Kaukauna Area School District Employee Benefits Booklet Kaukauna Area School District EMPLOYEE BENEFITS GUIDE

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1 Kaukauna Area School District Employee Benefits Booklet 2015 Kaukauna Area School District EMPLOYEE BENEFITS GUIDE

2 Quick Reference Guide Benefit Vendor Phone & Website Health Network Health Plan Dental Delta Dental Life and Disability Insurance Standard Insurance Health Reimbursement Account (HRA) Diversified Benefit Solutions The Fine Print This document is an outline of the coverage proposed by the carrier(s), based on information provided by your employer. It does not include all of the terms, coverage, exclusions, limitations, and conditions of the actual contract language. The policies and contracts themselves must be read for those details. Policy forms for your reference will be made available upon request. The intent of this document is to provide you with general information regarding the status of, and/or potential concerns related to, your current employee benefits environment. It does not necessarily fully address all of your specific issues. It should not be construed as, nor is it intended to provide, legal advice. Questions regarding specific issues should be addressed by your general counsel or an attorney who specializes in this practice area. Your benefits are calculated on a Calendar Year benefit period basis unless otherwise stated. At the end of a Calendar Year, anew benefit period starts for each Participant.

3 Eligibility and Enrollment Guidelines Eligible Employees You are an eligible employee if you have an assignment of at least fifty one percent (51%) of full-time equivalency per year. Coverage will commence on the employee s first day of employment or the day you enter into an eligible class. Eligible Dependents Dependents eligible for benefits include your legal spouse and your dependent child(ren). Dependent child(ren) include your biological children, legally adopted children or children placed for adoption, stepchildren, children for whom benefits must be provided through a Qualified Medical Child Support Order, and children for whom you are the legal guardian. Children are eligible for coverage from birth until age 26, regardless of student or marital status, even if they have another offer of coverage through an employer. If a child becomes mentally or physically handicapped while covered under the benefits plans, the child s coverage may be continued as long as the child remains handicapped and depends on you for support. Kaukauna Area School District reserves the right to conduct, at any time, an audit of dependent eligibility. More information is available from the Human Resources Office. Making Enrollment Changes During the Year In most cases, your pre-tax elections are irrevocable and remain in effect for the entire benefit year. During each annual enrollment period, you will have the opportunity to review your benefit elections and make changes for the coming year. Certain coverages allow limited changes to elections during the year. These benefits include Medical, and Dental. Under these benefits, you may only make changes to your elections during the year if you have a change in status. Status changes include: Marriage, divorce or legal separation Gain or loss of an eligible dependent for reasons such as birth, adoption, court order, disability, death, marriage, or reaching the dependent child age limit Changes in your spouse s employment affecting benefit eligibility Changes in your spouse s benefit coverage with another employer that affects benefit eligibility The change to your benefit elections must be consistent with the change in status. There are detailed rules on when a change in election is deemed to be consistent with a change in status. You have 31 days from the date of a change in status to complete an enrollment change form and return it to the Benefits Office. In most cases, your elections become effective the date of the event. Otherwise, you must wait until the next annual enrollment period to make a change to your elections. 3

4 Medical Coverage Network Health Plan Eligible Employees You are an eligible employee if you have an assignment of at least fifty one percent (51%) of full-time equivalency per year. Coverage will commence on the employee s first day of employment or the day you enter into an eligible class. Network Health Plan $500 / $1000 Plan Option* *Only Employees currently enrolled in the $500 Plan can remain on this plan General Plan Information Deductible In-Network $500 Single $1,000 Family Out-of-Network $1,000 Single $2,000 Family Coinsurance 100% Insurance / 0% Employee 80% Insurance / 20% Employee Out-of-Pocket Maximum $500 Single $1,000 Family $2,250 Single $4,500 Family Lifetime Maximum Unlimited Per Individual Physician Services Office Visits $10 Primary Care Copayment; then Deductible $25 Specialist Copayment; then Deductible $25 Primary Care Copay; then Deductible & Co-Ins. $50 Specialist Copay; then Deductible & Co-Ins. Preventive Care 100% Covered Deductible and Coinsurance apply Routine Vision Exam 100% Covered Deductible and Coinsurance apply Hospital Services Inpatient Deductible applies Deductible and Coinsurance apply Outpatient Deductible applies Deductible and Coinsurance apply Emergency and Urgent Care Emergency Room Urgent Care Value Choice Drugs $200 Copayment $75 Copay $200 Copayment $50 Copayment; the Deductible & Coinsurance apply $0 / $10 / $25 / $50 No Coverage Premium Rates Employer Contribution Per Month Employee Contribution Per Pay Month Employee - $ Family - $ *Employee Contributions per month noted are the example of a 100% FTE full time employee including the Buy Up from High Deductible Plan. 4 * With Personal Health Assessment 12.6% and Buy Up Without Personal Health Assessment 20% and Buy Up *Employee $ $ *Family $ $408.23

