincare.org/ Phone: 1.800.250.8427

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.hca.wa.gov/free-or-low-cost-health-care/program-administration/premium-payment-program Phone: 1.800.562.3022 ext. 15473

WEST VIRGINIA – Medicaid Website: http://mywvhipp.com/ Toll-free phone: 1.855.MyWVHIPP (1.855.699.8447)

WISCONSIN – Medicaid and CHIP Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf Phone: 1.800.362.3002

WYOMING – Medicaid Website: https://wyequalitycare.acs-inc.com/ Phone: 307.777.7531

To see if any other states have added a premium assistance program since July 31, 2018, or for more information on special enrollment rights, contact either:

U.S. Department of Labor

Employee Benefits Security Administration dol.gov/agencies/ebsa 866.444.EBSA (3272)

U.S. Department of Health & Human Services

Centers for Medicare & Medicaid Services cms.hhs.gov 877.267.2323

(Menu Option 4, Ext. 61565)


CERTIFICATE OF CREDITABLE PRESCRIPTION DRUG COVERAGE

IMPORTANT NOTICE FROM SOUTH KITSAP SCHOOL DISTRICT 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 South Kitsap School District 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 youjoin a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drugcoverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offermore coverage for a higher monthly premium.

2. Your company has determined that the prescription drug coverage offered by Kaiser Permanente and Premera Blue Cross is,on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays andis therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep thiscoverage 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?

You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th through December 7th. 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 may be affected. Your current coverage pays for other health expenses in addition to prescription drugs. If you enroll in a Medicare prescription drug plan, you and your eligible dependents may still be eligible to receive all of your current health and prescription drug benefits. If you do decide to join a Medicare drug plan and drop your current company coverage, be aware that you and your dependents may be able to get this coverage back by enrolling back into the company benefit plan during the Open Enrollment period under the company benefit plan.

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 the company 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 October to join.

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).


CERTIFICATE OF CREDITABLE PRESCRIPTION DRUG COVERAGE (CONTINUED)

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 the company 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 800.MEDICARE (800.633.4227). TTY users should call 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 800.772.1213 (TTY 800.325.0778).

Date: November 1, 2018 Name of Entity/Sender: South Kitsap School District Contact--Position/Office: Payroll Department Address: 2689 Hoover Ave SE, Port Orchard, WA 98366 Phone Number: 360.874.7025


YOUR BENEFITS CONTACTS

Benefit Administrator Contact Information Website

Medical Kaiser Permanente

of Washington Customer Service 888.901.4636 www.kp.org/WA

Medical Premera Blue Cross Customer Service 855.756.0798 www.premera.com

Dental Ameritas Customer Service 800.776.9446 www.ameritas.com

Vision Northwest

Administrators, Inc. Customer Service 800.732.1123 www.nwadmin.com

Life/AD&D Long-Term Disability Short-Term Disability

LifeMap Assurance Company

Customer Service 800.794.5390 www.lifemapco.com

Health Savings Accounts and Flexible Spending Accounts

WageWorks Customer Services

877.924.3967 www.wageworks.com

SOUTH KITSAP SCHOOL DISTRICT BENEFITS WEBSITE

Contains plan descriptions, SBCs, forms, and links to provider directories, helpful tools and other valuable online resources.

www.skschools.org (Benefits and Salaries page)

SOUTH KITSAP SCHOOL DISTRICT

Lalaina Olson, Supervisor of Payroll & Benefits Day to day employee contact and questions

360.874.7025 [email protected]

For questions regarding coverage through Dec 31, 2019.


KEY TERMS

BRAND NAME PRESCRIPTION DRUG

A prescription drug that is sold under a trademarked name. An equivalent generic drug may or may not be available at lower cost, depending on whether the patent on the brand name drug has expired.

COPAY

A flat dollar amount you pay for a medical service.

COINSURANCE

The percentage of the charges you are responsible for paying. For example, if the plan pays 80% and you pay 20%.

DEDUCTIBLE

This is the amount you pay before your plan begins covering expenses not subject to a copay.

EXPLANATION OF BENEFITS

The statement you receive from your insurance company detailing how much the provider billed, how much (if any) the plan paid, and the amount that you owe the provider (if any).

GENERIC PRESCRIPTION DRUG

A prescription drug made and distributed after the brand name drug patent has expired, and available at a lower cost than brand name prescriptions.

OUT-OF-POCKET (OOP) MAXIMUM

The most you pay in a calendar year for covered medical services. Once the OOP maximum is met, the plan will pay 100% of the allowed amount for the remainder of the calendar year for covered services.

IN-NETWORK

Services from a provider or facility that is contracted with the insurance company. In-network providers agree to accept set fees for covered medical services and not bill you for any amounts over those fees. In-network providers also agree to bill the insurance company directly, so you will not have to pay up front and submit your own claims to the insurance company.

OUT-OF-NETWORK

Services from a provider or facility that is not contracted with the insurance company. If you receive services out-of-network, then you will typically have a higher coinsurance and you will be responsible for the difference between the provider’s billed charge and the allowable charge.

PREVENTIVE CARE

Measures taken to prevent diseases. This includes routine cancer screenings, exams and certain drugs and immunizations. Most preventive care is covered-in-full by the plan, with no cost to you.


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Please note: This overview has been prepared to briefly highlight key features of your plan and is not to replace your insurance

contract or booklet. We have compiled information into summary form to answer questions we most commonly receive. Please refer to the insurance carriers’ contracts and booklets for more detailed information and plan

limitations. Actual claims paid are subject to the terms and conditions of the individual carriers’ contracts.

GUIDE 8 | 18 © Gallagher Benefit Services, Inc.

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