Kent School District

A Guide To Your Employee Benefits

2015 - 2016 Plan Year

The information herein is not a contract. It is a summary of the benefits available. It is not intended to be an all-inclusive description of Plan benefits, limitations or exclusions, and should not be used in lieu of a Plan book. Be sure to consult your Plan booklet, or consult with the insurance company representative before making your selection. If there are any discrepancies between this summary and the official Plan documents and booklets, the official Plan documents and booklets prevail. Questions may be directed to The Partners Group at (877) 455-5640. Any further information, revisions by bargaining units or by insurers after this date could change or modify the information contained herein.

WELCOME TO YOUR BENEFITS! Kent School District is proud to offer a comprehensive benefits package to its valued employees and their eligible family members. The package is designed to provide you with choice, flexibility and value. This benefits guide will help you learn more about your benefits, review highlights of the available plans and make selections that best fit your lifestyle and budget needs. This information is also available online on Staff Link. In addition you may contact the Human Resources Employee Benefits Department or our Benefit Specialist at The Partners Group for help understanding your benefits and completing your paperwork. Contact information for The Partners Group is located on the “Benefits Contact” page at the end of this guide. Access to insurance plan booklets that provide more detailed information on each of the programs can be found on Stafflink through the Human Resources page.

Table of Contents

Eligibility ................................................................................................................................................................................. 4 Making Changes to Your Dependents or Benefits ������������������������������������������������������������������������������������������������������������������ 4 Skyward Online Open Enrollment Instructions ������������������������������������������������������������������������������������������������������������������� 5-6 Mandatory Benefits Dental...................................................................................................................................................................................... 8 Vision (Classified Staff) ������������������������������������������������������������������������������������������������������������������������������������������������������ 9-10 Life/AD&D/Long Term Disability (Certificated Staff) ������������������������������������������������������������������������������������������������������������� 11 Life/AD&D/Long Term Disability (Classified Staff) ���������������������������������������������������������������������������������������������������������������� 12 Employees Assistance Plan ��������������������������������������������������������������������������������������������������������������������������������������������������� 13 Medical Benefits All Staff Medical Plan Options...............................................................................................................................................15 Important Information on Your Medical Benefit Plan ���������������������������������������������������������������������������������������������������������� 16 Medical Benefits—Plan Highlights ���������������������������������������������������������������������������������������������������������������������������������� 17-19 QHDHP/HSA Plan Questions & Answers ������������������������������������������������������������������������������������������������������������������������������� 20 Premium & Payroll Deduction Worksheets ��������������������������������������������������������������������������������������������������������������������� 21-24 Pooling................................................................................................................................................................................... 25 Saving Money on Medical Costs ������������������������������������������������������������������������������������������������������������������������������������������� 25 Voluntary Benefits Vision (Certificated Staff) ������������������������������������������������������������������������������������������������������������������������������������������������������ 27 Voluntary Short Term Disability ������������������������������������������������������������������������������������������������������������������������������������������� 28 Voluntary Long Term Care ���������������������������������������������������������������������������������������������������������������������������������������������������� 28 Advantage Home Plus.......................................................................................................................................................... 28 Voluntary Term Life and AD&D Insurance (Certificated Staff)...............................................................................................29 Voluntary Term Life Insurance (Classified Staff)....................................................................................................................29 Voluntary AD&D Insurance (Classified Staff) ������������������������������������������������������������������������������������������������������������������������ 30 MetLaw Legal Plan ���������������������������������������������������������������������������������������������������������������������������������������������������������������� 30 Flexible Spending Account ���������������������������������������������������������������������������������������������������������������������������������������������� 31-32 Healthy Kids Now! Program ������������������������������������������������������������������������������������������������������������������������������������������������� 33 COBRA Information �������������������������������������������������������������������������������������������������������������������������������������������������������������� 33 HIPPA Privacy Notice ������������������������������������������������������������������������������������������������������������������������������������������������������� 34-36 Certificate of Creditable Prescription Drug Coverage ����������������������������������������������������������������������������������������������������������� 37 Benefits Contact Information ����������������������������������������������������������������������������������������������������������������������������������������������� 38 Employee Discount Information ������������������������������������������������������������������������������������������������������������������������������������������� 39

Eligibility Regular Classified employees with a contract of 20.0 hours per week and Certificated employees with a contract of 18.75 hours per week (.50 FTE) are eligible for benefits and have 30 days to select plans from the first day of:

• • • •

Start date Return from an unpaid leave or a rehired employee that had a break in their insurance coverage while on leave Changing positions between the Kent Education Association (KEA) and a Classified or Leadership team position Increase in the number of hours such that the new total number of hours worked is 20.0 or more hours per week as a regular Classified employee or 17.5 hours per week (.50 FTE) as a regular Certificated employee. • The effective date for a newly eligible employee will be the 1st of the month following start date, if started on or before the 15th of the month; or the 1st of the next month following 30 days, if started after the 15th of the month. • Example: If an employee starts August 2nd, coverage will be effective September 1st. If an employee starts on August 16th, coverage will be effective October 1st.

Dependents Your legal spouse or domestic partner is eligible for coverage. Your domestic partner is eligible to enroll in all coverages. In addition to submitting your selection through Skyward Online Open Enrollment, you must also complete a Declaration of Domestic Partnership or submit your State Registration to enroll your partner in the medical, dental and vision plans. Note that the IRS considers benefits your employer provides for your domestic partner as taxable income. This means that in most cases, the difference between the fair market value of the benefit and your taxable payroll deduction is imputed income and is subject to federal income tax, FICA tax, and state taxes (where applicable). The fair market value is the amount it would cost you to buy insurance for your domestic partner using group policy rates. Your natural children, step children, and adopted children are eligible for coverage up to age 26 (Classified Staff vision coverage up to age 25). Coverage is also available beyond age 26 for incapacitated children. Please see Human Resources for more information.

Making Changes to Your Benefits

Types of Qualifying Events

You may make changes to your benefit choices once a year during the open enrollment period. Outside of this period, you can add or drop dependents if there has been a qualifying event (see right for examples.) Coverage will be effective for newborns on their actual date of birth. If you have been recently married, coverage becomes effective the 1st of the month after date of marriage.

• You get married or divorced

From a qualifying event, contact Human Resources Employee Benefits to request access to Skyward Online Open Enrollment.

• An enrolled family member dies

You have the following time periods to enroll:

• You (or your spouse) go on a leave of absence

• 60 days from birth/adoption to add a child. • 30 days from date of marriage to add a spouse and stepchildren. • 30 days to add a spouse or children if there has been a loss of other group coverage (60 days for Premera Blue Cross Plans). • 30 days to enroll dependents for voluntary benefits. Many of your benefits are on a pre-tax basis so the IRS requires you to have a qualified change in status in order to make changes to your benefits.

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• You enter into a domestic partnership • You have a child or adopt one

• You waived coverage for yourself or your family member because of other coverage and that coverage is lost for qualified reasons

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Mandatory Benefits

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Dental Benefits Kent School District provides its employees a comprehensive dental plan through either Delta Dental of WA (DDWA) or Willamette Dental. Under the Delta Dental of Washington Incentive Plan A*, you may receive care from any dentist. However, if you receive care from a member dentist, your benefits will be paid at a higher level, your out-of-pocket expenses will be lower, and your benefit maximum for the plan year will be greater.** The Delta Dental of WA DeltaCare is a managed care plan and Willamette Dental is an Exclusive Provider Organization (EPO) plan. In order to access benefits provided by these plans, you need to see an authorized provider. If you obtain care from a non-authorized provider, you will not receive any benefits provided by these plans. If you are newly eligible for benefits, you must select one of these plans within 30 days of your start date or date of eligibility. If you do not make your elections via Skyward Online Open Enrollment within those 30 days, you will automatically be enrolled in the DeltaCare plan and you will not be able to change plans until the next open enrollment period. Delta Dental Incentive Plan A Any Licensed Dentist*

Delta Dental DeltaCare Managed Care Delta Care Provider Only

Willamette Dental EPO Willamette Provider Only

Plan Year

11/1 to 10/31

Not Applicable

Not Applicable

Plan Year Max

$2,000 PPO Provider $1,750 Non-PPO Provider

No Maximum Amount

No Maximum Amount

Diagnostic and Preventive Services Exams, cleanings, x-rays

First Year 70% Second Year 80% Third Year 90% Fourth Year 100%

100% (co-pays will apply to some services)

$15 copay per visit then covered at 100%

Basic Services Fillings, oral surgery, periodontics, endodontics

First Year 70% Second Year 80% Third Year 90% Fourth Year 100%

100% (co-pays will apply to some services)

$15 copay per visit then covered at 100%

Crowns

First Year 70% Second Year 80% Third Year 90% Fourth Year 100%

Co-pay will depend on type of crown

$50 copay then covered at 100% ($15 per visit copay)

Major Services Dentures, bridges

50%

Co-pay will depend on type of service provided

$50 copay then covered at 100% ($15 per visit copay)

Orthodontia Children up to age 26

50% up to $1,500 lifetime maximum

50% up to $1,500 lifetime maximum

$2,000 copay then covered at 100%

Pre-determination Limit: No treatment plans require pre-determination. However, it is recommended for services greater than $300. *You must visit your dentist at least once during each plan year to increase or maintain your level of benefits under Incentive Plan A. If you do not, your benefits will fall by 10% but will never go below the 70% starting level. **Members are encouraged to visit the DDWA website to download a card with an alternate identification number to avoid using your SSN.

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Vision Benefits - Classified Staff Kent School District provides its eligible Classified employees vision care coverage through Northwest Benefit Network (NBN). This plan allows you to use any licensed provider. However, if you use an NBN panel provider your benefits are greater, your out of pocket costs are less, and payment is made directly to the provider. Please refer to the table below to find out how often you are eligible for services and what benefits are provided. Panel Provider

Non Panel Provider

100%

Reimbursed up to $40

$25

N/A

Many frames are available at no cost to you. If you desire frames in excess of what is allowed by the plan, you pay the difference between the allowed and covered costs.

Reimbursed up to $70

Exam once each consecutive 365 days Hardware Co-pay Once each consecutive 365 days Frames* once each consecutive 365 days Contacts** once each consecutive 365 days Allowance is toward the total cost of exam, lenses and fitting in lieu of all other benefits.

