2021-2022 BENEFITS - Scottsdale Unified School District
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2021-2022 BENEFITS
PAGE 2 2021–2022 BENEFITS
LET'S BEGIN!
1. Kairos’s medical network is changing to UnitedHealthcare (UHC), with UMR as the
medical claims payor/processor.
2. New medical/prescription ID cards will be sent to everyone this year. Be on the
lookout.
3. Kairos and UMR are teaming up to provide a new and improved health care
advocacy program. We can’t wait to show you!
4. We’re also adding a maternity program with a $25 reward and a chronic care
condition program with a $100 reward in the first year.
5. Teladoc is taking over as the telehealth provider, giving you access to general
medicine, behavioral health care, and now dermatology services.
6. ComPsych will be the new employee assistance program (EAP), providing 24/7
access to counseling and work-life resources.
7. 90-day prescriptions must be filled through mail order instead of through retail
pharmacies. This means more convenience and cost savings for you!
8. We have extended no-cost-share preventive service coverage to conditions like
diabetes and asthma.
9. We’re eliminating age restrictions on mammograms and colonoscopies. This
means more wellness services for you and your family.
10. Allowable HSA contributions are going up, so you can save more money this year.
See the HSA section for more info.
THIS GUIDE PRESENTS BENEFIT
OPTIONS AND COSTS FOR THE
PERIOD FROM JULY 1, 2021
THROUGH JUNE 30, 2022. IT
ALSO OUTLINES THE STEPS
YOU NEED TO TAKE TO
SELECT AND ENROLL IN
APPROPRIATE BENEFITS FOR
YOU AND YOUR DEPENDENTS.
PLEASE REVIEW THIS GUIDE
CAREFULLY AND CONTACT
YOUR BENEFITS DEPARTMENT
IF YOU HAVE QUESTIONS.
PAGE 3 2021–2022 BENEFITS
WHO SHOULD YOU CALL?
Contact our plan providers directly if you have questions or would like more detailed
information about our plans. If you need further assistance regarding your benefits,
contact your Benefit Department.
PLAN PROVIDER FOR QUESTIONS ABOUT… PHONE WEBSITE
UMR Medical eligibility and benefits; 844.212.6811 UMR.com
claims and appeals;
precertification; ID cards
MaxorPlus Prescription benefits 800.687.0707 MaxorPlus.com
Teladoc Virtual physician visits 800.835.2362 Teladoc.com
ComPsych Employee assistance program; 833.955.3386 GuidanceResources.com
counseling and work-life
services
BASIC COBRA and FSA 800.444.1922 BasicOnline.com
administration
HealthEquity Health savings account 866.346.5800 HealthEquity.com
Delta Dental Delta Dental plan 602.938.3131 DeltaDentalAZ.com
800.352.6132
Total Dental TDA DHMO dental plan 888.422.1995 TDAdental.com
Administrators
VSP Vision benefits 800.877.7195 VSP.com
MetLife Basic and supplemental life 877.638.7868 MetLife.com
and AD&D plans; voluntary MyBenefits.MetLife.com
short-term disability; worksite
benefits
MetLife Hyatt Legal Prepaid legal coverage 800.821.6400 LegalPlans.com
United Pet Care Pet insurance 602.266.5303 UnitedPetCare.com/Kairos
Nationwide Pet insurance 877.738.7874 PetInsurance.com
Kairos Plan administration and 888.331.0222 SVC.KairosHealthAZ.org
member services
PAGE 4 2021–2022 BENEFITS
ARE YOU READY
READY FOR
FOR THIS?
THIS?
During the open enrollment period, it's important that you complete the following steps:
CHOOSE YOUR PLAN
Select a medical program option and decide who you're going to cover. Your choices for
coverage are:
• employee;
• employee plus spouse;
• employee plus child(ren); or
• employee plus family.
MAKE A CONTRIBUTION TO YOURSELF
If you enroll in a high deductible health plan (HDHP), determine if you wish to contribute to
a health savings account (HSA). Refer to the health savings account section of this guide for
more information.
TAKE CARE OF YOUR LOVED ONES
Review and update beneficiary designations for life insurance benefits as needed.
ARE YOUR DEPENDENTS STILL ELIGIBLE?
Confirm that any dependents up to age 26 are still eligible to be enrolled.
CHOOSE YOUR VOLUNTARY PRODUCTS
If applicable, review and decide whether or not to add any voluntary products, and submit
required information.
NOTE: Please contact your Benefits
Department for your enrollment date.
Do not miss the enrollment period. It’s the one
time each year you can make changes (unless
you have a qualifying event; see page 6 for
more information).
PAGE 5 2021–2022 BENEFITS
WHO’S ELIGIBLE?
Full-time employees working at least 30 hours per week are eligible
Employees hired before 2009 working less than 30 hours per week may be eligible
for benefits at a cost subsidy commensurate with their full-time equivalent
Employees hired after 2009 working at least 30 hours per week are eligible
Employees in a job-share position are eligible for benefits if the position they share totals
30 or more hours per week, with employer-paid premiums to be pro-rated based on the
percentage of the position each employee is assigned
Dependents of enrolled employees are eligible, including:
— lawfully married spouses
— dependent children up to age 26
— unmarried children who are mentally or physically handicapped and fully dependent
on the enrolled employee for support and maintenance
NOTE: Duplicative coverage is prohibited, and no duplicative benefits will be paid. For
example, a man who is married to a district employee and who is also a district employee
himself may not enroll both as an employee and as a dependent spouse. It is each employee's
responsibility to make sure that they and their dependents do not have duplicative coverage.
THE ELECTIONS MADE DURING THIS ENROLLMENT PERIOD ARE EFFECTIVE FROM
July 1, 2021 to June 30, 2022
WHEN COVERAGE BEGINS
• New hires: Insurance elections are effective the first day of the month.
o Hire dates in the first half of the month result in a benefits effective date of the first of the
month immediately following the hire date.
o Hire dates in the second half of the month result in a benefits effective date of the first of the
month following 30 days.
• Open enrollment: Insurance elections and changes are effective on July 1, 2021.
• Allowable mid-year changes: Insurance elections and coverage changes are effective on
the first day of the month following the event date or date of birth for a newborn if
required enrollments have been completed and all required supporting documentation has
been received by the Benefits Department.
• Short-term disability: Elections made on or after the first day of a month will be effective
the first of the next month (this is for new hires only).
• For life insurance requiring a statement of health (SOH) form: The effective date may
be delayed according to SOH form completion, submission to the insurance carrier, and
approval by the insurance carrier.
PAGE 6 2021–2022 BENEFITS
WHEN CHANGES ARE ALLOWED
You can make changes or elect benefits once a year during open enrollment. Outside of open
enrollment, the IRS says a "qualified life event" must occur.
Examples?
Below are examples of qualified life events that may make a mid-year change possible:
• marriage, divorce, legal separation, or annulment;
• birth, adoption, placement for adoption, or legal guardianship of a child;
• death of a dependent;
• a change in your spouse’s employment, or involuntary loss of health coverage under another
employer’s plan;
• loss of coverage due to the exhaustion of another employer’s COBRA benefits, provided you were
paying premiums on a timely basis; and
• change in your dependent’s eligibility status.
