BENEFITS 1 EMPLOYEE - Kleinfelder
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EMPLOYEE
2021
BENEFITS
1
TABLE OF CONTENTS
At Kleinfelder, we’re proud of our accomplishments, our technology, and especially our people.
Our benefits program was developed to provide multiple benefit choices to support the needs
of you and your dependents. We are proud to provide you with a progressive and competitive
benefits program.
3 Important Resources 28 Supplemental Health Benefits
4 Eligibility & Enrollment 30 Dental Benefits
6 Qualifying Life Events 31 Vision Benefits Info on the Go!
7 Enrollment Instructions 32 Survivor Benefits Scan with Your
Smartphone to
9 Wellness 35 Income Protection
Access Enrollment
10 Live Well Incentives 37 Retirement Planning Materials Online
Anytime.
12 Medical Benefits 38 Family Care Benefits
15 Preventive Care 40 Milk Stork
16 Virtual Medicine 41 Additional Benefits
17 Where to Go For Care 44 Paid Time Off And Holidays
19 Pharmacy Benefits 45 Important Contacts
22 Health Savings Account 47 Glossary
25 Flexible Spending Accounts 50 Required Notices
27 FSA vs HSA
See page 50 for important information concerning Medicare Part
D coverage.
In this Guide, we use the term company to refer to The Kleinfelder Group, Inc. This Guide is intended to describe the eligibility requirements, enrollment procedures and
coverage effective dates for the benefits offered by the company. It is not a legal plan document and does not imply a guarantee of employment or a continuation of
benefits. While this Guide is a tool to answer most of your questions, full details of the plans are contained in the Summary Plan Descriptions (SPDs), which govern each
plan’s operation. Whenever an interpretation of a plan benefit is necessary, the actual plan documents will be used.
2
IMPORTANT RESOURCES
ULTIPRO BENEFITS THE BENEFITS ASSISTANCE CENTER
As an employee of Kleinfelder, you have access Lockton provides Kleinfelder employees with
to benefits information 24/7/365 through an access to a team of experienced customer care
online benefits portal. Access documents and individuals to assist you with your benefit questions
other resources that will help you obtain a better or concerns you may have at open enrollment or
understanding of your benefits. It also is the access throughout the plan year, such as:
point for the online enrollment tool to make open
• Eligibility & Enrollment
enrollment elections and most mid-year qualifying
life event changes. • Life Event Changes (marriage, birth/adoption,
divorce, etc.)
Following is an example of information you will find
on UltiPro Benefits: • Benefits
‹ Plan Details and Summaries • Claims Inquiries
‹ Benefit Plan Costs • Flexible Spending Accounts
‹ Carrier Contact Information • COBRA
‹ Access to the online enrollment system
Go to Kleinfelder.ultipro.com
BENEFITS ASSISTANCE CENTER
Phone: Fax:
844-398-0462
844-398-0461
Monday – Friday
5:00 a.m. – 4:00 p.m. Pacific Time Email:
7:00 a.m. - 6:00 p.m. Central Time kleinfelderbenefits@lockton.com
8:00 a.m. – 7:00 p.m. Eastern Time
3
ELIGIBILITY & ENROLLMENT
Kleinfelder offers a variety of benefits to support you and your family’s needs. Choose
options that cover what’s important to your unique lifestyle.
ELIGIBILITY NON-TOBACCO/NON-NICOTINE INCENTIVE
If you are an active, full-time employee working To receive the non-tobacco/nicotine incentive
a minimum of 40 hours per week or a part-time pricing of $25 per month, employees must certify,
employee working 20-39 hours per week, you are during the enrollment process or when first eligible,
eligible to enroll in the Kleinfelder benefits program. that they are non-tobacco/nicotine users. Failure to
do so will result in the higher employee contribution
WHEN COVERAGE BEGINS for the medical plan selected.