Reimbursed up to up to $275

$130 per pair or

(medically necessary paid in full)

$235 per pair for

 

(after cataract surgery) Reimbursed:

subnormal vision

Lenses***

 

 

Single Vision (per pair)

100%

up to $40

Bifocal (per pair)

100%

up to $60

Trifocal (per pair)

100%

up to $80

Lenticular (per pair) Lens Extras

100%  

up to $125  

once each consecutive 365 days

covered when necessary

not covered

Generic Flat Top Multifocal

100%

not covered

Blended

100%

not covered

Progressive****

100%

Reimbursed

Polycarbonate

100%

not covered

Oversize Blanks

100%

not covered

Prism & Double Segs

100%

not covered

Slab Off

100%

not covered

Laminated

100%

not covered

Pink #1 and #2 Tints

100%

not covered

Sun Tints

100%

not covered

Glass Photochromatic Lite Shades (e.g., Photogrey Extra)

100%

not covered

Glass Photocromatic Dark Shades (e.g., Photosun)

100%

not covered

not covered

not covered

Other Tints (solid, gradient, mirror (glass only), UV, Polaroid)

100%

not covered

Anti-Reflective Coat

100%

not covered

Anti-Relfective & Scratch Coat– Basic Types****

100%

not covered

Color, Edge & Special Lens Edge Treatments

100%

not covered

Scratch Coat

100%

not covered

High-Index****

up to $100 per pair

Plastic Photochromatic (e.g. Transitions)****

Dependent children are covered up to age 25. *

Patients choose from a wide selection of fully covered frames. Because of the cosmetic nature of frames and the rapidly changing styles, NBN has a limit on the cost of frames provided under the program.

**

To receive this allowance you must be eligible for both the exam and lenses at the time services for contacts begin.

***

Lenses refers to basic lenses. Extras are listed separately. Some new products may not be covered. To confirm coverage contact NBN directly.

****

If covered, plan pays for standard or basic styles. Patient pays difference in cost of “premium” progressive, “premium” photochromatic, “premium” antireflective + scratch coat and “premium” hi-index lens extras.

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Vision Benefits - Classified Staff (Continued)

How to obtain benefits from a panel provider:

Locate a panel provider any time online at www.nwadmin.com Obtain a claim form from Staff Link each time you or your covered dependents receive vision care from a panel provider. Complete the form and give it to the panel provider. You MUST bring this claim form to the provider at time of service or you may be charged the full retail price of any services provided. The panel provider will go over what services are covered by your plan. They will submit the claim form to NBN for reimbursement. Any costs not covered by the plan will be your responsibility at time of service.

How to obtain reimbursement for services at a non-panel provider: Send in your itemized statement and NBN claim form to the NBN claims office. NBN will process your claim and pay you directly in accordance with the non-panel schedule of benefits. Claims must be submitted within 365 days from the date of service. If you obtain services or eyewear before you are eligible, you will be responsible for all charges incurred.  If a noncovered lens extra or a frame that exceeds the plan allowable is ordered, you are responsible for the additional costs, including any fees.   Non-panel claims must be submitted within one (1) year from the date of service to be considered for payment.  There will be additional Patient Responsibility if a Premium version of a covered item is ordered; the plan covers Standard styles of lens extras. Please note:  This is a summary only of the benefits of the plan.  Actual benefits are based upon the plan agreement, which may contain plan details not specified in this summary.  Please contact NBN at (800) 732-1123 if you have any questions about the plan benefits and/or your eligibility status or you can register online at www.nwadmin.com to review your past claims history, eligibility status, view your plan brochure, print a claim form and more.

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Life and Disability Insurance - Certificated Staff Life and Disability Insurance is offered by Cigna. Kent School District provides all eligible employees with Basic Life Insurance, Accidental Death and Dismemberment (AD&D) Insurance and Long Term Disability Insurance. These benefits are mandatory and cannot be waived even if you have similar coverage elsewhere.

Basic Life Insurance - Certificated Staff The benefit from this policy is $50,000 to your beneficiary in the event of your covered death. This benefit is reduced by 35% at age 65, by 58% at age 70, by 70% at age 75, by 81% at age 80, by 86% at age 85 and by 90% at age 90. Upon termination, or if you become ineligible for benefits, you can convert this policy to an individual policy. Note: You will have an additional $12,500 decreasing term life policy through Unum if you enroll in a Premera Blue Cross medical plan.

Accidental Death & Dismemberment Insurance- Certificated Staff In the event of your accidental covered death, this plan will pay your beneficiary an additional benefit matching your life benefit. This benefit is reduced by 35% at age 65, by 58% at age 70, by 70% at age 75, by 81% at age 80, by 86% at age 85 and by 90% at age 90. If you are seriously injured as the result of an accident (e.g. loss of eyesight, paralysis, loss of limbs) this plan will pay a partial benefit to you.

Long Term Disability Insurance- Certificated Staff Long term disability coverage is provided by Cigna. This plan provides financial assistance if you are not able to return to work after 60 days of disability due to physical disease, injury, pregnancy or mental disorder. Benefits from this policy can replace the lesser of 60% of the first $8,333 of your monthly earnings or 70% of your monthly earnings reduced by deductible income, to a maximum benefit of $5,000 per month. Benefits are offset by any income from other sources including Social Security or Workers’ Compensation. Benefits begin after you have been disabled for 60 days and may continue until you are able to return to work or reach your normal Social Security Retirement Age. You are considered disabled if you cannot perform the material duties of your own occupation for the first 36 months or any occupation after 36 months. There are restrictions and limitations on these benefits so please review the Plan Summary for details. Premium is based on your monthly salary; for rates please refer to the Premium and Payroll Deduction Worksheet in this guide.

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Life and Disability Insurance - Classified Staff Basic Life Insurance helps provide financial protection by promising to pay a benefit in the event of an eligible employee’s covered death. Basic Accidental Death and Dismemberment (AD&D) Insurance may provide an additional amount in the event of a covered death or dismemberment as a result of an accident. Benefits Employee Coverage Amount The Basic Life coverage amount is $50,000. AD&D Insurance For accidental loss of life, the amount of this insurance benefit is equal to the employee Basic Life coverage amount. For other covered losses, the amount of this benefit is a percentage of the Basic Life coverage amount. Dependents Life Insurance The insurance policy provides $5,000 of coverage for the employee’s eligible spouse. The insurance policy also provides $2,000 of coverage for the employee’s eligible child(ren). Spouse coverage terminates at age 70. Child(ren) cover terminates at age 26. Age Reductions Under this policy, insurance coverage reduces to 50% at age 70. Other life Features and Services: Other AD&D Features: • Right to Convert Provisions • Seat Belt Benefit • Waiver of Premium

• Family Benefits Package

• Accelerated Benefit

• Occupational Assault Benefit • Common Disaster Benefit

Long Term Disability Insurance- Classified Staff Group Long Term Disability (LTD) insurance provides financial protection for eligible employees by promising to pay a percentage of monthly earnings in the event of a covered disability. Benefits Monthly Benefit Lesser of 60% of the first $8,333 of monthly predisability earnings for KAEOP, KAP, KSFSA, Teamsters, AFT-Kent. Lesser of 60% of the first $16,666 of monthly predisability earnings for Principals. Maximum Monthly Benefit $5,000 - KAEOP, KAP, KSFSA, Teamsters, AFT-Kent. $10,000 - Principals. Minimum Monthly Benefit $100 or 10% of maximum monthly benefit, whichever is greater. Waiting Period Before Benefits Become Payable 60 days Definition of Disability The Employee is considered Disabled if, solely because of Injury or Sickness, he or she is: 1. unable to perform the material duties of his or her Regular Occupation; and 2. unable to earn 80% or more of his or her Indexed Earnings from working in his or her Regular Occupation. After Disability Benefits have been payable for 36 months, the Employee is considered Disabled if; solely due to Injury or Sickness he or she is: 1. unable to perform the material duties of any occupation for which he or she is, or may reasonably become, qualified based on education, training and experience; and 2. unable to earn 60% or or more of his or her Index Earnings Maximum Benefit Period If an employee becomes disabled before age 62, LTD benefits may continue until age 65 or Social Security Normal Retirement Age (SSNRA). If an employee becomes disabled at age 62 or older, the benefit duration is determined by the age when disability begins. Other Features & Services: • 24 hour coverage, including coverage for work-related disabilities • Assisted Living Benefit • Survivor Benefit • Return to Work Responsibility and Incentive • Temporary Recovery Provision • Waiver of Premium while LTD benefits are payable • Rehabilitation Plan Provision • Conversion of Insurance Provision The above outlines are intended to highlight the key points of your plans. The Group Insurance Certificate provides the detailed and controlling descriptions of your insurance coverage. These certificates can be found on the Human Resources page through Staff Link (https://stafflink.kent.k12.wa.us/HRPub/Pages).

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Employee Assistance Program (EAP) Kent School District provides an Employee Assistance Program (EAP) through First Choice Health. The EAP provides costfree, convenient, and confidential assessment and referral services with a licensed behavioral health provider to you, your spouse or domestic partner, and children up to age 26. You can reach the EAP 24 hours a day, 7 days a week. When you call you’ll be greeted by a customer service professional ready to response to your questions, needs and preferences. A provider is always available to talk with you or your covered family members. The EAP is able to help with a variety of family, relationship, emotional, behavioral, mental health or chemical dependency concerns, including: • Stress & Anxiety

• Impulse Control

• Depression

• Crisis Management

• Couples & Relationships

• Sleep Problems

• Parenting & Family Concerns

• Grief & Loss

• Adolescence

• Work Conflict

• Legal or Financial Consultation

• Gambling Problems

• Alcohol/Drug Problems

• Child or Eldercare Consultations

• Communication

• ID Theft Resolution

• Change & Life Transitions

• Texting/Internet Addictions

WORK LIFE RESOURCES ONLINE OR WITH A CONSULTANT • Legal Consultation—Through First Choice Health EAP you have access to a free 30-minute legal consultation, face-toface or by telephone. • Financial Services—First Choice Health EAP provides free financial counselors who are available for consultation and education. The telephonic consultation includes 30-60 minutes of financial counseling. • Identity Theft Resolution—Many Americans have been victimized by identity theft and consumer fraud. The average consumer spends over 175 hours responding to and resolving instances of identity theft. Our Fraud Resolution Specialists are qualified legal professionals providing step-by-step guidance and consultation about identify theft or fraud. • Childcare Consultation—This convenient service offers families and parents information whenever a childcare need arises. Qualified childcare professionals help identify resources parents may need from prenatal care to college education. • Eldercare Services—If you’re concerned about an aging or disabled loved one, the EAP can connect you to eldercare experts and resources—regardless of where your family member lives.