NOTE: This list is not inclusive of all mid-year or special enrollment changes. For more information, please visit the
Kairos website or contact your Benefits Department.
Changes must be made within 31 days of the change in status event. If you don't make changes within
this timeframe, your next opportunity to make changes to your coverage will be during the next open
enrollment period.
Expecting a baby? Congratulations! Remember HELPFUL TIPS:
to complete the appropriate documentation Losing medical coverage
within 31 days following your baby’s birth. through the Marketplace is not
Coverage for newborns is not automatic, so you considered a qualified change in
must notify your Benefits Department within status event, and you will not be
this time period and pay the full premium for allowed to join the plan mid-
the month the child is added (if necessary). year. However, you can drop
your medical coverage to join a
Marketplace plan mid-year. You
will be required to provide proof
of coverage within 31 days of
your enrollment.
Voluntary termination from
COBRA is also not considered a
qualified life event.
PAGE 7 2021–2022 BENEFITS
ONLINE ENROLLMENT INSTRUCTIONS
Ivisions is your online enrollment tool.
The site is accessible via your single sign-on in the Ivisions portal.
Scottsdale Unified School District Benefits Department
NAME EMAIL TELEPHONE FAX
SUSD Benefits Department benefits@susd.org 480.484.6104 480.484.6268
BENEFITS OVERVIEW
All plan information and rates can be found in the idrive/Benefits Folder/2021-22 Open Enrollment
Information (Use SUSD Single Sign-On, then My Drives, then the "i" drive).
TO ENROLL THROUGH THE IVISIONS BENEFITS PORTAL
1. Log on to Ivisions portal.
2. Click on Benefits, then “HR Benefits Enrollment.”
3. Read through the Welcome Screen instructions. Please note: Do not use the “Back” button
on your browser.
4. If you need to make changes to your address or phone number, you will do that in your
Profile under the self service tab and not via the benefits enrollment portal.
5. To add/edit dependents or beneficiaries and/or update information, you will click the
magnifying glass to activate the screen. Save your edits by clicking “Update” when
finished.
6. You will move through the screens with the “Next” or “Previous” button on the bottom of
the page; do not hit the “Back” button on your browser.
7. To elect benefits, click on the radio button to make your election. If you choose
any dependents, make sure you scroll to the bottom to select the corresponding
dependent.
8. You may opt out of any benefit by scrolling to the bottom of the screen and clicking the
“Waive” radio button.
9. When you come to the end of the portal, make sure you hit “Submit” to complete
your enrollment.
10. You can print your enrollment after you have submitted to keep a copy for your records.
PAGE 8 2021–2022 BENEFITS
YOU HAVE CHOICES!
Scottsdale Unified School District offers a flexible benefits program that lets you choose from
different medical plan options using the UnitedHealthcare network. As you review the plan
information, keep in mind the following key terms:
Let’s break down some health insurance terms and make this easy.
PLAN YEAR DEDUCTIBLE COINSURANCE
This is the amount of money you have to pay This is a percentage of covered medical costs
each year for covered services before your you pay once you meet your deductible. The
health insurance benefits kick in. plan pays the rest.
EMBEDDED DEDUCTIBLE EXAMPLE: Let’s say you’ve met your
This is a deductible arrangement under which
deductible. Your recent doctor’s visit
individual family members have their own
was $100, and your coinsurance is
deductibles—plus there's a deductible for the
30%. This means your insurance will
family as a whole. After an individual meets
pay $70, and you owe the other $30.
his or her deductible, the plan begins to pay
benefits for that person. Once the family
deductible is met, the plan pays benefits for all. OUT-OF-POCKET MAXIMUM
This is the most you’ll pay for covered
NON-EMBEDDED DEDUCTIBLE services during the plan year. The out-of-
Under this deductible arrangement, the entire
pocket maximum puts a cap on healthcare
family shares a single deductible. The family
costs if you ever have a major illness or injury.
deductible must be met before the plan begins
to pay benefits.
I get it!
HIGH DEDUCTIBLE HEALTH PLAN (HDHP)
This is a plan that has a lower monthly premium
but a higher annual deductible. It’s usually
paired with a health savings account (HSA) to
help pay medical expenses.
IN-NETWORK VS. OUT-OF-NETWORK
In-network providers are contracted to provide
services at a discounted rate. Out-of-network
providers are not. Because of this, staying in-
network is usually the best way to save money
on your health care.
TIP: To gain the best savings, find an in-
network provider at:
go.umr.com/KairosHealthArizona
PAGE 9 2021–2022 BENEFITS
MEDICAL NETWORK
ue s t ions?
Q
Call 844.212.6811
or visit
umr.com
MEDICAL NETWORK
Starting July 1, 2021, UnitedHealthcare (UHC) will provide the
Kairos medical network, with UMR as the claims administrator.
What’s this mean for you? Be on the lookout!
Access to over 600,000 New claims New and improved
providers across the country processing contacts medical/Rx ID cards
To find an in-network provider, visit go.umr.com/KairosHealthArizona
PREVENTIVE BENEFITS With UMR’s member portal,
We want to keep you healthy. So, the Kairos plan covers you’ll be able to:
preventive care services for free when you visit an
in-network provider. • Order new ID cards
Examples of preventive benefits include: • View claims information
and EOBs
• Use the health cost
Annual wellness visits Mammogram screenings
estimator tool
Prostate screenings Colonoscopy screenings • And so much more!
Annual flu shots Cancer screenings Start browsing at umr.com.
Hearing exams Generic contraceptives
Don’t forget to register for
Well child visits Blood pressure tests your personal account
starting 7/1/2021.
You can see a full list of preventive services at: healthcare.gov/coverage/preventive-care-benefits/
PAGE 10 2021–2022 BENEFITS
PRESCRIPTION BENEFITS
ue s t ions?
Q
Call 800.687.0707
or visit
PRESCRIPTION BENEFITS maxor.com
When you enroll for Kairos medical coverage, you automatically receive prescription drug
coverage through MaxorPlus. This benefit allows you to obtain prescriptions from any
participating pharmacy listed in the MaxorPlus pharmacy network.
To manage your prescription benefits, register for the MaxorPlus Member
Portal. Once there, you can do things like:
Locate the closest View the plan formulary Sign up for mail order
network pharmacy (a list of prescription medications
that may be covered under the plan)
MYMAXORLINK DISCOUNT PROGRAM
Get the most from your pharmacy benefits and register for myMaxorLink. Once enrolled,
you’ll automatically receive information on lower-cost prescriptions, reminders specific to
your coverage, and other important health updates. This is a great discount savings resource!
To enroll, call 888.596.0723 or go to mymaxorlink.com/maxorplus. It’s as simple as that. And
it’s free to enroll!
Importan
t tip!
Starting July 1, 2021, you’ll have access to 90-day prescriptions through mail-
order only, instead of through retail pharmacies. This means lower out-of-pocket
costs for you and the convenience of having these delivered to your home!