5 Eligible Employees You are an eligible employee if you have an assignment of at least fifty one percent (51%) of full-time equivalency per year. Network Health Plan t $2,500 / $5,000 General Plan Information Deductible In-Network $2,500 Single $5,000 Family Out-of-Network $5,000 Single $10,000 Family Coinsurance 100% Insurance / 0% Employee 80% Insurance / 20% Employee Out-of-Pocket Maximum $2,500 Single $5,000 Family $7,500 Single $15,000 Family Lifetime Maximum Unlimited Per Individual Physician Services Office Visits $10 Primary Care Copayment; then Deductible $25 Specialist Copayment; then Deductible $25 Primary Care Copay; then Deductible & Co-Ins. $50 Specialist Copay; then Deductible & Co-Ins. Preventive Care 100% Covered Deductible and Coinsurance apply Routine Vision Exam 100% Covered Deductible and Coinsurance apply Hospital Services Inpatient Deductible applies Deductible and Coinsurance apply Outpatient Deductible applies Deductible and Coinsurance apply Emergency and Urgent Care Emergency Room Urgent Care Value Choice Prescription Drugs $200 Copayment $75 Copay $200 Copayment $50 Copayment; the Deductible & Coinsurance apply $0 / $10 / $25 / $50 No Coverage Premium Rates Employer Contribution Per Month Employee Contribution Per Month Employee - $ Family- $ *Employee Contributions per month noted are the example of a 100% FTE full time employee * With Personal Health Assessment 12.6% Without Personal Health Assessment 20% * Employee $59.44 $94.34 *Family $ $ Coverage will commence on the employee s first day of employment or the day you enter into an eligible class. 5

6 Dental Benefit Summary Delta Dental PPO Eligible Employees You are an eligible employee if you have an assignment of at least fifty one percent (51%) of full-time equivalency per year. Coverage will commence on the employee s first day of employment or the day you enter into an eligible class. How the Plan Works This Plan has been designed and selected by the Policyholder as one of the benefits of your employment. This employee booklet summarizes the plan benefits and provisions for Dental Benefits. Benefits for Covered Dental Services described in this booklet are determined by the benefit categories listed below. You are covered only for those benefit categories selected by the Policyholder and shown on the Schedule of Benefits. Type of Service Delta PPO/Premier Out-of-Network $0 Individual $0 Individual Deductible and Annual Max per member $0 Family $0 Family (excludes orthodontia services) $1,000 Annual Program $1,000 Annual Program Max Per Member Max Per Member Diagnostic & Preventive Care Exams Cleanings Fluoride Treatments X-Rays Space Maintainers Sealants Emergency Treatment to Relieve Pain (Deductible Applies) Basic & Major Services Fillings Endodontics Non-surgical Endodontics Surgical Periodontics Non-surgical Periodontics Surgical Extractions Non-surgical Extractions Surgical Crowns, inlays, onlays Repairs and adjustments to bridges and dentures (Deductible Applies) 100% 100% 100% 100% Orthodontia Coverage Copayment 50% of allowable 50% of allowable Individual Lifetime Maximum $1,500 $1,500 Dependents eligible to age: Adult Ortho? (Deductible Applies) Yes Yes Special Plan Provisions Vision Discount Program 35% Discount Program Not covered Premium Rates Employer Contribution Employee Contribution Per Month Per Month Employee - $43.10 Family - $ *Employee Contributions per month noted are the example of a 100% FTE full time employee * Employee - $5.43 * Family - $

7 Life/AD&D & Disability Benefits Standard Basic Life and Accidental Death & Dismemberment Life Insurance provides financial security for the people who depend on you. Your beneficiaries will receive a lump sum payment if you pass away while employed by Kaukauna Area School District. As an eligible employee, you are covered for Basic Life and AD&D insurance at no cost to you. Eligible Employees You are an eligible employee if you have an assignment of at least fifty one percent (51%) of full-time equivalency per year. Coverage will commence on the employee s first day of employment or the day you enter into an eligible class. Specific details of the plan are covered in the Employee Life Benefit Plan Certificate. Group Term Life/AD&D Insurance offered by Standard Insurance Premium Kaukauna Area School District pays this premium at 100% Amount of Life Insurance Benefit 1x Salary to max. of $100,000 Amount of AD&D Benefit Equal to term life Age Reduction Schedule To 65% at age 70; to 45% at age 75; to 30% at age 80 Short Term Disability Insurance offered by Standard Insurance Weekly Benefit Elimination Period Duration 66.67% up to $1,000 per Week 1st Day Accident / 5th Day Sickness 90 Days Long Term Disability Insurance offered by Standard Insurance Monthly Benefit Elimination Period Duration 90% up to $9,450 per Month Maximum 90 Days To age 65 if Totally Disabled 7

8 Employee voluntary benefit Supplemental Life Insurance offered by Standard Insurance In addition to the Basic Life and AD&D insurance provided by Kaukauna Area School District you also have the option to purchase Supplemental Life Insurance coverage for yourself, your spouse, and children. Supplemental Life Employee Coverage Spouse Coverage Child Coverage Benefit Amount Purchase in increments of $5,000 Maximum benefit of $500,000 Guarantee Issue During Initial Eligibility & Open Enrollment: $75,000 Purchase in increments of $2,500 Maximum benefit of $100,000 Guarantee Issue During Initial Eligibility & Open Enrollment: $25,000 Flat $7,500 Guarantee Issue During Initial Eligibility & Open Enrollment: $7,500 Age Reduction Schedule To 65% at age 65; To 50% at age 66; to 25% at age 67 Supplemental Life Insurance MONTHLY Rates Employee Rate Spouse Rate Child Rate Age Rate per $1,000 Rate per $1,000 Rate per $1,000 <30 $0.06 $ $0.08 $ $0.09 $ $0.13 $ $0.20 $0.20 $ $0.31 $ $0.51 $ $0.66 $ $1.27 $ $3.75 $3.75 Rate Calculator $ / $1,000 = $ x $ $ Supplemental Life Coverage You Want / $1,000 = Enter the Answer x Your Rate per Your Age Your Monthly Rate 8

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