CONFIDENTIAL SERVICES First Choice Health EAP understands the importance of maintaining reliable, confidential services available to employee families. We know that making it possible to consult discreetly with an EAP provider is essential – perhaps the most important role of the Employee Assistance Program. Information about your contact with the EAP is never released without your request and signed consent (unless we are required by law to do this in the interest of public safety). To initiate Assessment and Referral services contact us at (800) 777-4114 or online at www.FirstChoiceEAP.com. Username:

firstchoice

Password:

health2005

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Voluntary Medical Plan Summaries

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All Staff Medical Plan Options

Comprehensive and preventive health care coverage is important in protecting you and your family from the financial risks of unexpected illness and injury. Kent School District offers you a choice of five plans through Premera Blue Cross and one plan through Group Health Cooperative. All six plans cover most of the same benefits, but your out-of-pocket expenses and network physicians vary. 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. PREFERRED PROVIDER ORGANIZATION (PPO) type plans contract with a large number of providers. If you choose to receive your care through a preferred provider, the insurance company will pay a higher percentage of the charges. If you choose to receive your care through a nonpreferred provider, then the insurance company will pay a lower percentage of the charges.

HEALTH MAINTENANCE ORGANIZATION (HMO)/ MANAGED CARE type plans provide you with managed benefits and usually at a lower cost at the time of service. However, these plans require that you select a primary care provider (PCP) from their list of providers. Your PCP will then either provide or coordinate all of your care (except in the case of medical emergency).

Preferred Provider Plan Choices:

HMO / Managed Care Plan Choice:

Premera Blue Cross

Group Health Cooperative

Emergency Room (E.R.) Physicians And Hospitals

All online selections must be completed and submitted to Human Resources Employee Benefits Department by 15th of the month prior to coverage effective date.

NOTICE: E.R. Physicians and Hospitals they practice in are not always participating with the same insurance companies. The physicians and hospitals are usually under separate contracts. RECOMMENDATION: To receive the highest benefits your insurance provides, during open enrollment, it is a good idea to check your nearest emergency room and physician participation prior to needing these services. You may do this by calling your insurance company or checking their website.

If you need help using Skyward Online Open Enrollment, have questions regarding your employee benefits, or need help understanding the plans offered please contact: KSD Human Resources Employee Benefits Judy Weaver - Specialist for Certificated Staff 253-373-7186 Faith Huguley - Specialist for Classified Staff 253-373-7222 For advice on which plan is best for you, contact our benefits broker: Jeanette Busby Senior Account Manager The Partners Group 877-455-5640 or 425-285-2310 [email protected]

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IMPORTANT INFORMATION REGARDING YOUR MEDICAL BENEFIT PLAN PRE-EXISTING CONDITION LIMITATIONS Premera BlueCross and Group Health Cooperative medical plans do not have preexisting condition waiting periods (excluding transplant services - see below) under these plans. Please see contract for coverage details.

ORGAN TRANSPLANT Premera Blue Cross: Organ and bone marrow transplants require prior Premera Blue Cross approval.  Donor costs are limited to $75,000 for the EasyChoice Plans and the QHDHP. Benefits may be subject to a 12 month waiting period. See benefit booklet for specific information. This exclusion period may be waived for each day you had prior creditable coverage, provided there was not more than a 90 day lapse in coverage. Group Health Cooperative: Transplant benefit is subject to all applicable co-pays. Coverage for transplants, including follow-up care, is excluded until the subscriber has been continuously enrolled on the plan for 12 months. This waiting period may be credited for each day the participant had prior creditable coverage, provided there was no more than a 90 day lapse in coverage. The waiting period will not apply to transplant-related Rx.

WOMEN’S HEALTH AND CANCER RIGHTS ACT OF 1998 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 lymphedemas. 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 co-pays and co-insurance amounts.

OUT-OF-AREA BENEFITS Premera Blue Cross: If you are traveling or living outside of Washington and need medical care, you may use a Blue Cross or BlueShield PPO provider to receive the same benefits as the preferred level of your plan. When you are outside of the service area and need medical care, call the BlueCard Access Line at (800) 810-BLUE (2583) for information on the nearest PPO doctors and hospitals. The doctor or hospital will verify your membership and coverage information after you present your identification/ membership card. The doctor or hospital will electronically route your claim to your Blue Cross plan for processing. Because all PPO providers are paid by the plan directly, you are not required to pay for the care at time of service and then wait for reimbursement. You will only need to pay for out-of-pocket expenses, such as non-covered services, deductible, co-pays and co-insurance. Group Health Cooperative: Group Health provides worldwide emergency and urgent care. If you experience an emergency medical condition, you should call 911 or go to the nearest medical facility. The emergency room co-pay will apply. If you are admitted to a hospital, you need to contact your health plan immediately or as soon as reasonably possible (within 24 hours). If you need urgent care when you are outside of the service area, you should call your family doctor’s office during office hours or call Group Health’s 24-hour consulting nurse. If possible, Group Health will help you arrange care at a Group Health or Kaiser Permanente facility. Be prepared to pay up front for your medical care and Group Health will reimburse you for the covered costs when you submit the medical claim. You are responsible for the applicable office visit co-pay.

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 toward your or your dependents’ other coverage). However, you must request enrollment within 30 (Group Health Options: 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 30 (Group Health Options: 31) days after the marriage, birth, adoption, or placement for adoption. To request special enrollment or obtain more information, contact your Human Resources Employee Benefits Department.

16

All Staff Medical Plan (Network) Network Medical Deductible

Premera Blue Cross PPO 2 (Heritage) In Network

Coinsurance Medical Out of Pocket Max Rx Out of Pocket Max Office Visit Preventive Care*

In Network

Out of Network

Premera Blue Cross PPO 5 (Foundation) In Network

Out of Network

$200 person/ $600 family

$350 per person

$200 person / $600 family

$300 person / $900 family

None

None

None

Nov & Dec Only

Nov & Dec Only

Nov & Dec Only

Rx Deductible 4th Qtr. Carry Over

Out of Network

Premera Blue Cross PPO 3 (Heritage)

80%

60%

$1,700 person / $5,100 family

$3,400 person / $10,200 family

$2,000 person/$4,000 family

80%

60%

$2,950 person / $8,850 family

$5,900 person / $17,700 family

$2,000 person/$4,000 family

90%

70%

$700 person/ $2,100 family

None

$2,000 person/$4,000 family

$25 copay (dw)

$30 copay (dw)

$30 copay (dw)

$40 copay dw)

$15 copay (dw)

70%

100% (dw)

80% (dw)

100% (dw)

80% (dw)

100% (dw)

Not covered

Diagnostic Services

Deductible & Coinsurance

Deductible & Coinsurance

Deductible & Coinsurance

Emergency Care**

$75 copay + ded & coin

$100 copay + ded & coins

$50 copay + ded & coin

Ambulance

Deductible & Coinsurance

Deductible & Coinsurance

$50 copay + deductible

Hospital (Inpatient)

$150 copay per day / $450 max PCY then ded & coin

$300 copay per day / $900 max PCY then ded & coin

$150 copay per day / $450 max PCY then ded & coin

Hospital (Outpatient)

Surgery- $100 copay then ded & coin All other services- Ded & coin

Surgery- $150 copay then ded & coin All other services- Ded & coin

Deductible & Coinsurance

Spinal Manipulations Visits

Unlimited Visits

Unlimited Visits

Unlimited Visits

Not Covered

Not Covered

Not Covered

45 visits PCY Unlimited visits for PT

45 visits PCY Unlimited visits for PT

45 visits PCY

Vision Care RehabOutpatient (Speech, Massage, OT,PT) RehabInpatient (Speech, Massage, OT,PT)

$25 copay (dw) PT: ded & coin

$30 copay (dw) PT: ded & coin

$30 copay (dw) PT: ded & coin

$40 copay (dw) PT: ded & coin

120 days PCY

30 days PCY

See Hospital Inpatient

See Hospital Inpatient

$15 copay (dw)

Ded & coin

30 days PCY See Hospital Inpatient

Ded & coin

Generic / Preferred / Non - Preferred At Participating Pharmacies 

Prescriptions Retail Cost Share (30 Day Supply)

$10 / $20 / $35 (34 day supply)

$15 / $25 / $40 (34 day supply)

$10 / $15 / $30

Mail Order Cost Share (90 Day Supply)

$15 / $30 / $45 (100 day supply)

$20 / $35 / $50 (100 day supply)

$15 / $30 / $60

$50 Copay through Accredo or Walgreens Specialty Pharmacy Only

$60 copay through Accredo or Walgreens Specialty Pharmacy Only

$50 copay through Accredo or Walgreens Specialty Pharmacy Only

Specialty Cost Share (30 Day Supply)

Life/AD&D Insurance $12,500 Term Life and AD&D for Employee Only *Preventive Services as defined by the Affordable Care Act (dw)= Deductible Waived **Copay waived if admitted to hospital (PCY) = Per Calendar Year Ded & coin = Deductible & Coinsurance Apply OT = Occupational Therapy PT = Physical Therapy To locate a Premera provider, visit www.premera.com/wea. Rx = Prescription Medication

17

All Staff Medical Plan (Network) Network Medical Deductible

Premera Blue Cross EasyChoice A (Heritage) Out of Network

In Network

Out of Network

In Network

Out of Network

$1,000 person/ $3,000 family

$2,000 person/ $6,000 family

$750 person/ $2,250 family

$1,500 person/ $4,500 family

$1,250 person/ $2,500 family

$2,500 person/ $5,000 family

$500 person/ $1,000 family

Not covered

4th Qtr. Carry Over

Medical Out of Pocket Max Rx Out of Pocket Max Office Visit Preventive Care*

Premera Blue Cross Basic (Heritage Prime)

In Network

Rx Deductible

Coinsurance

Premera Blue Cross EasyChoice B (Heritage)

$500

$250

Nov & Dec Only

Nov & Dec Only

Nov & Dec Only

80%

50%

75%

50%

70%

50%

$4,000 person/ $8,000 family

None

$3,500 person/ $7,000 family

None

$4,500 person/ $9,000 family

Unlimited

$2,100 person/ $4,200 family

Not covered

$2,500 person/$5,000 family

$2,500 person/$5,000 family

$15 copay (dw)