Have your 90-day script ready? Sign up for mail-order using the MaxorPlus
member portal, maxorplus.com.PAGE 11 2021–2022 BENEFITS
BENEFITS WITH YOUR BENEFITS
With Kairos, you get more than just the basic benefits. Take advantage of all the resources
available to you, like these:
TELADOC® COMPSYCH®
TELEHEALTH EMPLOYEE ASSISTANCE
With Teladoc, you can use your telephone PROGRAM
or computer to conduct a live virtual visit
ComPsych offers 24-hour access to
with a board-certified medical
confidential counseling services that can
professional—any day, anytime, anywhere.
help with a variety of everyday issues and
You'll get fast help for non- challenges. Professional advisors are
emergency matters like: available to help you and your family with:
Stress, anxiety, and minor
Cold and flu Headache
depression management
symptoms Pink eye
Family and relationship matters
Skin irritations Sinus infection
Substance abuse
Stomach bugs Sore throat
Childcare and elder care resources
You’ll also have access to behavioral Legal and financial information and
health services and dermatology resources
services!
Will preparation services
Coverage includes up to six one-on-one
counseling sessions per family member,
per issue, per year at no cost to you.
And first responders get up to 12 one-on-
one counseling sessions for a traumatic on-
the-job event.
ue s tions? Questio
ns?
Q
Call 800.835.2362 Call 833.955.3386
or visit or visit
teladoc.com guidanceresources.com
Web ID: KairosEAPPAGE 12 2021–2022 BENEFITS
PPO PLAN IN-NETWORK4 OUT-OF-NETWORK4
BENEFIT OVERVIEW
$1,000/employee $2,000/employee
PLAN YEAR DEDUCTIBLE1
$2,000/employee +1 or more $4,000/employee +1 or more
$5,000/employee $10,000/employee
OUT-OF-POCKET MAXIMUM2
$10,000/employee +1 or more $20,000/employee +1 or more
$40 copay primary care physician;
OFFICE VISIT Plan pays 25% after deductible
$50 copay specialist
WELL ADULT CARE
Plan pays 100%, no deductible Plan pays 25%, no deductible
WELL CHILD CARE
TELADOC5 Plan pays 100%, no deductible N/A
EMERGENCY ROOM3 $250, then plan pays 70% $250, then plan pays 70%
URGENT CARE $75 copay
INPATIENT HOSPITAL
Plan pays 70% after deductible Plan pays 25% after deductible
OUTPATIENT HOSPITAL
OUTPATIENT BEHAVIORAL VISIT $40 copay
Rx Deductible: $100 individual/$200 family
RETAIL PRESCRIPTION DRUGS You pay:
After deductible is met • Generic: $10
(30-day supply) • Preferred: $35
• Non-preferred: $60
• Specialty: 20% (maximum of $60)
MAIL-ORDER DRUGS You pay:
After deductible is met • Generic: $20
(90-day supply) • Preferred: $70
• Non-preferred: $120
*This plan has an embedded individual deductible and an embedded out-of-pocket maximum. This means that although a
deductible and out-of-pocket maximum apply to the family as a whole, no individual will be responsible for more than his/her
individual deductible before the plan pays benefits for that person, and no individual will be responsible for more than his/her
individual out-of-pocket maximum.
1 The deductible must be met before the plan pays benefits. All benefits are subject to the deductible, unless otherwise noted.
2 The deductible applies toward the annual out-of-pocket maximum.
3
You pay one access fee per member, per day, per facility, plus in-network deductible and coinsurance. The fee is waived if
you are admitted to the hospital as an inpatient.
4The in-network and out-of-network deductibles and out-of-pocket maximums are separate and do not accumulate toward
one another.
5Teladoc general medicine services are covered at 100%, subject to the CARES Act. Behavioral and dermatology services have a
copay/cost-share associated.
Disclaimer: Information may be subject to change.PAGE 13 2021–2022 BENEFITS
$1,500 HDHP
($3,000 FAMILY*) IN-NETWORK3 OUT-OF-NETWORK3
BENEFIT OVERVIEW
$1,500/employee $3,000/employee
PLAN YEAR DEDUCTIBLE1
$3,000/employee +1 or more $6,000/employee +1 or more
$3,000/employee $6,000/employee
OUT-OF-POCKET MAXIMUM2
$6,000/employee +1 or more $12,000/employee +1 or more
OFFICE VISIT Plan pays 70%, after deductible Plan pays 25% after deductible
WELL ADULT CARE
Plan pays 25% after deductible
WELL CHILD CARE Plan pays 100%, no deductible
TELADOC5 N/A
EMERGENCY ROOM Plan pays 70% after deductible
URGENT CARE
INPATIENT HOSPITAL
Plan pays 70% after deductible
OUTPATIENT HOSPITAL
Plan pays 25% after deductible
OUTPATIENT LAB AND X-RAY
(INCLUDING MRI, PET, AND CT)
OUTPATIENT BEHAVIORAL VISIT
RETAIL PRESCRIPTION DRUGS You pay:
After deductible is met • Generic: $10
(30-day supply)4 • Preferred: $35
• Non-preferred: $60
• Specialty: 20% (maximum of $60)
MAIL-ORDER DRUGS You pay:
After deductible is met • Generic: $20
(90-day supply) 4 • Preferred: $70
• Non-preferred: $120
*This plan has a non-embedded deductible and out-of-pocket maximum. This means that families enrolling in the plan will need to meet
the entire family deductible before the plan pays benefits for any member of the family (other than for preventive/wellness care).
The deductible must be met before the HDHP plan pays benefits. All benefits are subject to the deductible, unless otherwise noted.
1
2 The deductible applies toward the annual out-of-pocket maximum on the HDHP plans.
3The in-network and out-of-network deductibles and out-of-pocket maximums are separate and do not accumulate toward one
another.
The annual deductible must be met before the plan pays a prescription drug benefit, with the exception of certain preventive
4
medications. For a detailed list of these medications, visit maxorplus.com.
5Teladoc general medicine services are covered at 100%, subject to the CARES Act. Behavioral and dermatology services have a
copay/cost-share associated.
Disclaimer: Information may be subject to change.PAGE 14 2021–2022 BENEFITS
$2,800 HDHP
BENEFIT OVERVIEW IN-NETWORK3 OUT-OF-NETWORK3
$2,800/employee $5,000/employee
PLAN YEAR DEDUCTIBLE1
$5,600/employee +1 or more $10,000/employee +1 or more
$5,000/employee $10,000/employee
OUT-OF-POCKET MAXIMUM2
$10,000/employee +1 or more $20,000/employee +1 or more
OFFICE VISIT Plan pays 70% after deductible Plan pays 25% after deductible
WELL ADULT CARE
Plan pays 25% after deductible
WELL CHILD CARE Plan pays 100%, no deductible
TELADOC5 N/A
EMERGENCY ROOM Plan pays 70% after deductible
URGENT CARE
INPATIENT HOSPITAL
Plan pays 70% after deductible
OUTPATIENT HOSPITAL
Plan pays 25% after deductible
OUTPATIENT LAB AND X-RAY
(INCLUDING MRI, PET, AND CT)
OUTPATIENT BEHAVIORAL VISIT
RETAIL PRESCRIPTION DRUGS You pay:
After deductible is met • Generic: $10
(30-day supply)4 • Preferred: $35
• Non-preferred: $60
• Specialty: 20% (maximum of $60)
MAIL-ORDER DRUGS You pay:
After deductible is met • Generic: $20
(90-day supply) 4 • Preferred: $70
• Non-preferred: $120
*This plan has an embedded deductible and out-of-pocket maximum. This means that although a deductible and out-of-pocket
maximum apply to the family as a whole, no individual will be responsible for more than his/her individual deductible before the
plan pays benefits for that person, and no individual will be responsible for more than his/her individual out-of-pocket maximum.