Your elections are effective 30 days from your ‹ Tobacco use is defined as the use of tobacco
date of hire or on the date of a change in status. products within the last six months in such forms
You won’t be able to change your benefits until the as cigarettes, pipes, cigars, snuff, e-cigarettes
next enrollment period unless you experience a or chewing tobacco. Using smoking cessation
qualifying life event. products that contain nicotine is not considered
tobacco use.
WHEN COVERAGE ENDS
Coverage in Kleinfelder’s medical, dental, vision ‹ Kleinfelder offers a discounted medical premium
and employee assistance programs for you and for employees that are non-tobacco/nicotine users.
your eligible dependents ends on the last day of Employees who have recently stopped smoking
the month in which you leave employment. Life should complete a non-tobacco/nicotine affidavit
and disability coverage, as well as participation in (available under the Benefit Document Library
the health savings account and flexible spending in UltiPro) and send it to the Benefits Assistance
accounts, ends on your last day of employment. Center to obtain the discounted medical premium
rate. The discounted medical premium rate will be
Covered employees and qualified dependents applied beginning the month following receipt of
are permitted to continue coverage at their own the affidavit.
expense after leaving the company as provided
Any questions pertaining to the Non-Tobacco/
by federal law (COBRA). Dependent children are
Non-Nicotine incentive can be answered by the
covered until the end of the month in which they
Benefits Assistance Center at 844-398-0461 or at
reach age 26.
kleinfelderbenefits@lockton.com.
4
Dependents eligible for coverage in the Kleinfelder benefits plans include:
‹ Your legal spouse/domestic partner (or common law or civil union partner where recognized).
‹ Children up to age 26 (includes birth children, stepchildren, legally adopted children, children placed for
adoption, foster children and children for whom legal guardianship has been awarded to you or your spouse).
‹ Dependent children 26 or more years old and primarily supported by you and incapable of self-sustaining
employment by reason of mental or physical disability (periodic certification may be required).
Verification of dependent eligibility is required upon enrollment. Failure to provide verification or required
documentation may result in the termination of dependent benefits.
REQUIRED DOCUMENTATION FOR PROOF OF ELIGIBILITY
SPOUSE
Marriage certificate showing date and jurisdiction of marriage. If your marriage certificate is in a different
language other than English, it must be translated into English and both documents provided.
DOMESTIC PARTNER
Completed Statement of Domestic Partnership and Certificate from local or state Domestic Partner Registry.
CHILD(REN)
BIOLOGICAL CHILD(REN) Birth Certificate reflecting the employee named as parent
STEPCHILD(REN) Birth Certificate reflecting the employee's spouse named as parent
LEGALLY ADOPTED CHILD(REN) Adoption order reflecting the employee or employee's spouse named as adoptive parent
FOSTER CHILD(REN) Court order reflecting the employee or employee's spouse named as the child's legal guardian
UNDER COURT ORDER Court order reflecting the employee or employee's spouse named as the child's legal guardian
GRANDCHILD(REN) UNDER
Court order reflecting the employee or employee's spouse named as the child's legal guardian
COURT-ORDERED CUSTODY
DOMESTIC PARTNER'S CHILD(REN) Birth Certificate reflecting the employee's Domestic Partner named as parent
Birth Certificate reflecting the employee or employee's spouse named as parent or legal guardian
DISABLED CHILD(REN)
and certification from physician of the child's disability
5
QUALIFYING LIFE EVENTS
ENROLL NOW. YOU’VE GOT ONE SHOT! Common qualifying events include:
What is a Qualifying Life Event? Most people know ‹ A change of domestic partnership status, legal
you can change your benefits when you start a marital status (marriage, divorce, legal separation,
new job or during Open Enrollment. But did you or annulment)
know that changes in your life may permit you to ‹ A change in the number of your dependents (for
update your coverage at other points in the year? example, through birth or adoption, or if a child is
Qualifying Life Events (QLEs) determined by the no longer an eligible dependent)
IRS could allow you to enroll in health insurance or
‹ A change in your spouse’s employment status
change your elections outside of the annual time.