50%

$30 copay (dw)

50%

$30 copay (dw)

Ded & coin

100% (dw)

Screenings-50% Exams Only

100% (dw)

Screenings-50% Exams Only

100% (dw)

Screenings-50% Exams Only

Ded & coin

Ded & coin

Diagnostic Services

Paid in full to $1,000 then ded & coin

Deductible & Coinsurance

Emergency Care**

$100 copay + ded & coin

$150 copay + ded & coin

$200 copay + Ded & coin

Ambulance

Deductible & Coinsurance

Deductible & Coinsurance

Deductible & coinsurance

Hospital (Inpatient)

Deductible & Coinsurance

Deductible & Coinsurance

Ded & coin

Ded & coin

Hospital (Outpatient)

Deductible & Coinsurance

Deductible & Coinsurance

Ded & coin

Ded & coin

Spinal Manipulations

12 visits PCY

12 visits PCY

12 visits PCY

Vision Care

Not Covered

Not Covered

Not Covered

RehabOutpatient (Speech, Massage, OT,PT)

30 visits PCY

45 visits PCY

30 visits

RehabInpatient (Speech, Massage, OT,PT) Prescriptions

$15 copay (dw)

50%

$30 copay (dw)

30 days PCY

45 days PCY

Ded & coin

Ded & coin

50%

$30 copay (dw)

Ded & coin

30 days PCY Ded & coin

Ded & coin

Generic / Preferred / Non - Preferred At Participating Pharmacies 

Retail Cost Share (30 Day Supply)

$5 (dw) / 30% / 30%

$5 (dw) / $30 / $45

$15 / $30 / $45

Mail Order Cost Share (90 Day Supply)

$10 (dw) / 25% / 25%

$10 (dw) / $75 / $112

$15 / $60 / $90

30% through Accredo or Walgreens Specialty Pharmacy Only

30% through Accredo or Walgreens Specialty Pharmacy Only

30% through Accredo or Walgreens Specialty Pharmacy Only

Specialty Cost Share (30 Day Supply)

Life/AD&D Insurance $12,500 Term Life and AD&D for Employee Only *Preventive Services as defined by the Affordable Care Act (dw)= Deductible Waived **Copay waived if admitted to hospital (PCY) = Per Calendar Year Ded & coin = Deductible & Coinsurance Apply OT = Occupational Therapy PT = Physical Therapy To locate a Premera provider, visit www.premera.com/wea. Rx = Prescription Medication

18

All Staff Medical Plan (Network) Network Medical Deductible Rx Deductible

Premera Blue Cross QHDHP (Foundation) In Network

Out of Network

At a GHC Facility/Provider Only

$1,500 person/ $3,000 familyƗ

$3,000 person/ $6,000 familyƗ

$500 person / $1,000 family

Subject to Medical Deductible

None

Does NOT Apply

Applies

4th Qtr. Carry Over Coinsurance Medical Out of Pocket Max

80%

50%

100%

$4,000 person/ $8,000 family

None

$3,000 person / $6,000 family

Rx Out of Pocket Max Office Visit Preventive Care*

Diagnostic Services

Group Health

Included in Medical

Included in Medical

80%

50%

$25 copay (dw)

100% (dw)

Screenings-50% Exams/Immunizations Not Covered

100% (dw)

80%

50%

100% after deductible 100% (dw) for Outpatient

Emergency Care

80%

$100 copay + deductible

Ambulance

80%

80%

Hospital (Inpatient)

80%

50%

100% after deductible

Hospital (Outpatient)

80%

50%

$25 copay (dw)

Spinal Manipulations

12 visits PCY

10 visits PCY

Vision Care

Not Covered

One exam every 12 months

RehabOutpatient (Speech, Massage, OT,PT)

15 visits PCY

60 visits PCY

RehabInpatient (Speech, Massage, OT,PT)

80%

50%

$25 copay (dw)

30 days PCY 80%

60 days PCY 50%

100% after deductible

Generic / Preferred / Non- Preferred At Participating Pharmacies 

Generic / Formulary At GHC Pharmacies Only

Retail Cost Share (30 Day Supply)

80% (30 day supply)

$15 / $30

Mail Order Cost Share (30 Day Supply)

80% (90 day supply)

$30 / $60

Specialty Cost Share (30 Day Supply)

80% (30 day supply)

Subject to applicable retail copay through GHC Specialty Medication Pharmacy Only

Prescriptions

Life/AD&D Insurance $12,500 Term Life and AD&D for Employee Only *Preventive Services as defined by the Affordable Care Act **Copay waived if admitted to hospital Premera QHDHP, the deductible must be satisfied before benefits are payable. If benefits are payable for ANY enrolled person.

None (dw)= Deductible Waive PCY= Per Calendary Year OT= Occupational Therapy PT= Physical Therapy Rx = Prescription Medication

To locate a Premera provider, visit www.premera.com/wea. To locate a Group Health provider, visit www.ghc.org.

19

QHDHP-HSA PLAN QUESTIONS AND ANSWERS How does the High Deductible Health Plan (QHDHP) and Health Savings Account (HSA) work? On the QHDHP, the deductible must be met prior to Your Medical Plan making payment for any service, except for Preventive Care. All services including prescriptions must be paid for in full until the Deductible is met. You can use the funds in your HSA to pay for services and prescriptions. Once the Deductible is met, you are responsible for Coinsurance including Prescription Drugs. If there is family coverage, the entire family deductible must be met prior to Your Medical Plan making payment. You do NOT need to enroll in an HSA to enroll in the QHDHP. Procedure: 1. When going to the doctor or a pharmacy for a prescription, always present your Medical Insurance card at the time of service. 2. Your doctor will then bill your Medical Plan, or the Pharmacy will apply your insurance information to the prescription. Your Medical Plan will process the claim, applying the charges to the deductible. If you go to a participating doctor or pharmacy, any discounts Your Medical Plan has negotiated will apply and will reduce your out of pocket costs. You will also receive an Explanation of Benefits (EOB) from Your Medical Plan, which will explain what your responsibility is and how much of the charges have been applied to your deductible. 3. You can now pay the provider with your HSA debit card. Many providers will bill you and provide space on the bill for you to write in your HSA debit card number to pay for the charges. If a provider or pharmacy (such as Costco) does not allow credit card payments, you will need to submit your receipt for reimbursement. (Note: although the HSA card is a debit card, it can only be run as a credit card. There is no pin number, and therefore the card cannot be run as a debit card). Contributions: You can contribute to your HSA up to the federal annual limit. The total allowed contributions for 2015, is $3,350 for an individual and $6,750 for a family. These contributions will be deducted from your paycheck on a pre-tax basis. Distributions: Any time you go to the doctor or fill a prescription before your deductible is met, you can use the funds from your HSA. In addition, you are allowed to use your HSA for any “qualified medical expense” for medical, dental, vision, or other items that are allowed according to IRS Publication 502. For example, if you have a child who will need braces, you are allowed to contribute to your HSA with pre-tax dollars to pay for the braces. Over-the-counter drugs (with the exception of insulin) are not eligible expenses unless you have a written prescription from a physician. Important facts about your HSA • The HSA is an account in your name that belongs to you. If you leave the school district, the account goes with you, and you can continue to use the account for qualified medical expenses. • Unlike an FSA, you can only use funds that have been already been deposited into your HSA account. If you have a bill for $400, but only $200 deposited to date in your HSA, you only have the $200 available to you. • If you use HSA funds for anything that is not a qualified medical expense, there is a 10% tax penalty, and you must report the amount to the IRS as regular income. You should keep all receipts for purchases made with your HSA card, to prove the purchases were a qualified medical expense in case you are audited by the IRS. • If you choose to go to a pharmacy that participates with the IIAS system, charges will be auto-adjudicated at the time of purchase. (a list of participating merchants is available at www.sig-is.org). • You cannot use your HSA funds for any item or service prior to your effective date on the plan. For example, if your plan was effective 10/1/15 and dentist performed a crown for you on September 5, 2015, and your portion is $400 of the cost of the crown, you cannot use your HSA funds for this service. • Any person covered under the QHDHP can only participate in a limited purpose Flex-Spending Account (such as vision or dental), or a non-medical FSA such as Day Care. • You or your spouse cannot be covered under another medical plan if they are on the school district’s QHDHP unless the other plan is also an IRS qualified QHDHP. If a spouse is covered by the school district, and is also covered by their employer with a non-QHDHP plan, they must choose only one of the Medical plans. • You can use HSA funds for qualified medical expenses for any dependent, even if they are not covered by the Kent Public Schools Health Plan. However, you cannot use HSA funds for qualified medical expenses for someone who is not a dependent according to the IRS, for example, a child who is over age 26. • If you are no longer covered by a High Deductible Health Plan, or you enroll in Medicare, you cannot continue to contribute to the HSA, but you can continue to use the funds to pay for qualified medical expenses.

20

Premiums and Payroll Deduction Worksheet - Certificated Staff Below are the rates for our current mandatory and voluntary medical policies as well as the current Benefit Allocation Table. Out of your Benefit Allocation, three mandatory benefits are deducted. The remaining balance can then be used to purchase medical benefits. If you do not use all of your Benefit Allocation, the remainder will go into a pool for your union. If you exceed your Benefit Allocation, you may receive funds from that pool (if available) to reduce your payroll deduction for your medical benefit election. Keep in mind that pooling funds are not guaranteed, cannot be predicted and fluctuate monthly.