The deductible must be met before the HDHP plan pays benefits. All benefits are subject to the deductible, unless otherwise noted.
1
The family deductible must be met before claims are paid for any member of the family.
2
The deductible applies toward the annual out-of-pocket maximum on the HDHP plans.
3The in-network and out-of-network deductibles and out-of-pocket maximums are separate and do not
accumulate toward one another.
4The annual deductible must be met before the plan pays a prescription drug benefit, with the exception of certain
preventive medications. For a detailed list of these medications, visit maxorplus.com.
5Teladoc general medicine services are covered at 100%, subject to the CARES Act. Behavioral and dermatology services
have a copay/cost-share associated.
Disclaimer: Information may be subject to change.PAGE 15 2021–2022 BENEFITS
$5,000 HDHP IN-NETWORK3 OUT-OF-NETWORK3
BENEFIT OVERVIEW
$5,000/employee $10,000/employee
PLAN YEAR DEDUCTIBLE1
$10,000/employee +1 or more $20,000/employee +1 or more
$6,750/employee $13,500/employee
OUT-OF-POCKET MAXIMUM2
$13,500/employee +1 or more $27,000/employee +1 or more
OFFICE VISIT Plan pays 70% after deductible Plan pays 25% after deductible
WELL ADULT CARE
Plan pays 25% after deductible
WELL CHILD CARE Plan pays 100%, no deductible
TELADOC5 N/A
EMERGENCY ROOM Plan pays 70% after deductible
URGENT CARE
INPATIENT HOSPITAL
Plan pays 70% after deductible
OUTPATIENT HOSPITAL
Plan pays 25% after deductible
OUTPATIENT LAB AND X-RAY
(INCLUDING MRI, PET, AND CT)
OUTPATIENT BEHAVIORAL VISIT
RETAIL PRESCRIPTION DRUGS You pay:
After deductible is met • Generic: $10
(30-day supply)4 • Preferred: $35
• Non-preferred: $60
• Specialty: 20% (maximum of $60)
MAIL-ORDER DRUGS You pay:
After deductible is met • Generic: $20
(90-day supply) 4 • Preferred: $70
• Non-preferred: $120
*This plan has an embedded deductible and out-of-pocket maximum. This means that although a deductible and out-of-pocket
maximum apply to the family as a whole, no individual will be responsible for more than his/her individual deductible before the
plan pays benefits for that person, and no individual will be responsible for more than his/her individual out-of-pocket maximum.
The deductible must be met before the HDHP plan pays benefits. All benefits are subject to the deductible, unless otherwise noted.
1
The family deductible must be met before claims are paid for any member of the family.
2 The deductible applies toward the annual out-of-pocket maximum on the HDHP plans.
3The in-network and out-of-network deductibles and out-of-pocket maximums are separate and do not
accumulate toward one another.
4The annual deductible must be met before the plan pays a prescription drug benefit, with the exception of certain
preventive medications. For a detailed list of these medications, visit maxorplus.com.
5Teladoc general medicine services are covered at 100%, subject to the CARES Act. Behavioral and dermatology
services have a copay/cost-share associated.
Disclaimer: Information may be subject to change.PAGE 16 2021–2022 BENEFITS
PLAN FEATURES PPO PLAN $1,500 HDHP $2,800 HDHP $5,000 HDHP
In- Out-of- In- Out-of- In- Out-of- In- Out-of-
network network network network network network network network
ANNUAL DEDUCTIBLE
Individual $1,000 $2,000 $1,500 $3,000 $2,800 $5,000 $5,000 $10,000
Family $2,000 $4,000 $3,000 $6,000 $5,600 $10,000 $10,000 $20,000
OUT-OF-POCKET MAXIMUM (OOP)
Individual $5,000 $10,000 $3,000 $6,000 $5,000 $10,000 $6,750 $13,500
Family $10,000 $20,000 $6,000 $12,000 $10,000 $20,000 $13,500 $27,000
PREVENTIVE CARE
Wellness visits 100% 25% 100% 25% 100% 25% 100% 25%
Mammogram 100% 25% 100% 25% 100% 25% 100% 25%
DOCTOR AND SPECIALIST
Doctor visits $40 25% 70%* 25%* 70%* 25%* 70%* 25%*
Specialist visit $50 25% 70%* 25%* 70%* 25%* 70%* 25%*
URGENT AND EMERGENCY CARE
Urgent care visit $75 25% 70%* 25%* 70%* 25%* 70%* 25%*
$250, $250,
Emergency room then then 70%* 70%* 70%* 70%* 70%* 70%*
70% 70%
HOSPITAL CARE
Outpatient surgery 70%* 25%* 70%* 25%* 70%* 25%* 70%* 25%*
Lab/X-ray 70%* 25%* 70%* 25%* 70%* 25%* 70%* 25%*
Hospital stay 70%* 25%* 70%* 25%* 70%* 25%* 70%* 25%*
Maternity stay 70%* 25%* 70%* 25%* 70%* 25%* 70%* 25%*
ADDITIONAL SERVICES
Embedded deductible
Yes Yes No No Yes Yes Yes Yes
& OOP max
Combined medical &
No No Yes Yes Yes Yes Yes Yes
Rx deductible
OOP max includes
Yes Yes Yes Yes Yes Yes Yes Yes
deductible
PRESCRIPTION
Retail (30-day Rx deductible
Medical deductible applies
supply) applies**
Generic $10* $10* $10* $10* $10* $10* $10* $10*
Preferred $35* $35* $35* $35* $35* $35* $35* $35*
Non-preferred $60* $60* $60* $60* $60* $60* $60* $60*
Mail-order (90-day Rx deductible
Medical deductible applies
supply) applies**
Generic $20* N/A $20* N/A $20* N/A $20* N/A
Preferred $70* N/A $70* N/A $70* N/A $70* $70*
Non-preferred $120* N/A $120* N/A $120* N/A $120* $120*
*After deductible
**A $100 individual/$200 family Rx deductible applies on the PPO Plan.PAGE 17 2021–2022 BENEFITS
ue s t ions?
Q
Call 866.346.5800
or visit
HEALTH SAVINGS ACCOUNT (HSA) healthequity.com
If you enroll in a high deductible health plan, you have the option of
opening a health savings account (HAS) with HealthEquity. An HSA is a
personal savings account that you can use to pay for qualified health care
expenses.
HSA Advantages
Triple Tax Benefit It’s Yours Forever Grow and Save
Contributions come out of your The money in your HSA You can invest the funds, and
check pre-tax; qualified medical rolls over every year and your earnings grow tax-free.
expenses are tax-free; and is yours to keep, even if After age 65, you can use the
interest and investment you leave your employer. HSA like a traditional
earnings are tax-free. retirement account.
YOU'RE ELIGIBLE FOR AN HSA IF:
You’re enrolled in a qualified high You aren’t enrolled in Medicare or another
deductible health plan (HDHP). non-qualified healthcare plan.