(resulting in a loss or gain of coverage)
If you have a Qualifying Life Event during the plan
‹ A change in your employment status from full-time
year, your election changes must be made within 31
or part-time to flexible or from flexible to full-time
days of the event. Changes due to a Qualifying Life
or part-time resulting in a gain or loss of eligibility
Event becomes effective the date of the event.
‹ Entitlement to Medicare or Medicaid
Requests to drop coverage outside of Open
Enrollment must be submitted to the Benefits ‹ Eligibility for coverage through the Marketplace
Assistance Center. Proof of other coverage will be ‹ A change in your address or location that may
required. affect the coverage for which you are eligible
Some lesser-known qualifying events are:
‹ Turning 26 and losing coverage through a
parent’s plan
‹ Death in the family (leading to change in
dependents or loss of coverage)
‹ Changes that make you no longer eligible for
Medicaid or the Children’s Health Insurance
Program (CHIP)
You CANNOT change your benefit elections
NOTE
during the plan year unless you have a
Qualifying Life Event, such as marriage and/
or the birth or adoption of a child.
6
ENROLLMENT INSTRUCTIONS
STEP 1: LOG INTO ULTIPRO
To begin enrollment, sign in to Kleinfelder.ultipro.com
and select Myself > Manage my Benefits > Get
Started.
You may encounter questionnaires through
the enrollment process. Questionnaires track
STEP 2: VERIFY YOUR PROFILE
information that is pertinent to your plan
NOTE
If you see anything that needs to be updated, go
elections. Please note some questionnaires
to Menu > Myself > Personal and select the change
you would like to make under Things I can do. If all may have multiple questions to answer
of your information is accurate, you may click Next: before you are able to save.
Review My Family. To complete a questionnaire:
1. Select or enter your answer
STEP 3: ADD DEPENDENT INFORMATION 2. Click the green right arrow
If you need to add eligible family members, 3. Save your response
click Add Family Member and fill in all required
information (indicated by an asterisk). Once all of
your dependents are listed, click Next: Shop for
Benefits.
7
STEP 4: SHOP FOR BENEFITS STEP 5: REVIEW AND CHECKOUT
To enroll in Medical, Dental and Vision coverage: Once you have made your elections, you will be
taken to the review and checkout screen. This screen
1. Review your family members listed in Family
will summarize everything you elected. You can view
Covered. Check or uncheck the box next to their
additional details, including covered family members,
name to add or remove a family member.
by clicking the grey plus button beneath the plan.
2. You may compare plans by checking the Compare
You may edit coverage by either using the shopping
Plans box below two or more plans and then
cart at the top of the page or by selecting Modify
selecting Compare Plans at the top.
Coverage next to the plan. Scroll to the bottom and
3. Once you are ready to choose your plan, select
click Review and Checkout. On the checkout screen,
View Plan and then Update Cart.
you have one last chance to change your elections.
4. If you wish to decline coverage, select the Decline
You may make modifications to your coverage if
Benefits box.
needed, otherwise, simply select the green Checkout
Certain plans (such as Flexible Spending Accounts button at the bottom of the page.
and the Health Savings Account), require you to
select an annual goal. You can make your election
using one of these methods:
1. Use the slider bar to slide over to your desired
annual goal amount
2. Enter your goal amount in the box provided
3. Decline coverage using the Decline link
Company-paid life insurance only requires you to
select the plan so you can assign your beneficiaries.
Since this is provided at no cost to you, you are
not able to decline this coverage. If you would like
to enroll in additional Voluntary Life Insurance,
select your desired coverage from the dropdown
list. If you elect a coverage that requires Evidence
of Insurability, you will see both the amount of
coverage that you are eligible for immediately and
the amount of coverage you would like to have, both
with their associated costs.