Benefit Allocation

Mandatory Long Term Disability Rates

CONTRACT FTE

Hours Per Day

Benefit Allocation

Annual Earnings

Monthly Earnings

Monthly Premium

0.50 to .57

3.75 to 4.25

$429.00

$15,000

$1,250.00

$3.00

.60 to .63

4.50 to 4.75

$491.40

$20,000

$1,666.67

$4.00

.67 to .77

5.00 to 5.75

$569.40

$25,000

$2,083.33

$5.00

.80 to .97

6.00 to 7.25

$702.00

1.00

7.50

$780.00

$30,000

$2,500.00

$6.00

$35,000

$2,916.67

$7.00

$40,000

$3,333.33

$8.00

$45,000

$3,750.00

$9.00

$50,000

$4,166.67

$10.00

$60,000

$5,000.00

$12.00

$65,000

$5,416.67

$13.00

$70,000

$5,833.33

$14.00

Mandatory Dental Rates  

Delta Dental of WA Incentive Plan A

Delta Dental of WA Deltacare

Willamette

$117.25

$68.20

$90.30

Employee, Spouse & Child(ren)

Medical Rates  

Group Health

Premera Plan 2

Premera Plan 3

Premera Plan 5

Premera QHDHP

Premera Easychoice A&B

Premera Basic

Employee

$734.42

$900.05

$794.35

$1052.80

$456.30

$580.40

$529.05

Employee & Child(ren)

$1090.24

$1201.60

$1060.55

$1436.45

$604.85

$769.85

$701.60

Employee & Spouse

$1311.10

$1647.15

$1453.75

$2023.00

$827.65

$1054.05

$960.40

Employee, Spouse & Child(ren)

$1669.42

$1974.70

$1742.90

$2437.05

$977.85

$1262.85

$1150.55

Enter Your Benefit Allocation Enter Mandatory Dental Premium Mandatory Group Life Premium Enter Mandatory LTD Premium Total of Mandatory benefits (add lines 2 through 4) Subtract Line 5 from Line 1 (this is the amount you have to spend on medical insurance) Enter Medical Premium Subtract Line 7 from Line 6 (if negative this will be your approx. monthly payroll deduction.)

Payroll Deduction Worksheet (Certificated Staff)

$ $6.18 $ $ $ $ $

21

If line 8 is a positive number, you will have no additional monies taken from your paycheck for your medical insurance purchase and the remaining balance will go into pooling. If Line 8 is a negative number, this amount will be taken from your paycheck as a monthly payroll deduction to pay for your medical insurance.

Premiums and Payroll Deduction Worksheet- Classified Staff Below are the rates for our current mandatory and voluntary medical policies as well as the current Benefit Allocation Table. Out of your Employee Benefit Allocation, four mandatory benefits are deducted. The remaining balance can then be used to purchase medical benefits. If you do not use all of your Employee Benefit Allocation, the remainder will go into a pool for your bargaining unit (union). If you exceed your Employee Benefit Allocation, you may receive funds from that pool (if available) to reduce your payroll deduction for your medical benefit election. Keep in mind that pooling funds are not guaranteed, cannot be predicted and fluctuate monthly. Employee Benefit Allocation

Employee Benefit Allocation

Employee Benefit Allocation

AFT

TEAMSTERS

Hours Per Year

KAEOP

KAP

KSFSA

Hours Per Year

Non-Rep, ProfTech, KPA,Mgmt

4.0 - 4.99

 

$452.40

741

$428.22

$428.22

$428.22

756

$428.22

4.0 - 5.4

$561.60

 

841

$482.04

$482.04

$482.04

840

$482.04

5.0 - 5.99

 

$585.00

941

$536.64

$536.64

$536.64

940

$536.64

5.5 - 8.0

$780.00

 

1041

$590.46

$590.46

$590.46

1040

$590.46

6.0 - 6.99

 

$717.60

1141

$646.62

$646.62

$644.28

1140

$644.28

7.0 - 8.0

 

$780.00

1241

$698.88

$698.88

$698.88

1240

$698.88

8.0

 

 

1341+

$780.00

$780.00

$780.00

1340

$752.70

 

 

 

 

 

 

 

1440+

$780.00

Hours Per Day

 Hour Conversion Chart Hours Worked Per Day 4.00 4.25 4.50 4.75 5.00 5.25 5.50 5.75 6.00 6.25 6.50 6.75 7.00 7.50 7.75 8.00

189 Days

190 Days

212 Days

260 Days

Assigned Annual Hours 756 804 851 898 945 993 1,040 1,087 1,134 1,182 1,229 1,276 1,323 1,418 1,465 1,512

760 808 855 903 950 998 1,045 1,093 1,140 1,188 1,235 1,283 1,330 1,425 1,473 1,520

848 901 954 1,007 1,060 1,113 1,166 1,219 1,272 1,325 1,378 1,431 1,484 1,590 1,643 1,696

1,040 1,105 1,170 1,235 1,300 1,365 1,430 1,495 1,560 1,625 1,690 1,755 1,820 1,950 2,015 2,080

MANDATORY DENTAL/VISION Monthly Dental/Vision Premium

Delta Dental of WA Incentive Plan A

Delta Dental of WA DeltaCare

Willamette

NBN Vision

Employee & Family

$117.25

$68.20

$90.30

$20.00

22

MANDATORY—Long Term Disability Premium Chart (Classified Staff) Annual Earnings

Monthly Earnings

KAEOP

KAP

KSFSA

Teamsters

AFT

Non-Rep Prof-Tech

Principals

$8,000

$666.67

$2.93

$4.64

$10.29

$6.67

$5.12

$2.40

$10,000

$833.33

$3.67

$5.80

$12.87

$8.33

$6.40

$3.00

$12,000

$1,000.00

$4.40

$6.96

$15.44

$10.00

$7.68

$3.60

$14,000

$1,166.67

$5.13

$8.12

$18.01

$11.67

$8.96

$4.20

$16,000

$1,333.33

$5.87

$9.28

$20.59

$13.33

$10.24

$4.80

$18,000

$1,500.00

$6.60

$10.44

$23.16

$15.00

$11.52

$5.40

$20,000

$1,666.67

$7.33

$11.60

$25.73

$16.67

$12.80

$6.00

$22,000

$1,833.33

$8.07

$12.76

$28.31

$18.33

$14.08

$6.60

$24,000

$2,000.00

$8.80

$13.92

$30.88

$20.00

$15.36

$7.20

$26,000

$2,166.67

$9.53

$15.08

$33.45

$21.67

$16.64

$7.80

$28,000

$2,333.33

$10.27

$16.24

$36.03

$23.33

$17.92

$8.40

$30,000

$2,500.00

$11.00

$17.40

$38.60

$25.00

$19.20

$9.00

$32,000

$2,666.67

$11.73

$18.56

$41.17

$26.67

$20.48

$9.60

$34,000

$2,833.33

$12.47

$19.72

$43.75

$28.33

$21.76

$10.20

$36,000

$3,000.00

$13.20

$20.88

$46.32

$30.00

$23.04

$10.80

$38,000

$3,166.67

$13.93

$22.04

$48.89

$31.67

$24.32

$11.40

$40,000

$3,333.33

$14.67

$23.20

$51.47

$33.33

$25.60

$12.00

$42,000

$3,500.00

$15.40

$24.36

$54.04

$35.00

$26.88

$12.60

$44,000

$3,666.67

$16.13

$25.52

$56.61

$36.67

$28.16

$13.20

$46,000

$3,833.33

$16.87

$26.68

$59.19

$38.33

$29.44

$13.80

$48,000

$4,000.00

$17.60

$27.84

$61.76

$40.00

$30.72

$14.40

$50,000

$4,166.67

$18.33

$29.00

$64.33

$41.67

$32.00

$15.00

$8.00

$52,000

$4,333.33

$33.28

$15.60

$8.32

$54,000

$4,500.00

$34.56

$16.20

$8.64

$56,000

$4,666.67

$35.84

$16.80

$8.96

$58,000

$4,833.33

$37.12

$17.40

$9.28

$60,000

$5,000.00

$38.40

$18.00

$9.60

$64,000

$5,333.33

$40.96

$19.20

$10.24

$70,000

$5,833.33

$21.00

$11.20

$74,000

$6,166.67

$22.20

$11.84

$80,000

$6,666.67

$24.00

$12.80

$84,000

$7,000.00

$25.20

$13.44

$90,000

$7,500.00

$27.00

$14.40

$94,000

$7,833.33

$28.20

$15.04

$100,000

$8,333.33

$30.00

$16.00

$110,000

$9,166.67

$33.00

$17.60

$120,000

$10,000.00

$36.00

$19.20

$130,000

$10,833.33

$39.00

$20.80

$140,000

$11,666.67

$42.00

$22.40

$150,000

$12,500.00

$45.00

$24.00

$160,000

$13,333.33

$48.00

$25.60

$170,000

$14,166.67

$51.00

$27.20

$180,000

$15,000.00

$54.00

$28.80

$190,000

$15,833.33

$57.00

$30.40

$200,000

$16,666.67

$60.00

$32.00

8

23

Medical Premiums Medical Rates

Group Health

Premera Plan 2

Premera Plan 3

Premera Plan 5

Premera QHDHP

Premera EasyChoice A&B

Premera Basic

Employee

$734.42

$900.05

$794.35

$1052.80

$456.30

$580.40

$529.05

Employee & Child(ren)

$1090.24

$1201.60

$1060.55

$1436.45

$604.85

$769.85

$701.60

Employee & Spouse

$1311.10

$1647.15

$1453.75

$2023.00

$827.65

$1054.05

$960.40

Employee, Spouse & Child(ren)

$1669.42

$1974.70

$1742.90

$2437.05

$977.85

$1262.85

$1150.55

Payroll Deduction Worksheet- Classified Staff Enter Your Benefit Allocation

$

Enter Mandatory Dental Premium

$

Mandatory Vision Premium

$20.00

Mandatory Group Life Premium

$6.96

Enter Mandatory LTD Premium

$

Total of Mandatory benefits (add lines 2 through 5)

$

Subtract Line 6 from Line 1 (this is the amount you have to spend on medical insurance)

$

Enter Medical Premium

$

Subtract Line 8 from Line 7 (if negative this will be your approx. monthly payroll deduction)

$

If line 9 is a positive number, you will have no deduction taken from your paycheck for your medical insurance and the remaining balance will go into pooling. If Line 8 is a negative number, this amount will be deducted from your monthly paycheck on a pre-tax basis to pay for your medical insurance.

24

What is Pooling? The Kent School District provides a benefit allotment to help pay for mandatory benefits and voluntary medical benefits for you and your family. If you do not use your entire benefit allocation, the remaining amount will go into a “pool” for your employee group (union). This pool is distributed monthly based on the ratio of full-time employees to members in your group who have elected medical coverage. Pooling levels vary month to month based on enrollment. Note: The benefit allotment and pooling are available for use toward domestic partner coverage as well as legal spouses and dependent children. Please see the “Dependents” section on page 6 for information regarding the taxation of domestic partner premiums.

