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Insurance Coverage Group Health Insurance - EBMC Kenyon College is interested in the health and well-being of both you and your family. Accordingly, a comprehensive health insurance program is available for benefit eligible employees, their spouses and/or same or opposite sex domestic partners and their children. Participation in the College’s health insurance program is optional and becomes effective on the first day of eligible employment. Premiums are based on salary levels. Please contact the Office of Human Resources for current premiums and rates of participation. Schedule of Benefits - General Plan Information The following benefits are provided, as further defined and limited in the literature provided by Kenyon College and EBMC: Benefit Period 7/1 through 6/30
Dependent Age Limit End of year of 23rd birthday
Pre-Existing ConditionWaiting Period 90 Days
Copayment As set forth in the Schedule of benefits provided at enrollment High Plan: Deductible per benefit period Individual $250 Family $500 Low Plan: Individual $500 Family $1,000 Coinsurance High Plan:
Preferred Provider 20% Non-Preferred Provider 40% Low Plan: Preferred Provider 30% Non-Preferred Provider 50%
Coinsurance Limits High Plan: Preferred Provider A. Individual $ 1,000 B. Family $2,000 Non-Preferred Provider A. Individual $2,000 B. Family $4,000 Low Plan: Preferred Provider A. Individual $ 3,000 B. Family $6,000 Non-Preferred Provider A. Individual $5,000 B. Family $10,000 Amounts incurred toward the Preferred Provider Coinsurance Limit will be applied to the Non-Preferred Provider Coinsurance Limit. In addition, amounts incurred toward the Non-Preferred Provider Coinsurance Limit will be applied to the Preferred Provider Coinsurance Limit. Lifetime Maximum Benefit $2,000,000
HEALTH CARE COVERAGE High Plan:
Inpatient Hospital Services 20% After Deductible 40% After Deductible Inpatient Medical Services 20% After Deductible 40% After Deductible Surgical Services 20% After Deductible 40% After Deductible Outpatient Services Physician Office Visits $15 Copayment, No 40% After Deductible
Diagnostic Services 20% After Deductible 40% After Deductible Physical Therapy 20% After Deductible 40% After Deductible Chiropractic Care 20% After Deductible 40% After Deductible Child Preventative Care Services* $15 Copayment, No 40% After Deductible Deductible & No Coinsurance * Benefits for these services are limited to age 9. Routine Mammography Screenings** 20% After Deductible 40% After Deductible ** Benefits for these services are limited to $85 per screening. In addition, routine mammography screenings will be covered on an Outpatient basis subject to the following schedule: 1. For women age 35-39, one baseline mammogram; 2. For women age 40-49, one screening every two benefit periods; 3. For women age 50 and over, one screening per benefit period. Routine Prostate Cancer Screenings *** 20% After Deductible 40% After Deductible *** Benefits for these services are limited to one per benefit period and $65 per screening. In addition, routine prostatic screenings will be covered on an Outpatient basis subject to the following schedule: 1. For men age 50 and over, one screening per benefit period. 2. For men age 40-49, one screening per benefit period, if a Physician deems the Covered Person at increased risk. All Other Services Listed in Outpatient Services Section 20% After Deductible 40% After Deductible Psychiatric and Substance Abuse Services Inpatient Services 20% After Deductible 40% After Deductible
Outpatient Services 50% up to $550, then 50% up to $550, then 20% After Deductible 40% After Deductible Home Health Care Services 20% After Deductible 40% After Deductible Skilled Nursing Facility Services 20% After Deductible 40% After Deductible Ambulance Services 20% After Deductible 40% After Deductible Private Duty Nursing Services 20% After Deductible 40% After Deductible Prescription Drugs Not covered under your Medical Coverage. Refer to your Prescription Drug Coverage at the end of your Schedule of Benefits. Medical Supplies, Equipment & Appliances 20% After Deductible 40% After Deductible Human Organ Transplant Services Transplant Surgery 20% After Deductible 40% After Deductible up to a $250,000 up to a $250,000 lifetime maximum lifetime maximum Acquisition 20% After Deductible 40% After Deductible up to a $10,000 up to a $10,000 maximum per transplant maximum per transplant Dental Services for an Accidental Injury 20% After Deductible 40% After Deductible PRESCRIPTION DRUG COVERAGE Benefit Period 7/1 through 6/30
Dependent Age Limit End of year of 23rd birthday Retail Coverage A. Deductible $50 single/$150/family B. Coinsurance 20% (if you use a non-member pharmacy, the payment will be 75% of the Pharmacy's billed charges, after the Deductible and Coinsurance are applied) Prescription Drugs are available as covered drugs when obtained from a Pharmacy. Under this portion of your Prescription Drug Coverage, covered drugs are drugs which require a prescription under federal law, are approved for general use by the Food and Drug Administration and are dispensed for your outpatient use by a licensed Pharmacy on or after your effective date. When obtaining Prescription Drugs from a Pharmacy, you should present your Prescription Drug Card. Mail Service Coverage (30 to 90 day supply) Copayment A. Generic $15.00 per prescription B. Brand Formulary $30.00 per prescription C. Non-Preferred/Other Brand $45.00 per prescription Maintenance Drugs prescribed in quantities of 30 to 90-day supplies are covered when dispensed for your Outpatient use by the Mail Service Drug Company on or after your effective date. Each prescription or refill is limited to a 90-day supply. Insulin syringes and needles are covered only when prescribed and dispensed at the same time as insulin. The Plan will pay for all charges except the Copayment amount. Low Plan:
Inpatient Hospital Services 30% After Deductible 50% After Deductible Inpatient Medical Services 30% After Deductible 50% After Deductible Surgical Services 30% After Deductible 50% After Deductible Outpatient Services Physician Office Visits $20 Copayment, No 50% After Deductible
Diagnostic Services 30% After Deductible 50% After Deductible Physical Therapy 30% After Deductible 50% After Deductible Chiropractic Care 30% After Deductible 50% After Deductible Child Preventative Care Services* $20 Copayment, No 40% After Deductible Deductible & No Coinsurance * Benefits for these services are limited to age 9. Routine Mammography Screenings** 30% After Deductible 50% After Deductible ** Benefits for these services are limited to $85 per screening. In addition, routine mammography screenings will be covered on an Outpatient basis subject to the following schedule: 1. For women age 35-39, one baseline mammogram; 2. For women age 40-49, one screening every two benefit periods; 3. For women age 50 and over, one screening per benefit period. Routine Prostate Cancer Screenings *** 30% After Deductible 50% After Deductible *** Benefits for these services are limited to one per benefit period and $65 per screening. In addition, routine prostatic screenings will be covered on an Outpatient basis subject to the following schedule: 1. For men age 50 and over, one screening per benefit period. 2. For men age 40-49, one screening per benefit period, if a Physician deems the Covered Person at increased risk. All Other Services Listed in Outpatient Services Section 30% After Deductible 50% After Deductible Psychiatric and Substance Abuse Services Inpatient Services 30% After Deductible 50% After Deductible
Outpatient Services 50% up to $550, then 50% up to $550, then 20% After Deductible 40% After Deductible Limited to 40 visits per year. Home Health Care Services 30% After Deductible 50% After Deductible Limited to one visit per day. Skilled Nursing Facility Services 30% After Deductible 50% After Deductible Ambulance Services 30% After Deductible 50% After Deductible Private Duty Nursing Services 30% After Deductible 50% After Deductible Prescription Drugs Not covered under your Medical Coverage. Refer to your Prescription Drug Coverage at the end of your Schedule of Benefits. Medical Supplies, Equipment & Appliances 30% After Deductible 50% After Deductible Human Organ Transplant Services Transplant Surgery 30% After Deductible 50% After Deductible up to a $250,000 up to a $250,000 lifetime maximum lifetime maximum Acquisition 30% After Deductible 50% After Deductible up to a $10,000 up to a $10,000 maximum per transplant maximum per transplant Dental Services for an Accidental Injury 30% After Deductible 50% After Deductible PRESCRIPTION DRUG COVERAGE Benefit Period 7/1 through 6/30
Dependent Age Limit End of year of 23rd birthday Retail Coverage A. Deductible $75 single/$225/family B. Coinsurance 20% ($10 minimum) Prescription Drugs are available as covered drugs when obtained from a Pharmacy. Under this portion of your Prescription Drug Coverage, covered drugs are drugs which require a prescription under federal law, are approved for general use by the Food and Drug Administration and are dispensed for your outpatient use by a licensed Pharmacy on or after your effective date. When obtaining Prescription Drugs from a Pharmacy, you should present your Prescription Drug Card. Mail Service Coverage No Coverage Enrollment Information for Domestic Partners As a Kenyon College benefits eligible employee, you may enroll an unmarried same or opposite sex Domestic Partner and/or your Domestic Partner’s child(ren) in the Kenyon College health insurance plan through Central Benefits. To enroll yourself and your Domestic Partner and/or your Domestic Partner’s child(ren), you must: 1. Complete the regular Medical Plan enrollment form. 2. Complete, sign and have your Partner sign the Certification of Domestic Partnership form. Definition of a Domestic Partner Kenyon College defines Domestic Partner as the partner of an eligible employee who is of the same or opposite sex, sharing a long-term committed relationship of indefinite duration with the following characteristics:
Eligibility Requirements for Your Domestic Partner’s Children In order for your Partner’s child to be claimed as a dependent under Kenyon College’s plan, the child must meet all of the following requirements: A. The child(ren) of the employee's Domestic Partner must be the legal tax dependents of the employee under IRS Sec. 152. Legal tax dependent is defined as follows: (1) is a citizen of the United States, Mexico, Canada, the Canal Zone or the Republic of Panama, (2) is a member of your household for the year, had his or her principal place of abode in your home for the year, (3) by engaging in the relationship, does not violate local law, (4) receives over half of his or her support for the year from you. Support includes food, shelter, clothing, medical and dental care, and education, and, (5) the dependent’s gross income must be less than the Federal personal exemption amount unless the dependent is under age 19 OR a full-time student (enrolled as a full-time student for at least five months during the year), under age 24. Change in family status If an employee needs to change his or her coverage due to a change in his or her family status (i.e., marriage or the birth or adoption of a child, addition of a domestic partner, etc.) the employee should contact the Office of Human Resources within thirty-one days of the event. Health Insurance for Eligible Dependents After the Death of an Active Employee In the event of the death of an active employee who was enrolled on Kenyon’s health insurance plan, the spouse and eligible dependents may continue to be enrolled for a period of one year at the same contribution levels as active employees. After the one year, the surviving spouse may continue the coverage by paying the full cost of the applicable premium. If the surviving spouse remarries or if dependents should lose their dependent status (as defined in the health insurance certificates), they will be eligible for continued coverage under COBRA. Health Insurance/Medicare - Active Employees When active employees become eligible for Medicare, they will be contacted by the Office of Human Resources, who will advise them of their right to designate the College’s health plan as the primary carrier (i.e., the plan that pays on all covered medical expenses before any other plans pay). They will also be advised that they have the right to waive enrollment in Part B of Medicare until retirement. These rights will also be applicable to spouses of active employees who are eligible for Medicare. Employees should notify the Office of Human Resources when their spouses become eligible for Medicare. Please refer to the health insurance "Summary Plan Description" for more information. Health Insurance at Retirement When employees retire, they and their eligible dependents may continue enrollment in the College’s group health plan providing they pay the cost of the applicable premiums. The spouse or domestic partner of a retiree must have been enrolled on the health plan prior to the date the employee becomes a retiree. Retirees may not add spouses, domestic partners or dependents to the health plan after their date of retirement. The earliest age an employee may retire and keep the health insurance benefits is age 59 ½. For employees hired before 6-30-00: If the employee retires after age 59 1/2 but before age 65, they may pay the same premiums as active employees if at least ten years of continuous service while enrolled in the health plan prior to the date of retirement were completed; OR if the employee completed less than ten years of service, he or she must have been enrolled in the health insurance plan during the total term of employment. For employees hired after 7-01-00: If the employee retires after age 59 1/2 but before age 65, they may pay the same premiums as active employees if at least ten years of continuous service while enrolled in the health plan prior to the date of retirement were completed. Employees with less than ten years of service are not eligible to continue the health insurance plan after their retirement date. If an employee retires at age 65 or over and meets the service requirements, Kenyon will contribute 30% of the Medicare carve-out premium as detailed below. When a retired employee is eligible for Medicare at age 65, Medicare becomes the primary carrier (i.e., the plan that pays on all covered medical expenses before any other plans pay). This also applies to spouses of retirees who are eligible for Medicare. Retirees, and employees who plan to retire at age 65 or later, should contact the Social Security Administration several months prior to their eligibility date and enroll in Parts A and B of Medicare. If the retiree and eligible dependents continue their coverage under the College health insurance plan, it will act as the secondary carrier (i.e., the plan paying the balance of covered bills, if any are payable, only after all benefits have been paid by Medicare). Using this carve-out approach where Medicare is primary and Kenyon’s plan is secondary, and providing the employee meets the above referenced service requirements, the College will pay 30% of the premium for the secondary coverage through Kenyon’s health plan. In most instances, the combination of these two plans will provide retirees and their dependents with the same full coverage they enjoyed as active employees. Group Dental Insurance - EBMC A comprehensive dental insurance program is available for benefit eligible employees and their spouses and/or same or opposite sex domestic partners and their children. (See definition of a domestic partner on page 68 under Group Health Insurance.) Participation is optional and becomes effective