You’re not also covered by a spouse’s You can’t be claimed as a dependent on
non-HDHP employer plan. someone else’s tax return.
Discover the many uses for your HSA: https://learn.healthequity.com/qme/
HOW MUCH CAN YOU CONTRIBUTE?
COVERAGE TYPE
2021 CONTRIBUTION
LIMIT
HSA increases
INDIVIDUAL $3,600 for 2021
HSA contribution limits are determined on a calendar-
FAMILY $7,200
/tax-year basis. This means that the
limits you see here apply to the January 1 through
AGE 55+ CATCH-UP CONTRIBUTION Additional $1,000 December 31 period. This is a little different from the
Kairos plan year, which runs July 1 to June 30.
Kairos, Scottsdale USD and HealthEquity do not provide legal, tax, or financial advice. Please consult your personal tax advisor or
legal counsel for this information.PAGE 18 2021–2022 BENEFITS
Call 800.444.1922
or visit
basiconline.com
FLEXIBLE SPENDING ACCOUNT (FSA)
Set aside pre-tax dollars for eligible healthcare and dependent care expenses in a flexible
spending account (FSA) administered by BASIC. (These accounts are also referred to as
consumer-driven accounts, or CDAs.) You elect how much you want to contribute in equal
installments throughout the year.
MEDICAL REIMBURSEMENT FSA DEPENDENT CARE FSA
WHAT ARE Up to $2,750 Up to $5,000 (tax-filing status and
THE ANNUAL participation in other plans may affect
CONTRIBUTION contribution limits)
LIMITS?
WHAT CAN THE Eligible medical, dental, and vision expenses Eligible childcare expenses
MONEYBE USED that are not already covered or deducted on
FOR? your income taxes
HOW ARE Claim form submitted via BASIC's mobile Claim form submitted via BASIC's
REIMBURSEMENTS app, employee portal, fax, or mail mobile app, employee portal, fax, or mail
MADE?
IF YOU ENROLL IN AN HDHP PLAN WITH A HEALTH SAVINGS ACCOUNT, YOU ARE
NOT ELIGIBLE FOR A MEDICAL EXPENSE REIMBURSEMENT ACCOUNT. HOWEVER,
YOU ARE STILL ELIGIBLE TO ENROLL IN A DEPENDENT CARE ACCOUNT.
HOW FLEXIBLE SPENDING ACCOUNTS WORK
• You decide how much you want to contribute on an annual basis into one or both of the FSAs.
• It’s a “use it or lose it” plan, meaning you must use the funds to pay for eligible expenses during
the plan year, otherwise you will lose them.
• Your FSA contributions are deducted from your paychecks on a pre-tax basis, in equal amounts
each pay period.
• Your election stays in effect for the entire plan year (July 1 through June 30). You may not
increase, decrease, or cancel your contributions outside of the plan’s enrollment period, unless
you have a qualified life status change (see page 6 for information about status changes).
• You use your FSA contributions to pay for eligible expenses under the Medical Expense
Reimbursement Account or Dependent Care Account. The IRS clearly defines eligible expenses,
and only those that comply with the Internal Revenue Code are eligible for reimbursement.
• You may not use the contributions you make to the Medical Expense Reimbursement Account to
reimburse yourself for eligible expenses under the Dependent Care Account, or vice versa.
i See IRS Publications 503 for more information on FSAs, contributions, and eligible
expenses: https://www.irs.gov/publications/p503PAGE 19 2021–2022 BENEFITS
ue s t ions?
Q
Call 800.352.6132
or visit
deltadentalaz.com
DELTA DENTAL
Delta Dental’s dental plans allow you and your eligible dependents to visit any dentist or specialist
without a referral. The plans also travel with you anywhere in the country. Delta Dental issues ID
cards, so be on the lookout for yours if enrolled.
You can save money on out-of-pocket costs and maximize your annual benefit by verifying that
i your dentist is an in-network PPO provider when making an appointment. You can also check
provider status on deltadentalaz.com.
PPO/Premier PPO/Premier
CORE PLAN Dentist PREMIER PLAN Dentist
ANNUAL MAXIMUM BENEFIT1 $1,000 ANNUAL MAXIMUM BENEFIT1 $2,000
ANNUAL DEDUCTIBLE
ANNUAL DEDUCTIBLE $50/$150
$50/$150 (INDIVIDUAL/FAMILY)1
(INDIVIDUAL/FAMILY)1
LIFETIME ORTHODONTIA MAXIMUM1 $1,500
PREVENTIVE SERVICES (TWICE A
YEAR) PREVENTIVE SERVICES (TWICE A YEAR)
• Exams •Exams
• Routine cleanings •Routine cleanings
• Fluoride: for children up to age 18 100%
•Fluoride: for children up to age 18
• Sealants: for children up to age 19 •Sealants: for children up to age 19 100%
• X-rays •X-rays
• Space maintainers: for children •Space maintainers: for children missing
missing baby teeth up to age 14 baby teeth up to age 14
BASIC SERVICES
BASIC SERVICES •Fillings
• Fillings 80%2 •Stainless steel crowns
• Stainless steel crowns •Emergency treatment
• Emergency treatment •Endodontics: root canal treatment 90%2
•Periodontics: treatment of gum disease
•Oral surgery: simple and surgical
MAJOR SERVICES extractions
• Endodontics: root canal treatment
• Periodontics: treatment of gum
disease
MAJOR SERVICES
• Prosthodontics: bridges, partial • Prosthodontics: bridges, partial dentures,
dentures, complete dentures 50%2 complete dentures
• Bridge and denture repair • Bridge and denture repair
60%2
• Implants • Implants
• Restorative: crowns and onlays • Restorative: crowns and onlays
• Oral surgery: simple and surgical
extractions
ORTHODONTIC SERVICES (AGES 8+) 50%
1 Combination of in-network and out-of-network.
2 Deductibles apply to these services.PAGE 20 2021–2022 BENEFITS
ue s t ions?
Q
Call 888.422.1995
or visit
TDADental.com
SUMMIT CARE PLUS DHMO DENTAL PLAN
Total Dental Administrators (TDA) provides comprehensive dental care on a predetermined fee
schedule. There are no deductibles, no claim forms, and no annual or lifetime benefit maximums.
Services are covered in the state of Arizona only.
WHAT SORT OF THINGS ARE COVERED?
Preventive, diagnostic, and TMJ
restorative care
Endodontics, periodontics, and
Orthodontics for children and adults prosthodontics
Oral surgery
For a more detailed list of services, visit TDADental.com.
How Do I Pick My Provider?
STEP 1 STEP 3
While in the iVisions portal, click the TDA link Make note of the provider code number listed to
to navigate to the website. the right of the dental office. You’ll use this code
number to identify your selection when enrolling
STEP 2 for benefits or calling customer service.
Click on “find a provider” and select your
DHMO dental plan network. Contact TDA customer service at 888.422.1995 if
you need to change your provider mid-year.PAGE 21 2021–2022 BENEFITS
ue s t ions?
Q
Call 800.877.7195
or visit
VSP.com
VSP VISION CHOICE PLAN
Using your VSP Choice benefit is easy. Simply create an account at VSP.com. Once your account
is activated, you can review your benefit information and find an eye doctor who’s right for you.