When Will My Premiums 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. If you are participating in the Health Care or Dependent Care portion of the Flexible Spending Account, 1/12 of your annual election will be deducted from your paycheck each month starting with October’s payroll through September payroll. Food Service, 1/9 of your annual election will be deducted starting with October’s payroll through June. Bus Drivers, 1/10 of your annual election will be deducted started with October’s payroll through July. If you are newly eligible during the plan year, deductions will be taken once per month over the remaining months of the plan year. The first deduction depends on when enrollment forms are received and the effective date of coverage and may include one or two catch-up deductions. This is because enrollment forms received after the 16th of each month are processed for the next pay period. Example: • Deductions for coverage effective November 1 are taken from your October pay warrant.

How Can I Save Money on My Medical Costs?

Health care costs can be expensive. You can help keep costs down for yourself and everyone under our plans by choosing wisely. Use the Emergency Room for Emergencies Only If you have a life-threatening emergency, get to an ER, but if your condition is not a true emergency, use an urgent care facility or see your doctor. Select Generic Drugs When Available If a generic drug is available and will work for you, use the generic. Generic drugs are considerably less expensive for you and your insurance plan. In addition, the Premera EasyChoice Plans include a deductible for prescription drugs that is waived for generics. Participate in the Flexible Spending Account Flexible Spending Accounts (FSA) allow you to pay many out-of-pocket expenses (such as deductibles, co-pays, coinsurance, non-covered health care services and dependent care) with before-tax dollars. The healthcare FSA also allows you to spread these costs over the year – a portion of your annual election is deducted from each paycheck. On average an employee can save 25-40% on their FSA dollars. Network Needs To make sure you are getting maximum coverage, ask if the physician or the medical facility whose services you want to use is in your plan’s “preferred provider” network. Be sure to always ask when being referred for any services. For example, while your physician or hospital may be a preferred provider, the lab they use or refer you to for tests may be outside of the network.

25

Voluntary Benefits

Allocation and pooling monies cannot be used toward these benefits.

26

Voluntary Vision Coverage - Certificated Staff Kent School District’s voluntary vision plan for Certificated staff is offered by United Healthcare. This plan allows you to see any licensed provider. However your benefits will be greater, your out of pocket costs will be less, and payment will be made directly to the provider if you use a provider in the United Healthcare Network.  

In-Network

Any licensed provider

$25

None

$10 copay then 100%

Reimbursed up to $40

 

Reimbursed

 

 

• Single Vision

100%

up to $40 per pair

• Bifocals

100%

up to $60 per pair

• Trifocals Contact Lenses (in lieu of glasses)

100%

up to $80 per pair

 

Reimbursed

once every 12 months

 

 

• Medically necessary

100%

up to $210

Up to plan maximum

up to $105

100% up to $130 plan allowance

Reimbursed up to $45

  Deductible Basic Exams once every 12 months Lens Allowance once every 12 months

• Elective Frames once every 24 months

Vision Cost per Month Employee $6.75

Employee/Spouse $12.85 Employee / Children $13.50 Family $20.70

Voluntary Accident, Cancer & Critical Illness Insurance (Available to All Staff) We now offer Voluntary Accident, Cancer & Critical Illness Insurance through Aflac. This provides benefits in the event of a covered accident, illness, or cancer diagnosis. Regular Classified employees with a contract of 20.0 hours per week and Certificated employees with a contract of 18.75 hours per week (.50 FTE) are eligible as well as spouses and dependent children. The rates you pay for this benefit are considerably less than the rates you would pay for an identical individual plan that is not tied to the District. Benefits and premiums vary based on plan selected.

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Voluntary Short-Term Disability Insurance (Available to all Staff) Voluntary Short Term Disability coverage through Cigna is intended to protect your income for a short duration in the event you are unable to work due to an illness or injury that is not work related. Your STD benefits will be offset by any federal or state disability benefits as well as workers compensation. All active Certificated employees working 18.75 hours or more per week and all active Classified employees working more than 20 hours per week are eligible to enroll. Maximum Weekly Benefit:

66.67% of your weekly salary up to a maximum of $1,000 per week. You must elect a benefit amount in $50 increments subject to a $100 minimum.

Maximum Benefit Duration:

9 weeks

Elimination Period: Benefits will begin on: 1st day from an accident 4th day from a sickness For full plan details including exclusions contact Human Resources Employee Benefits x7222

Voluntary Long Term Care (Available to all Staff)

Long Term Care Insurance (LTC) is designed to provide coverage for one or more necessary or medically necessary diagnostic, preventive, therapeutic, rehabilitative, maintenance, or personal care services, provided in a setting other than an acute care unit of a hospital, such as in a nursing home, in the community, or in the home. Enrollment in this plan is available to employees, their spouses, parents, parents-in-laws, grandparents and grandparents-in-law. Monthly Benefit: You are eligible for a monthly benefit if you are assessed as suffering a covered loss of functional capacity and are unable to perform 2 or more Activities of Daily Living (ADLs) or cognitive impairment. You must be under the regular care of a doctor according to the condition. Activities of Daily Living are bathing, dressing, toileting, transferring, continence and eating. Cognitive Impairment means a deterioration or loss in intellectual capacity resulting from Alzheimer’s disease or similar forms of irreversible dementia.

Advantage Home Plus Through a partnership with Advantage Home Plus, they provide employees and their families with unlimited access to home ownership assistance and secures employees pre-negotiated discounts with a network of prescreened, authorized real estate, title, escrow and home mortgage providers. Contact customer service at 1-844-613-HOME or use their secure website Advantagehomeplus.com. Relationship Manager - Nicole Manley [email protected] Phone: 503-267-3395

28

Voluntary Term Life and AD&D Insurance (Certificated Staff)

Voluntary Term Life/AD&D Insurance is available through Cigna for all active Certificated employees working at least 18.75 hours per week. Your Term Life/AD&D coverage options are: Term Life Insurance

AD&D Insurance

Employee Plan 1

$10,000

$10,000

Child(ren) Plan 1

$5,000

$5,000

Employee Plan 2

You must enroll in Employee Plan 1 to receive this option. You must enroll in Employee Plan 1 to receive this option.

5 times your annual 5 times your annual salary in increments salary in increments of $25,000 to a max of of $25,000 to a max of $300,000. If you are $300,000. initially eligible, your first $25,000 is offered at Guarantee Issue. Spouse Plan 2 50% of the Employee 50% of the Employee You must enroll in Employee Plan 2 coverage in Plan 2 coverage. Plan 1 & 2 to receive this increments of $12,500. option. There is no guarantee issue on this plan. Child(ren) Plan 2 $10,000 benefit. Full $10,000 benefit. You must enroll in Employee amount is available at Plan 1 & 2 to receive this Guarantee Issue. option. Insurance amount reduces to the following amounts upon the age attained as stated below: Age

Term Life Insurance

AD&D

70

65% of original amount

65% of original amount

75

45% of original amount

45% of original amount

80

30% of original amount

30% of original amount

85

20% of original amount

15% of original amount

90

15% of original amount

95

10% of original amount

Voluntary Term Life Insurance (Classified Staff) Voluntary Life Insurance is available through Cigna for all active Classified employees working at least 20 hours per week. Your Term Life coverage options are: Employee: Increments of $10,000, not to exceed $500,000. Spouse: Up to 50% of employee amount in increments of $5,000. Not to exceed $250,000. Benefits will be paid to the employee. Coverage terminates at age 70. Child: Coverage amount of $10,000. The maximum death benefit for a child between the ages of live birth and 6 months is $1,000. Benefits will be paid to the employee. In order to purchase Life coverage for your spouse and/or child, you must purchase life coverage for yourself. Coverage amount(s) will reduce according to the following schedule: Age: Insurance amount reduces to: 70 65% of original amount 75 50% or original amount Coverage may not be increased after an age reduction. For full plan details including rates contact Human Resources Employee Benefits.

29

Voluntary Accidental Death and Dismemberment (AD&D) Insurance (Classified Staff) All active Classified employees who work more than 20 hours per week can elect to participate in this voluntary benefit through CIGNA. The benefit amounts are as follows: Employee Benefit Amount:

Units of $100,000 up to a maximum of $500,000.

Spouse/Domestic Partner Benefit Amount:

Units of $50,000 up to a maximum of $250,000.

Child Benefit Amount:

Flat $10,000.

AD&D Benefits:

If the employee suffers an accident or injury that results in a covered loss within 90 days of the accident and the loss results directly from the injury independent of other causes, CIGNA group insurance will pay as follows:



100% Benefit for loss of Life, Both Hands or Both Feet or Sight of Both Eyes, Speech and Hearing, or Either Hand or Foot and Sight of One Eye.



50% Benefit for loss of Either Hand or Foot, Sight of One Eye, Speech or Hearing.



25% Benefit for loss of Thumb and Index Finger of Same Hand or all Toes on the Same Foot.

Additional benefits include:

Paralysis Benefit, Coma Benefit, Exposure and Disappearance Benefit, Seatbelt & Airbag Benefit, Bereavement & Trauma Counseling Benefit, Rehabilitation Benefit and Identity Theft and Protection Assistance.

Benefit Costs:

Employee: $.02 per $1,000 Spouse: $.02 per $1,000. Child $2.00 per month.

This Benefit Highlight Sheet explains the general purposes of the insurance described, but in no way changes or affects the policy as actually issued. In the event of any discrepancy between this document and the policy, the terms of the policy apply. Complete coverage information is in the certificate of insurance. Please read it carefully and keep it in a safe place with your other important papers.

Voluntary MetLaw Legal Coverage (Available to all Staff)

Hyatt Legal Plans, a MetLife Company, offers unlimited telephonic and face to face consultations on many personal legal matters such as: • Preparation of wills, trusts, codicils, living wills and living trusts • Preparation of powers of attorney, deeds, demand letters, promissory notes & mortgages • Review of personal legal documents • Representation for purchase/sale/refinancing of residence, debt collection defense, adoptions & guardianships You can locate an attorney either by phone at 800-821-6400 or via the web at www.legalplans.com. Your login information is the last 4 digits of your SSN and your home zip code.

30

Flexible Spending Accounts (FSA) A Flexible Spending Account (FSA) program enables you to set aside money on a pre-tax basis to pay for health and day care costs. An FSA is the only benefit that actually saves you money on the cost of health and day care expenses. On average you can save anywhere from 25%-40%! You must complete a new enrollment form each plan year to continue to take advantage of the tax savings offered by this plan. Forms must be submitted to Human Resources Employee Benefits Department within 30 days of your start date.