8
WELLNESS
Kleinfelder is promoting healthy, happier lifestyles with the Live Well Program
Live Well is a complete program that gives you the
incentives, tools, social support and strategies to HOW DO I SIGN UP?
adopt and maintain healthy behaviors that can last 1. Access the wellness platform at
a lifetime. Participating in Live Well can help you https://www.klflivewell.com.
be your best you. We offer rewards through raffles, 2. Click “SIGN UP.”
payroll credits and a medical premium incentive in
2022 for participating! 3. Select your affiliation (Central, Corporate, East,
West, AUS or CAN).
INCENTIVES INCLUDE: 4. Enter your Date of Birth and 6-digit Unique ID. Your
‹ Raffle entry once you earn 50 points Unique ID is your employee number with leading
zeros to make a 6 digit number. Spouses will enter
‹ One entry per quarter for a $100 gift card
the employee’s 6-digit Unique ID + S (e.g. 123456S)
‹ 20 Winners Quarterly!
5. Enter your First name, Last name, Email address
‹ Biometric Screening + Health Risk Assessment (Username) and Password.
Completion = $150 payroll credit*
6. Accept the Terms of Service.
‹ NEW! 2022 Medical Premium Incentive -
7. Begin your Health Risk Assessment.
Employees who are enrolled in Kleinfelder’s Medical
Plan and complete the Health Risk Assessment, You can also access Live Well through K-Net.
Biometric Screening and earn 150 program points
in 2021 will earn a $50 monthly premium incentive
in 2022. That is $600 a year!
*For 2021, all US employees and their spouses/domestic partners
are eligible to receive $150 for completing both the Health Risk
Assessment and Biometric Screening.
NOTE
Refer to the Live Well Incentive Chart on the next page for details on
eligibility and activity due dates based on your hire date.
9
LIVE WELL INCENTIVES
CURRENTLY ENROLLED
ELIGIBLE POPULATION ACTIVITIES DUE DATE INCENTIVE
US Employees & Spouses/ Benchmark 1 - Biometric Payroll Credit - $150
10/31/21
Domestic Partners Screening + HRA (Quarterly Pay Out 2021)
Benchmark 2 - Biometric
US Health Plan Enrolled 2022 Premium Incentive -
CURRENTLY ENROLLED Screening + HRA + 150 10/31/21
Employees $600 ($50 a Month)
Program Points
All Employees & Spouses/ Engagement - 50 points
Quarterly - 12/31/2021 Quarterly Raffles
Domestic Partners per quarter
2021 NEW HIRES
NEW HIRE DATE ELIGIBLE POPULATION ACTIVITIES DUE DATE INCENTIVE
US Employees & Spouses/ Benchmark 1 - Biometric Payroll Credit - $150
10/31/21
Domestic Partners Screening + HRA (Quarterly Pay Out 2021)
Benchmark 2 - Biometric
US Health Plan Enrolled 2022 Premium Incentive -
1/1/2021 - 5/31/2021 Screening + HRA + 150 10/31/21
Employees $600 ($50 a Month)
Program Points
All Employees & Spouses/ Engagement - 50 points
Quarterly - 12/31/2021 Quarterly Raffles
Domestic Partners per quarter
US Employees & Spouses/ Benchmark 1 - Biometric Payroll Credit - $150
10/31/21
Domestic Partners Screening + HRA (Quarterly Pay Out 2021)
Benchmark 2 - Biometric
6/1/2021 - 10/31/2021 N/A Screening + HRA + 150 N/A N/A
Program Points
All Employees & Spouses/ Engagement - 50 points
Quarterly - 12/31/2021 Quarterly Raffles
Domestic Partners per quarter
Benchmark 1 - Biometric
N/A N/A N/A
Screening + HRA
Benchmark 2 - Biometric
11/1/2021 - 12/31/2021 N/A Screening + HRA + 150 N/A N/A
Program Points
All Employees & Spouses/ Engagement - 50 points
Quarterly - 12/31/2021 Quarterly Raffles
Domestic Partners per quarter
10Notice Regarding Protections from Disclosure of Medical Information
We are required by law to maintain the privacy and security of your
Wellness Program
personally identifiable health information. Although the wellness
program and Kleinfelder may use aggregate information it collects to
design a program based on identified health risks in the workplace, the
Live Well Program will never disclose any of your personal information
The Kleinfelder Live Well Program is a voluntary wellness program either publicly or to the employer, except as necessary to respond to a
available to all employees and their spouses or domestic partners; request from you for a reasonable accommodation needed to participate
however, some incentives may be limited to the health plan enrolled in the wellness program, or as expressly permitted by law. Medical
employees only. The program is administered according to federal information that personally identifies you that is provided in connection
rules permitting employer‑sponsored wellness programs that seek to with the wellness program will not be provided to your supervisors or
improve employee health or prevent disease, including the Americans managers and may never be used to make decisions regarding your
with Disabilities Act of 1990, the Genetic Information Nondiscrimination employment.