At your appointment, tell the office staff that you have VSP.
You may visit any vision care provider, but know that benefits are provided at significantly
higher levels when you visit an in-network doctor.
i
There’s no ID card necessary. Just give your provider your social security number and let them
know you have VSP vision coverage. However, if you’d like a card for reference, you can print
one at vsp.com.
CHOICE PLAN DESCRIPTION COPAY FREQUENCY
BENEFIT COVERAGE
Focuses on your eyes and overall $10 Every 12
WELL VISION EXAM wellness months
$25 See Frames &
PRESCRIPTION GLASSES
Lenses
$180 allowance for select frames Included in Every 12
$200 allowance for featured frames prescription months
glasses
FRAMES 20% savings on the amount over your
copay
allowance
$100 Costco and Walmart frame
allowance
Single vision, lined bifocal, and Included in Every 12
lined trifocal lenses prescription months
LENSES
Polycarbonate lenses for glasses
dependent children copay
Standard progressive lenses $0 Every 12
LENS ENHANCEMENTS months
UV protection $0
Premium progressive lenses $95–$105
Average savings of 20–25% on other
Custom progressive lenses $150–$175
lens enhancements
$150 allowance for contacts; the Up to $60 Every 12
copay for the fitting and evaluation months
CONTACTS (INSTEAD OF GLASSES) exam does not apply toward the cost
of contact lensesPAGE 22 2021–2022 BENEFITS
ue s t ions?
Q
Call 888.331.0222
or visit
metlife.com
BASIC LIFE INSURANCE
The district provides eligible employees with basic term life and accidental death and
dismemberment insurance coverage for each eligible employee who works a .75 or greater contract.
Employees hired prior to 2009 who work between .5 and .74 receive a prorated level, commensurate
with their contract. Eligible classified and certified employees are provided basic life coverage in the
amount of $50,000. Administrative employees are provided their annual salary plus $50,000 to a
maximum of $250,000.
After you reach age 65, the policy amount is reduced by 35%, and then reduced again at age 70
by 50%. An accelerated death benefit is also available in the event of your terminal illness.
You must designate a beneficiary at least 18 years of age for the basic life insurance benefit. To
update your beneficiary information, you can do so in the iVisions system.
SUPPLEMENTAL LIFE INSURANCE
If eligible, you have the opportunity to purchase supplemental life insurance coverage for yourself
and your eligible spouse and dependent children. The covered employee must elect supplemental
life for him/herself to be eligible for supplemental dependent coverage. Note: The amount of
coverage, once elected, will not automatically reduce with age. However, your premium will
increase as you age.
i
MetLife provides extended support services such as travel assistance, will preparation,
estate resolution, and grief counseling. Please contact Kairos for more information.
SCOTTSDALE OFFERS THE FOLLOWING SUPPLEMENTAL COVERAGE AMOUNTS
EMPLOYEE $10,000–$500,000, not to exceed five times annual earnings
(NOTE: Initial member enrollment provides up to $150,000 and
is guaranteed issue.)
SPOUSE $10,000–$250,000, not to exceed 100% of employee voluntary and
basic life combined
(NOTE: Initial member enrollment provides up to $30,000 and
is guaranteed issue. Spousal rates are based on age of
employee.)
CHILD (0–15 days) $1,000
CHILD (15 days–26 years) $10,000PAGE 23 2021–2022 BENEFITS
ue s t ions?
Q
Call 877.638.7868
or visit
metlife.com
SHORT-TERM DISABILITY INSURANCE
Voluntary short-term disability coverage helps provide income protection for employees with
unexpected health events, associated expenses, and possible time away from work due to a
non-occupational injury or sickness.
Eligible employees can elect to purchase voluntary short-term disability coverage. The plan
provides benefits in the amounts of 40%, 50%, and 66.67% of your salary, up to a $1,154
weekly maximum benefit. Benefits are paid in the event you cannot work due to a covered
non-occupational sickness or injury, for up to 25 weeks of continuous disability. This plan
covers maternity the same as a sickness.
Benefits begin following the plan’s 7-day elimination period. Benefits are paid in addition to
accumulated sick leave—even when school is not in session—if you are unable to work. Your
benefit will be offset by other income sources as defined by MetLife group policies. These
sources include, but are not limited to, Social Security and state retirement systems. However, the
minimum weekly benefit amount payable under the voluntary short-term disability policy cannot
be lower than a $20 weekly benefit, regardless of the amount of income you receive from other
sources. Income received from salary continuation or accumulated sick leave plans will not be
deducted from your gross disability benefit.
PRE-EXISTING CONDITION LIMITATIONS
The policy does not cover an illness or accidental injury that arose in the three months prior to
your plan effective date. In addition, to be eligible for coverage during pregnancy, your
pregnancy must occur on or after the benefit effective date (e.g., July 1, 2021 if you are enrolling
during open enrollment).
IMPORTANT
If you receive a salary increase,
your short-term disability does
not increase automatically.
You may sign up for this coverage
only during open enrollment, or as
a new hire.
You may not drop coverage until
the next open enrollment period.PAGE 24 2021–2022 BENEFITS
ue s t ions?
Q
Call 877.638.7868
or visit
legalplans.com
METLIFE LEGAL SERVICES PLAN
Kairos’s legal plan through MetLife provides access to a national network of over 17,000 attorneys
to help navigate important life events such as buying a home or creating a will. Through the
program, you can participate in telephone and office consultations with attorneys on a broad range
of legal services.
The MetLaw advantage
• Telephone advice and office consultation • Money-back guarantee
on an unlimited number of legal matters
• No deductibles or copays
(exclusions may apply)
• Access to attorneys in person, or by phone, • No claim forms
email, or mobile app • No usage limits
LOW PLAN HIGH PLAN
(IN ADDITION TO LOW PLAN FEATURES)
Identity theft defense Personal bankruptcy
Tenant negotiations/foreclosures Tax audit representation
Powers of attorney, guardianship, Purchase or sale of a home/property
conservatorship, demand letters, school
hearings Revocable and irrevocable trusts
Disputes over consumer goods Civil litigation defense and pet liability
Defense of traffic tickets Juvenile court defense
Elder care law Adoption
For a full list of services, visit the benefits folder on the iDrive.PAGE 25 2021–2022 BENEFITS
ue s t ions?
Q
Call 877.638.7868
or visit
mybenefits.metlife.com
HOSPITAL INDEMNITY (worksite benefit)
Scottsdale’s hospital indemnity plan through MetLife offers a cash benefit when you require
hospitalization and are admitted to the hospital. The policy provides one cash benefit per hospital
confinement, and cash benefits per day of hospitalization. There are no pregnancy or pre-existing
condition exclusions. Benefits reduce by 25% at age 65; and by 50% at age 70.
BENEFIT TYPE PLAN PAYS
HOSPITAL COVERAGE (SICKNESS OR ACCIDENT)
ADMISSION $500
(Payable once per calendar year) $500 (ICU)
CONFINEMENT $200 a day for up to 15 days
(Paid per sickness) $200 a day (ICU) for up to 15 days
OTHER BENEFITS
HEALTH SCREENING BENEFIT (WELLNESS)
$50
(Payable once per covered person, per calendar year)
INPATIENT REHABILITATION BENEFIT $200 per day
Want a free $50? Just get an eligible health screening and submit your claim
with MetLife. They’ll send you $50. Easy as that!