HOW THE FLEXIBLE SPENDING ACCOUNT (FSA) WORKS You can elect to set aside up to $2,500 before taxes into your Health Care Account. This pre-tax money can be used to pay for qualified health care expenses not covered by your medical, dental, or vision plans. You can also choose to set aside up to $5,000 before taxes into your Dependent Care Account. (If you are married and filing separately, your limit is $2,500.) This pre-tax money can be used to pay for qualified day care expenses for your children or disabled spouse. There are some rules to consider before enrolling in a Dependent Care FSA. • The expense must be allowing you and your spouse to work, actively look for work or be a full-time student. • Your dependent must live with you and must be 12 years old or younger. A dependent age 13 or older can be eligible if you can provide proof that the dependent cannot physically or mentally care for him/herself. • The day care provider cannot be a dependent on your tax return or your child under the age of 19. • A Dependent Care FSA works like a bank account. The reimbursement cannot exceed the account balance. Your FSA operates on a plan year basis. • Some types of expenses are not eligible. These include tuition for school at the The plan year is November 1 to October kindergarten level or above, overnight camp, nursing home expenses, meals, 31. The claimed expenses must have activity/supply fees and transportation costs. dates of service that fall within the plan The total amount you choose to set aside into these accounts will be taken out of your paycheck in even monthly portions from the effective date until October 31 of next year (June 30 for Food Service, July 31 for Transportation). The money deducted from your paycheck will be pre-tax, so you don’t pay FICA (7.65%) or Federal Income Tax (10-35%). Once you have elected the amounts you want to set aside into these accounts, you cannot change them until November 1, 2016. An exception can be made if you have a qualified change in status, such as getting married or divorced, or having a baby. Please note that money cannot be transferred between accounts. For example, you cannot use your Dependent Care Account to reimburse yourself for health care expenses and vice versa.

HOW TO PAY FOR EXPENSES AND GET REIMBURSEMENTS

year. However, Kent School District allows a maximum of $500 of unused dollars to roll to the next plan year. Any unused amount that exceeds the $500 and is not used by the end of our plan year will be lost. This $500 rollover has replaced the 2.5 month grace period, so you must incur your claims by October 31 to include them in the plan year. This benefit is specific to the FSA ONLY. The Dependent Care and HSA claim filing period is still 90 days. Carryover amounts of the FSA are carried forward AFTER the claim filing period. To help you plan, use the online calculator: www.flex-plan.com/taxcalc. aspx

You have the option of obtaining a Debit Card that you may use to pay for health care expenses. (You cannot pay for Dependent Care expenses with this card.) When using the Debit Card, keep the receipt for your expense in a safe place. You may receive an e-mail or letter asking you to send in your receipt to support your claim. Send in the receipt and a copy of the letter, as requested. If you do not send the receipt or if you used the card to pay for an expense that is not qualified, you will be asked to pay back the amount of the expense you put on the card. A delay in providing substantiation may cause your card to be turned off. Please make sure to send your receipts promptly upon request. If you do not use the Debit Card, you will need to complete a Claim Form (available on the Navia Benefit Solutions website or through KSD Staff Link ) and mail or fax it and the receipt to Navia Benefit Solutions. You can also use the mobile App for iPhones and Androids. Deductions for your District-sponsored benefits are taken pre-tax from your paycheck through the Premium Conversion portion of this plan. You are automatically enrolled in this portion of the plan.

EXAMPLES OF QUALIFIED HEALTH CARE EXPENSES:

Please refer to your Navia Benefit Solutions enrollment paperwork for more information and examples of qualified and non-qualified expenses.

• Co-pays for doctor visits and prescription drugs • Deductibles and coinsurance for your medical or dental plans • Vision expenses like exams, lenses or frames

31

Flexible Spending Account—How Does It Work? Understanding the tax savings behind an FSA can seem confusing or complicated. Where and how are the savings coming from? The federal government takes a portion of each dollar you earn in income taxes and FICA. With an FSA, you can set aside money from your paycheck BEFORE the federal government takes their portion. You can use this money to pay for medical and day care expenses. For example: Employee A earns $35,000/year after exemptions and her standard deduction. She has one child and pays $2,400/year for her family’s medical expenses. Employee B earns $35,000/year after exemptions and her standard deductions. She also has one child and pays $2,400/ year for her family’s medical expenses, however, she participates in a Health Care FSA. How much money will this employee save?

Employee A

$35,000

Employee B Gross Pay Based on this example, Employee B will save over $543 a year!



$35,000

Gross Pay

-

$2,400

Medical Costs



$32,600

Take home Pay

- $7,092.5

Taxes

$27,908.5

Take home Pay

-

Medical Costs

- $6,548.9

Taxes

Net Pay

$26,051.1

Net Pay

$2,400

$25,507.5

Since Employee B’s medical costs were taken PRE-TAX , they did not have to pay FICA or Federal Income Tax on this amount!

If you’re interested in finding out what your savings would be under an FSA plan, consult Navia Benefit Solutions’ Website at: www.flex-plan.com/taxcalc.aspx and use their tax savings calculator. The password for this tool is “purple81”.

32

Healthy Kids Now! Free or Low-Cost Health Insurance for Kids & Teens in Washington State Infants through teenagers can receive free or low-cost health insurance. Many families in Washington State qualify and don’t know it. These programs are flexible and cover kids in many types of households. This health insurance program covers a full range of services that all children need to stay healthy. For more information, please call (877)-543-7669 or visit www.insurekidsnow.gov.

Consolidated Omnibus Budget Reconciliation Act (COBRA) and Continuation of Coverage COBRA Notification, Rights and Responsibilities for Employees and Dependents COBRA Notices and Further Information. It is very important that you notify your employer regarding any change in status such as: change in address, eligibility for Medicare, divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child. For changes in address or eligibility for Medicare, you must notify your employer immediately. For divorce, separation, and overage dependent children, you must notify your employer within 60 days of the change in status. Please contact your payroll officer for the form (s) that may need to be filled out. COBRA Notices and Further Information. If you or a qualifying family member have any questions about notices provided to you by your employer, or questions about COBRA, please contact your employer representative below.

Judy Weaver - Specialist for Certificated Staff 253-373-7186 Faith Huguley - Specialist for Classified Staff 253-373-7222

Kent School District Human Resources Employee Benefits Department 12033 SE 256th St Kent, WA 98030-6503

33

HIPAA PRIVACY NOTICE THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires a health plan to notify plan participants and beneficiaries about its policies and practices to protect the confidentiality of their health information. This notice describes the ways the Kent School District #415 (the “Health Plan”) may use and disclose health information about you and your rights to review and control disclosure of this information. The Health Plan needs to create, receive, maintain and disclose health information about you and your enrolled family members to administer the Health Plan and provide you with health care benefits. This notice describes the Health Plan’s health information privacy practices with respect to your Medical, Prescription Drug, Dental, Vision and Employee Assistance Program benefits, and your Health Flexible Spending Account component of your Section 125 Plan. It does not address the health information policies or practices of your health care providers, such as your physician. The privacy policy and practices of the Health Plan protects confidential health information that identifies you or could be used to identify you and relates to a physical or mental health condition or the payment of your health care expenses. Your health information will not be used or disclosed without a written authorization from you, except as described in this notice or as otherwise permitted by federal and state health information privacy laws. HOW THE HEALTH PLAN MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU The following are the different ways the Health Plan may use and disclose your health information. Not every use or disclosure in a category is listed, but the ways in which the Health Plan is permitted to use and disclose information falls within one of the categories. • For Treatment. The Health Plan may disclose your health information to a health care provider who renders treatment on your behalf. For example, if you are unable to provide your medical history as the result of an accident, the Health Plan may advise an emergency room physician about the types of prescription drugs you currently take. • For Payment. The Health Plan may use and disclose your health information so claims for health care treatment, services, and supplies you receive from health care providers may be paid according to the terms of the plan. The Health Plan may need to obtain your authorization for this. For example, the Health Plan may receive and maintain information about surgery that you received to enable the Health Plan to process a hospital’s claim for reimbursement of surgical expenses incurred on your behalf. • For Health Care Operations. The Health Plan may use and disclose your health information to enable it to operate or operate more efficiently or make certain all participants receive their health benefits. For example, the Health Plan may use your health information for case management or to perform population-based studies designed to reduce health care costs. In addition, the Health Plan may use or disclose your health information to conduct compliance reviews, audits, actuarial studies, and/or for fraud and abuse detection. The Health Plan may also combine health information about many Health Plan participants and disclose it to Kent School District #415 in summary fashion so it can decide what coverages the Health Plan should provide. • To Kent School District #415 as Plan Sponsor. The Health Plan may disclose your health information to designated employees of Kent School District #415 so they can carry out their Health Plan-related administrative functions, including the uses and disclosures described in this notice. These individuals will protect the privacy of your health information and ensure it is used only as described in this notice or as permitted by law. • To a Business Associate. Certain services are provided to the Health Plan by third party administrators and other third parties known as “business associates.” For example, the Health Plan may input information about your health care treatment into an electronic claims processing system maintained by the Health Plan’s business associate so your claim may be paid. In so doing, the Health Plan will disclose your health information to its business associate so it can perform its claims payment function. However, the Health Plan will require its business associates, through contract, to appropriately safeguard your health information. • Treatment Alternatives and Health-Related Benefits and Services. The Health Plan may use and disclose your health information to tell you about possible treatment options or alternatives and health-related benefits that may be of interest to you. • Individual Involved in Your Care or Payment of Your Care. The Health Plan may disclose health information to a close friend or family member involved in or who helps pay for your health care. The Health Plan may also advise a family member or close friend about your condition or your location (for example, that you are in the hospital). • As Required by Law. The Health Plan may disclose your health information when required to do so by federal, state, or local law, including those that require the reporting of certain types of wounds or physical injuries.

34

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU You have rights with regard to your health information. If you wish to exercise any of the following rights, please contact the Health Plan Privacy Official. • Right to Inspect and Copy. You have the right to inspect and copy your health information. This includes information about your plan eligibility, claim and appeal records, and billing records, but does not include psychotherapy notes. To inspect and copy health information maintained by the Health Plan, submit your request in writing to the Health Plan. The Health Plan may charge a fee for the cost of copying and/or mailing your request. In limited circumstances, the Health Plan may deny your request to inspect and copy your health information. • Right to Amend. If you feel that health information the Health Plan has about you is incorrect or incomplete, you may ask the Health Plan to amend it. In certain situations, the Health Plan may deny your request to amend your health information. • Right to an Accounting of Disclosures. You have the right to request an accounting of certain disclosures of your health information. However, no accounting is available of disclosures prior to April 14, 2003. • Right to Request Restrictions. You have the right to request a restriction or limitation on the health information the Health Plan uses or discloses about you for treatment, payment, or health care operations, or to someone who is involved in your care or the payment for your care. For example, you could ask that the Health Plan not use or disclose information about a surgery you had. The Health Plan is not required to agree to your request. • Right to Request Confidential Communications. You have the right to request that the Health Plan communicate with you about health matters in a certain way or at a certain location. For example, you can ask that the Health Plan send you explanation of benefits (EOB) forms about your benefit claims to a specified address. The Health Plan will attempt to accommodate all reasonable requests. • Right to a Paper Copy of this Notice. You have the right to a paper copy of this notice upon request.