Act of 2008, and the Health Insurance Portability and Accountability
Act, as applicable, among others. If you choose to participate in the Your health information will not be sold, exchanged, transferred, or
wellness program you will be asked to complete a voluntary health otherwise disclosed except to the extent permitted by law to carry out
risk assessment or “HRA” that asks a series of questions about your specific activities related to the wellness program, and you will not be
health‑related activities and behaviors and whether you have or had asked or required to waive the confidentiality of your health information
certain medical conditions (e.g., cancer, diabetes, or heart disease). You as a condition of participating in the wellness program or receiving
will also be asked to complete a biometric screening, which will include an incentive. Anyone who receives your information for purposes of
a blood test for total cholesterol, HDL, LDL, triglycerides and glucose providing you services as part of the wellness program will abide by
(include cotinine screening, if appropriate). Your blood pressure, height, the same confidentiality requirements. In order to provide you with
weight, and waist circumference will also be measured. You are not services under the wellness program, your personally identifiable health
required to complete the HRA or to participate in the blood test or other information may be shared with one or more of the following: Lockton
medical examinations. Companies and StayWell
However, employees who choose to participate in the wellness program In addition, all medical information obtained through the wellness
could receive an incentive of $150 payroll credit, a $50 monthly medical program will be maintained separate from your personnel records,
premium incentive and other raffles and prizes. Although you are not information stored electronically will be encrypted, and no information
required to complete the HRA or participate in the biometric screening, you provide as part of the wellness program will be used in making any
only employees who do so will receive the incentive. employment decision. Appropriate precautions will be taken to avoid any
data breach, and in the event a data breach occurs involving information
Additional incentives may be available for employees who participate you provide in connection with the wellness program, we will notify you
in certain health‑related activities or achieve certain health outcomes. immediately.
If you are unable to participate in any of the health‑related activities
or achieve any of the health outcomes required to earn an incentive, You may not be discriminated against in employment because of the
you may be entitled to a reasonable accommodation or an alternative medical information you provide as part of participating in the wellness
standard. You may request a reasonable accommodation or an program, nor may you be subjected to retaliation if you choose not to
alternative standard by contacting StayWell or your Human Resources participate.
Department.
If you have questions or concerns regarding this notice, or about
The information from your HRA and the results from your biometric protections against discrimination and retaliation, please contact your
screening will be used to provide you with information to help you Human Resources Department.
understand your current health and potential risks, and may also be
used to offer you services through the wellness program, such as
wellness programming and content. You also are encouraged to share
your results or concerns with your own doctor.
11MEDICAL BENEFITS
Medical benefits are provided through Aetna. Choose the plan that works best for your
life. Consider the physician networks, premiums and out-of-pocket costs for each plan.
Keep in mind your choice is effective for the entire 2021 plan year, unless you have a
Qualifying Life Event.
MEDICAL PREMIUMS
Premium contributions for medical are deducted from your paycheck on a pre-tax basis. Your level of
coverage determines your monthly contributions.