HOW IT WORKS
On his way to work, Bill’s car is hit by a large truck on the highway. Bill is immediately taken
to the emergency room at a local hospital. Upon evaluation by the attending doctor, Bill
is admitted to the Intensive Care Unit for close observation of trauma to his head and a
fractured disk in his neck. After two days in the ICU, he is moved to a standard room and
stays there for five more days. Bill is then transferred for in-patient care at a rehabilitation
facility. His stay there is seven days. Bill would receive a lump-sum payment totaling $4,200.
COVERED EVENT BENEFIT AMOUNT
Hospital admission $500
ICU supplemental admission ICU $500
Confinement for 2 days ICU $800 ($400 per day)
Confinement for 5 days hospital $1,000 ($200 per day)
In-patient rehab unit $1,400 ($200 per day)
$4,200 TotalPAGE 26 2021–2022 BENEFITS
ue s t ions?
Q
Call 877.638.7868
or visit
mybenefits.metlife.com
CRITICAL ILLNESS (worksite benefit)
Scottsdale’s critical illness plan through MetLife can provide financial protection to help
lessen the burden of large out-of-pocket costs for employees who suffer a critical illness.
COVERED PERSON INITIAL BENEFIT REQUIREMENT
Coverage is guaranteed, provided
EMPLOYEE $10,000, $20,000, or $30,000 you are actively at work.*
Coverage is guaranteed, provided you are
actively at work and your spouse/domestic
SPOUSE/DOMESTIC PARTNER 50% of the initial benefit partner is not subject to a medical restriction
as set forth on the enrollment form and in
the coverage certificate.*
Coverage is guaranteed, provided you
are actively at work and your
DEPENDENT CHILD(REN) 50% of the initial benefit dependent is not subject to a medical
restriction as set forth on the enrollment
form and in the coverage certificate.*
OTHER BENEFITS
HEALTH SCREENING BENEFIT (WELLNESS)
$50
(Payable once per covered person, per calendar year)
*Coverage is guaranteed subject to terms and conditions, including pre-existing condition limitations.
HOW IT WORKS
John suffers a heart attack. Upon further examination, it is revealed that John also has a
blocked coronary artery and needs to undergo heart surgery. He is diagnosed a year later
with lung cancer. John had elected $10K in critical illness insurance, so he would receive:
COVERED EVENT BENEFIT AMOUNT
Heart Attack $10,000
CABG $10,000
Lung Cancer $10,000
The total benefit payout over the life of the policy would be $30K, which is the maximum
benefit (300% of elected amount).PAGE 27 2021–2022 BENEFITS
ue s t ions?
Q
Call 877.638.7868
or visit
mybenefits.metlife.com
ACCIDENT INSURANCE (worksite benefit)
Kairos’s accident insurance plan through MetLife provides a financial cushion to absorb expenses
like copays and deductibles. Benefits are paid regardless of medical insurance coverage, and
benefit dollars can be spent as participants choose. Benefits reduce by 25% at age 65; and by
50% at age 70.
BENEFIT TYPE* PLAN PAYS
AMBULANCE $300–$1,000
EMERGENCY CARE $50–$100
INPATIENT SURGERY $200–$2,000
HOSPITAL ADMISSION $1,000 (non ICU)–$2,000 (ICU) per accident
$200 a day (non ICU)—up to 31 days
HOSPITAL CONFINEMENT
$400 a day (ICU)—up to 31 days
$200 a day, up to 15 days per accident, not to exceed
INPATIENT REHAB
30 days per calendar year
ACCIDENTAL DEATH
$50,000
Employee receives 100% of amount shown; spouse receives
50%, and children receive 20%. $150,000 for common carrier
DISMEMBERMENT, LOSS AND PARALYSIS $500–$50,000 per injury
OTHER BENEFITS
LODGING: Pays for lodging for companion up to 30 $200 per night, up to 30 nights; up to $6,000 in total
nights per calendar year lodging benefits available per calendar year
HEALTH SCREENING BENEFIT (WELLNESS) $50
(Payable once per covered person, per calendar year)
*Refer to the plan summary for a complete listing of covered accidents.
HOW IT WORKS
Kathy’s daughter, Molly, plays soccer. During a recent game, Molly collided with an opposing player, was
knocked unconscious, and was taken to the ER by ambulance. The ER doctor diagnosed a concussion
and a broken tooth. He also ordered a CT scan. After thorough evaluation, Molly was released to her
primary care physician for follow-up treatment, and her dentist repaired her broken tooth with a crown.
COVERED EVENT1 BENEFIT AMOUNT
Ambulance (ground) $300
Emergency room $100
Physical follow-up ($75 x 2) $150
Medical testing $200
Concussion $400
Broken tooth (repaired by crown) $200
Kathy would receive a lump-sum payment totaling $1,350.
1 Covered services/treatments must be the result of a covered accident or sickness as defined in the group policy/certificate.PAGE 28 2021–2022 BENEFITS
PET INSURANCE—UNITED PET CARE
ions?
Quest
Call 602.266.5303
or visit
unitedpetcare.com
United Pet Care offers a unique and affordable pet healthcare program that saves you 20–50%
at the veterinarian. All pets are eligible. Savings are immediate, with no claim forms or
deductibles. A selection of veterinary clinic is required at enrollment time.
You will enroll through the Ivisions benefits portal, and coverage is eligible for payroll deduction.
After you enroll through the portal, visit unitedpetcare.com/susd to register your pet.
ions?
Quest
PET INSURANCE—NATIONWIDE
Call 877.738.7874
or visit
petsnationwide.com
Pet insurance pays, partly or in total, the cost of veterinary treatment for your ill or injured pet. The
My Pet Protection plans from Nationwide help you provide your pets with the best care possible:
• Up to 90% cash back: Use any vet and get your choice of 90%, 70%, or 50% reimbursement on
the bill.
• Open to all ages: No age limits or age-based premium increases.
• More than just accident and illness coverage: optional wellness coverage is available for
spay/neuter, dental cleaning, exams, vaccinations, and more.
• Exclusive: Available only for employees, not to the general public.
• Easy enrollment: Just a few simple questions to get coverage.
• Bigger savings: Save an average of 40% over similar plans from other pet insurers.