PRIVACY OBLIGATIONS OF THE HEALTH PLAN The Health Plan is required by law to maintain the privacy of your health information, give you this notice of its legal duties and privacy practices with respect to health information, and to follow the terms of the notice that is currently in effect.

CHANGES TO THIS NOTICE The Health Plan reserves the right to change this notice at any time and to make the revised or changed notice effective for health information the Health Plan already has about you, as well as any information the Health Plan receives in the future.

COMPLAINTS If you believe your privacy rights under this policy have been violated, you may file a complaint with the Health Plan Privacy Official at the address listed below. Alternatively, you may complain to the Secretary of the U.S. Department of Health and Human Services, generally, within 180 days of when the act or omission complained of occurred. Please contact the Privacy Official for additional information. You will not be penalized or retaliated against for filing a complaint.

CONTACT INFORMATION If you have any questions about this notice, please contact the Health Plan Privacy Official. You may contact the Privacy Official as follows: Human Resources Employee Benefits Department Kent School District 12033 SE 256th Street, A-100 Kent, WA 98030-6503 (253) 373-7205

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OTHER USE AND DISCLOSURE SITUATIONS The Health Plan may also use or disclose your health information in accordance with the law under the following circumstances: • Lawsuits and Disputes. The Health Plan may disclose your health information in response to a court or administrative order, a subpoena, warrant, discovery request, or other lawful due process. • Law Enforcement. The Health Plan may disclose your health information for law enforcement purposes, for example, to identify or locate a suspect, material witness, or missing persons. • Correctional Institutions. The Health Plan may disclose your health information to correctional institutions or law enforcement officials if the individual is in custody. • Military and Veterans. The Health Plan may disclose medical information about you as deemed necessary by military command authorities. • To Avert Serious Threat to Health or Safety. The Health Plan may use and disclose your health information when necessary to prevent a serious threat to your health and safety, or the health and safety of the public or another person. • Public Health Risks. The Health Plan may disclose your health information for public health activities, such as preventing or controlling disease, injury or disability; reporting births and deaths; or reporting reactions to medication or problems with medical products or to notify people of recalls of products they have been using. • Victims of Abuse, Neglect, or Domestic Violence. The Health Plan may disclose your health information as required with respect to victims of abuse, neglect or domestic violence. • Health Oversight Activities. The Health Plan may disclose your health information to a health oversight agency for audits, investigations, inspections, and licensure necessary for the government to monitor the health care system and government programs. • Research. The Health Plan may use and disclose your health information for medical research purposes under certain circumstances. • National Security, Intelligence Activities, and Protective Services. The Health Plan may disclose your health information to authorized federal officials: (1) for intelligence, counterintelligence, and other national security activities authorized by law and (2) to enable them to provide protection to the members of the U.S. government or foreign heads of state, or to conduct special investigations. • Organ and Tissue Donation. The Health Plan may disclose your health information to facilitate organ or tissue donation and transplantation if you are an organ donor. • Coroners, Medical Examiners, and Funerals Directors. The Health Plan may disclose your health information to a coroner or medical examiner, or funeral director, for example, to identify a deceased person or to determine the cause of death. • De-identified Health Information. The Health Plan may disclose health information if it has been de-identified so that it does not identify an individual. • Limited Data Sets. The Health Plan may disclose your health information as part of a limited data set for research, public health and health care operations activities. • Incidental Disclosures. The Health Plan may disclose your health information incidental to otherwise-permitted disclosures. • Other Uses and Disclosures. Other uses and disclosures will be made only with your authorization. Generally, if you authorize the Health Plan to use or disclose your health information, you may revoke the authorization, in writing, at any time, except to the extent that the Health Plan has already relied on your authorization.

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CERTIFICATE OF CREDITABLE PRESCRIPTION DRUG COVERAGE IMPORTANT NOTICE FROM KENT 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 Kent 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 you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. Kent School District has determined that the prescription drug coverage offered by the Group Health and Premera Blue Cross plans is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. WHEN CAN YOU JOIN A MEDICARE DRUG PLAN? You can join a Medicare drug plan when you first become eligible for Medicare and each year from November 15th through December 31st. 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 Kent School District 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 Kent School District coverage, be aware that you and your dependents may be able to get this coverage back by enrolling back into the Kent School District benefit plan during the open enrollment period under the Kent School District 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 Kent School District and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following November to join. 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 Kent School District changes. You also may request a copy of this notice at any time. FOR MORE INFORMATION ABOUT YOUR OPTIONS UNDER MEDICARE PRESCRIPTION DRUG COVERAGE… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. FOR MORE INFORMATION ABOUT MEDICARE PRESCRIPTION DRUG COVERAGE: • Visit www.medicare.gov • Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help • Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048 If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778). Date: October 1, 2015 Name of Entity/Sender: Kent School District Contact--Position/Office: Human Resources Employee Benefits Department Director Address: 12033 SE 256th Street, A-100 Kent, WA 98030-6643

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Benefit Contacts Group Health Cooperative—HMO Plan (#00365) Toll Free ��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� (888) 901-4636 Nurseline ������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� (800) 297-6877 Internet ������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� www.ghc.org Premera Blue Cross—WEA Select Medical Plans (#8000099) Toll Free ��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� (800) 932-9221 Nurseline ������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� (800) 842-5357 Internet ������������������������������������������������������������������������������������������������������������������������������������������������������������������������� www.premera.com/wea NBN Vision Care Plan— Classified Staff Vision Plan (#KN100605) Northwest Administrators �����������������������������������������������������������������������������������������������������������������������������������������������������������(800) 732-1123 In the Seattle Area �����������������������������������������������������������������������������������������������������������������������������������������������������������������������(206) 726-3278 Internet �������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� www.nwadmin.com United Healthcare—Certificated Staff Vision Plan (#717996) Customer Service �������������������������������������������������������������������������������������������������������������������������������������������������������������������������(800) 638-3120 Provider Locator ��������������������������������������������������������������������������������������������������������������������������������������������������������������������������(800) 839-3242 Internet ��������������������������������������������������������������������������������������������������������������������������������������������������������������������������� www.myuhcvision.com Delta Dental of Washington—Dental Plans (Plan A: #186, Delta Care: #8170702) Toll Free ��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� (800) 554-1907 Internet ������������������������������������������������������������������������������������������������������������������������������������������������������������������������ www.deltadentalwa.com Willamette Dental—Dental Plan (#WA415) Customer Service �������������������������������������������������������������������������������������������������������������������������������������������������������������������������(800) 360-1909 Appointments ������������������������������������������������������������������������������������������������������������������������������������������������������������������������������(800) 359-6019 Internet �������������������������������������������������������������������������������������������������������������������������������������������������������������������� www.willamettedental.com Cigna—Mandatory Group Life/AD&D and Long Term Disability Toll Free ��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� (800) 362-4462 Internet ��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� www.cigna.com Flex-Plan Services—Flexible Spending Account (#FSA-KSD) All areas ��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� (800) 669-3539 Internet ��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� www.flex-plan.com MetLaw—Voluntary Legal Services (#609-0098) All areas ��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� (800) 821-6400 Internet ������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� www.legalplans.com First Choice Health—Employee Assistance Program All areas ��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� (800) 777-4114 Internet ��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� www.fchn.com/eap Cigna—Voluntary Term Life/AD&D and Voluntary Short Term Disability Toll Free ��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� (800) 362-4462 Internet ��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� www.cigna.com Unum—Voluntary Long Term Care Toll free - LTC ������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� (800) 227-4165 Internet �������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� www.unum.com Aflac—Voluntary Accident, Cancer & Critical Illness Toll free - LTC �������������������������������������������������������������������������������������������������������������������������������������������������������������������������������(800) 99-AFLAC Internet ����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������www.aflac.com Advangate Home Plus All Areas ......................................................................................................................................................................................(503) 267-3395 Internet...............................................................................................................................................................www.advantagehomeplus.com If you have any questions regarding any of your benefits, please contact Jeanette Busby at The Partners Group Toll free line ��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� (877) 455-5640 Email ��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������[email protected]

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Congratulations on being a public school employee, which gives you significant discounts on personal purchases of computer hardware and software. Please note that these links are NOT to be used for any Kent School District-funded purchases. Below is a list of major vendors that offer educational discounts to employees: Cellular Discounts Business Name

Discount Details

AT&T Wireless

Receive a 15% Discount on your personal monthly cellular bill

Sprint Wireless

Receive a 15% Discount on your personal monthly cellular bill

T-Mobile Wireless

Receive a 15% Discount on your personal monthly cellular bill

Verizon Wireless

Receive a 17% Discount on your personal monthly cellular bill

 Hardware Technology Discounts Business Name

Discount Details

Hewlett Packard 

Receive a 10% discount on your hardware purchase - use code 2180

Epson

Enroll in the Epson Partner Purchase program and you’ll receive special pricing ranging from 1015% off most Epson ink jet printers, impact printers, scanners and projectors.

Apple Education

Special Educational Pricing

 Health & Fitness Discounts Business Name

Discount Details

King Lasik

15% discount

Qliance

Qliance Overview; Employee Registration Form

VPI Pet Insurance

www.petsvpi.com. 1-877-PETS-VPI. Discounted rates based on type of animal.

Victory Get Fit Club

No membership dues & no enrollment fees. Must email [email protected] for KSD discount code.

Retail Discounts Business Name

Discount Details

Sole Perfection

15% discount

 Technology Software Discounts Business Name

Discount Details

Microsoft Office

Purchase the Microsoft Office Home Use Program for $9.95 10% discount on designated items

Education Software

Techhead.org - Discounted K12 Educational Software

Atomic Learning

Online Training and Resources

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Summary Prepared By: The Partners Group for the Kent School District