on the date of employment if elected. Please contact the Office of Human Resources for current premiums and rates of participation. Dental insurance may not be continued at retirement. Definitions and Brief Plan Description Preventive Services - Oral exams, teeth cleaning, x-rays, flouride treatment for children, space maintainers, and topical sealants for children, etc. Basic Services - Diagnostic services, restorative services, endodontics, certain periodontic services, oral surgery, certain prosthodontic services, general anesthesia, injectable antibiotics, etc. Major Services - Restorative services, prosthodontic services, etc. Orthodontia Services - Covers braces and appliances for children to the age of 19. There is a lifetime maximum of $1,000 per covered child. Benefit Levels: No Network All dental charges will be subject to UCR. UCR stands for usual, customary and reasonable. This pla will utitlize the 90th percentile (9 out of 10 dentist's charges will fall at or below the amount the plan will allow for a particular procedure). You may be responsible for payment on any amount above the UCR. Preventive 100% Basic 90% Major 60% Orthodontia 50% Deductible: None for Preventive. $50 per plan year (July 1 through June 30) for Basic and Major services, limited to only three deductibles per family. Benefit Level Maximum: Maximum of $1,000 per covered person per year. Dependent Children: Covered to the age of 20; covered to the age of 26 if a full-time student.
Long-Term Disability Insurance If you are a benefits eligible employee of Kenyon College, you will be enrolled on our long-term total disability policy through TIAA. This total disability insurance becomes effective the first day of the month after one year of eligible employment with Kenyon. This one-year waiting period is waived if the employee was enrolled in a prior employer’s total disability plan within three months of joining Kenyon and the plan with the previous employer provided income benefits for five or more years of total disability. The total cost of the premium is paid by the college. Should an employee become disabled and apply for the total disability benefit, there is a six month elimination period before benefits begin. Kenyon will normally continue the employee’s salary during the elimination period provided the employee is certified as disabled by TIAA. For more details regarding the benefits this policy provides, please refer to your certificates. Disability insurance cannot be continued at retirement.
Canada Life Insurance If you are a benefits eligible employee of Kenyon College, you are covered by our Group Life Insurance. This insurance is payable in the event of your death and includes an Accidental Death and Dismemberment provision. The benefit is equal to the employee’s annual earnings (excluding overtime); at age 65 the amount is decreased by 35%. You may change your beneficiary whenever you wish by submitting the appropriate documents to the Office of Human Resources. The College pays the entire cost of the premium. Should an employee become totally disabled before his or her 60th birthday, and continue to be disabled until death, the life insurance coverage will continue, provided required proof of disability and its continuance is submitted each year to Canada Life Insurance Company. At retirement or termination of employment, this policy may be converted to a personal policy at the employee’s expense. Refer to the literature provided by our insurance company for more details on this life insurance coverage.
The Standard Life and Accidental Death and Dismemberment Insurance If you are a benefits eligible employee of Kenyon College, you are eligible to enroll in the elective plan provided by Standard. This insurance has an optional Accidental Death and Dismemberment provision. The rates and coverage amount varies according to age of the employee. The College funds a portion of the monthly cost of this elective benefit. Refer to the literature provided by our insurance company for more details on this life insurance coverage. Termination of Insurance/COBRA Consolidated Omnibus Budget Reconciliation Act (COBRA). This federal regulation states that if employees lose health insurance coverage due to a reduction in hours or termination of employment (for reasons other than gross misconduct), they and their eligible dependents can continue that coverage for up to eighteen months from the date of loss of coverage. (In certain situations, such as the covered persons total disability during the first 60 days of the COBRA period, the continuation of coverage would extend up to 29 months.) Your insurance will terminate when the insurance policy terminates, when you fail to make an agreed contribution to premium when due, when you cease to be eligible for coverage under the terms of our group insurance program, when you cease to be eligible for benefits with Kenyon, or when you are no longer employed by Kenyon. Kenyon College may, by continuing to pay the premium, keep your insurance in effect for a brief period if you cease to be an eligible employee for any reason other than resignation, dismissal, or failure to meet the terms of eligibility of our group insurance program. |
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