To enroll in this benefit, please visit:
petinsurance.com/kairoshealthaz
IMPORTANT:
This benefit is not deducted from
your paycheck. You will be
responsible for paying the monthly
premium directly to Nationwide.PAGE 29 2021–2022 BENEFITS
THIS GUIDE IS
INTENDED ONLY AS A
BRIEF DESCRIPTION OF
YOUR PLAN BENEFITS
This guide attempts to describe important details and changes to the Scottsdale
Unified School District health plans in a clear, simple, and concise manner. If there
is a conflict between this guide and the wording of plan documents, the plan
documents will govern. Scottsdale Unified School District retains the right to
change, modify, suspend, interpret, or cancel some or all of the benefits or
services at any time.PAGE 30 2021–2022 BENEFITS
MID-YEAR CHANGES TO YOUR HEALTH CARE BENEFIT ELECTIONS
IMPORTANT: After this open enrollment period is enrollment within 60 days after the Medicaid or
completed, generally you will not be permitted to S-CHIP coverage ends.
change your benefit elections or add/delete
• become eligible for a premium assistance program
dependents until next year’s open enrollment, unless
through Medicaid or S-CHIP. However, you must
you have a special enrollment event or a mid-year
request enrollment within 60 days after you
change in status event as outlined below:
(or your dependents) are determined to be eligible
Special enrollment event: If you are declining for such assistance.
enrollment for yourself or your dependents To request special enrollment or obtain more
(including your spouse) because of other health information, contact Scottsdale Unified School
insurance or group health plan coverage, you may be District at 480.484.6104.
able to enroll yourself and your dependents in this
Mid-year change in status event: Because Scottsdale
plan if you or your dependents lose eligibility for that
Unified School District pre-taxes benefits, we are required
other coverage (or if your employer stops
to follow Internal Revenue Service (IRS) regulations
contributing toward your or your dependents’ other
regarding whether and when benefits can be changed in
coverage). However, you must request enrollment
the middle of a plan year. The following events may allow
within 31 days after your or your dependents’
certain changes in benefits mid-year, if permitted by the
other coverage ends (or after the employer stops
IRS and your employer’s respective Section 125 plan,
contributing toward the other coverage).
which provides final authority:
In addition, if you have a new dependent as a result
of marriage, birth, adoption, or placement for • change in legal marital status (e.g., marriage,
adoption, you may be able to enroll yourself and divorce/legal separation, death);
your dependents. However, you must request • coverage of the employee’s or spouse’s plan; and
enrollment within 31 days after the marriage, birth, • changes consistent with special enrollment rights and
adoption, or placement for adoption. FMLA leaves.
You and your dependents may also enroll in this plan if You must notify the plan in writing within 31 days of the
you (or your dependents): mid-year change in status event by contacting Scottsdale
• change in number or status of dependents Unified School District. The plan will determine if your
(e.g., birth, adoption, death); change request is permitted, and if so, changes will
• change in employee’s/spouse’s/dependent’s become effective prospectively on the first day of the
employment status, work schedule, or residence month following the approved change-in-status event
that affects eligibility for benefits; (except for the case of newborn and adopted children,
• have a Qualified Medical Child Support Order who are covered retroactively to the date of birth,
(QMCSO); adoption, or placement for adoption).
• have a change in entitlement to or loss of
eligibility for Medicare or Medicaid; Losing medical coverage through the Marketplace is not
• experience certain changes in the cost of considered a qualified life event with Scottsdale Unified
coverage, composition of coverage, or School District, and you will not be allowed to join the
curtailment of coverage of the employee’s or plan mid-year. However, you can drop your Scottsdale
spouse’s plan; and Unified School District medical coverage to join a
• have coverage through Medicaid or a State Marketplace plan mid-year. You will be required to provide
Children’s Health Insurance Program (S-CHIP) and
proof of coverage within 31 days of your enrollment.
you (or your dependents) lose eligibility for that
coverage. However, you must request
WOMEN’S HEALTH AND CANCER RIGHTS ACT OF 1998 (WHCRA)
You or your dependents may be entitled to certain
• prostheses; and
benefits under the Women’s Health and Cancer
Rights Act of 1998 (WHCRA). For individuals • treatment of physical complications of the
receiving mastectomy-related benefits, coverage will mastectomy, including lymphedema.
be provided in a manner determined in consultation
with the attending physician and the patient for:
Plan limits, deductibles, copayments, and coinsurance
apply to these benefits. For more information on
• all stages of reconstruction of the breast on
WHCRA benefits, contact Kairos at 888.331.0222 or
which the mastectomy was performed;
your Benefits Department at 480.484.6104.
• surgery and reconstruction of the other breast
to produce a symmetrical appearance;PAGE 31 2021–2022 BENEFITS
PRIVACY NOTICE REMINDER
The Health Insurance Portability and Accountability Act This plan’s HIPAA privacy notice explains how the group
(HIPAA) of 1996 requires health plans to comply with health plan uses and discloses your personal health
privacy rules. These rules are intended to protect your information. You are provided a copy of this notice when
personal health information from being inappropriately you enroll in the plan. You can get another copy of this
used and disclosed. The rules also give you additional notice from Scottsdale Unified School District.
rights concerning control of your own healthcare
information.
DIRECT ACCESS TO PRIMARY CARE PROVIDER (PCP) AND OB/GYN PROVIDER
The medical plans offered by Scottsdale Unified School obstetrical or gynecological care from a healthcare
District do not require the selection or designation of a professional who specializes in obstetrics or
primary care provider (PCP). You have the ability to gynecology. The healthcare professional, however,
visit any network or non-network healthcare provider; may be required to comply with certain procedures,
however, payment by the plan may be less for the use including obtaining prior authorization for certain
of a non-network provider. services, following a pre-approved treatment plan, or
procedures for making referrals. For a list of
You also do not need prior authorization from participating healthcare professionals who specialize
the plan or from any other person (including a in obstetrics or gynecology, contact Scottsdale Unified
primary care provider) in order to obtain access to School District at 480.484.6104.
REQUIREMENT TO PROVIDE THE TAXPAYER IDENTIFICATION NUMBER (TIN) OR
SOCIAL SECURITY NUMBER (SSN) OF EACH HEALTH PLAN ENROLLEE
Employers are required by law to collect the taxpayer To request one:
identification number (TIN) or social security number http://www.socialsecurity.gov/online/ss-5.pdf.
(SSN) for each medical plan participant and include that Applying for a social security number is FREE.
number on reports that are provided to the IRS each
year. If you have a covered dependent who does not yet If you have not yet provided the social security number
have a social security number, you can go to this website (or other TIN) for each dependent enrolled in the health
plan, please contact your Benefit Department at
480.484.6104.
PAPERWORK REDUCTION ACT STATEMENT
According to the Paperwork Reduction Act of 1995 control number. See 44 U.S.C. 3512.
(Pub. L. 104-13) (PRA), no persons are required to
respond to a collection of information unless such The public reporting burden for this collection of
collection displays a valid Office of Management and information is estimated to average approximately
Budget (OMB) control number. The Department notes seven minutes per respondent. Interested parties are
that a federal agency cannot conduct or sponsor a encouraged to send comments regarding
collection of information unless it is approved by OMB the burden estimate or any other aspect of this
under the PRA, and displays a currently valid OMB collection of information, including suggestions for
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MEDICARE NOTICE OF CREDITABLE COVERAGE REMINDER
If you or your eligible dependents are currently Medicare- following prescription drug plan options is
eligible, or will become Medicare-eligible during the next “creditable”: PPO, 1,500 HDHP, 2,800 HDHP and
12 months, be sure you understand whether the 5,000 HDHP.
prescription drug coverage that you elect through
Scottsdale USD is creditable with (as valuable as) If you have questions about what this means for you,
Medicare’s prescription drug coverage. review the plan’s Medicare Part D Notice of
Creditable Coverage, which is available from
Scottsdale USD has determined that the prescription Scottsdale USD at 480.484.6104.
drug coverage under theYou can also read