AETNA HDHP 2000 AETNA HDHP 3000
MONTHLY CONTRIBUTIONS
EMPLOYEE ONLY $110 $54
EMPLOYEE + SPOUSE $292 $181
EMPLOYEE + CHILD(REN) $243 $142
EMPLOYEE + FAMILY $448 $272
HOW TO FIND AN IN-NETWORK PROVIDER
You can locate participating physicians based on
geographical location, medical specialty and hospital
affiliation by using Aetna’s online directory at
aetna.com/docfind. You may also call the provider’s
office or Aetna Member Services at 877-204-9186.
12MEDICAL PLAN SUMMARY
You have a choice between two plans: The Aetna HDHP 2000 Plan and the Aetna HDHP 3000 Plan. Both
plans are qualified High Deductible Health Plans (HDHP) and provide the freedom to choose between two
levels of coverage: In-Network and Out-of-Network. You will receive higher benefit levels when seeking care
In-Network.
AETNA HDHP 2000 AETNA HDHP 3000
IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK
ANNUAL DEDUCTIBLE
AGGREGATE DEDUCTIBLE(1) EMBEDDED DEDUCTIBLE(2)
INDIVIDUAL $2,000 $4,000 $3,000 $6,000
FAMILY $4,000 $8,000 $6,000 $12,000
COINSURANCE (YOU PAY) 20%* 40%* 20%* 40%*
ANNUAL OUT-OF-POCKET MAXIMUM (INCLUDES DEDUCTIBLE)
EMBEDDED OUT-OF-POCKET MAXIMUM EMBEDDED OUT-OF-POCKET MAXIMUM
INDIVIDUAL $5,000 $10,000 $6,000 $12,000
FAMILY $10,000 $20,000 $12,000 $24,000
COPAYS/COINSURANCE (YOU PAY)
0% 0%
PREVENTIVE CARE 40%* 40%*
(deductible waived) (deductible waived)
PRIMARY CARE 20%* 40%* 20%* 40%*
SPECIALIST SERVICES 20%* 40%* 20%* 40%*
URGENT CARE 20%* 40%* 20%* 40%*
EMERGENCY ROOM 20%* 20%* 20%* 20%*
INPATIENT HOSPITAL 20%* 40%* 20%* 40%*
OUTPATIENT HOSPITAL 20%* 40%* 20%* 40%*
*After Deductible
The Aetna HDHP 2000 Plan has an aggregate deductible, meaning the family deductible amount will include
(1)
all combined eligible expenses that you and your covered dependents incur. The family deductible amount
may be satisfied by one member or a combination of two or more members covered under your medical
plan.
The Aetna HDHP 3000 Plan has an embedded deductible, meaning the individual deductible amount must
(2)
be met by each member enrolled under your medical coverage. If you have several covered dependents,
all charges used to apply toward a “per individual” deductible amount will also be applied toward the “per
family” deductible amount. When the family deductible amount is reached, no further individual deductibles
will have to be met for the remainder of that plan year.
13OUR PLANS ARE SELF-FUNDED AETNA ONLINE TOOLS AND RESOURCES
Our Medical, Pharmacy and Dental plans are Once you register with your member portal, you will
self-funded, which means that the company bears have a wealth of information, tools, and resources to
the financial risk of the plan. Rather than paying help you manage your benefits and stay healthy.
insurance premiums to an insurance carrier as with
‹ Claims Information: Look up the status of a claim
fully insured plans, the company pays fixed costs for
and view Explanation of Benefits statements
using the insurance carrier’s network of physicians
(EOBs). You can also use the “send a message”
and variable costs for the members’ claims. Self-
feature to email Aetna Member Services with
insured plans allow for more control and freedom in
claim-related questions.
plan design. Together, the company and employees
share the cost for healthcare. ‹ Benefits Information: View a summary of your
medical plan benefits and the names of your
RISING COSTS OF HEALTHCARE dependents covered under the plan.
The cost of healthcare in the U.S. has been steadily ‹ Cost-of-Care Tools: Research estimated average
growing each year. Why? Some of the factors costs of procedures and tests as well as treatments
include an aging population, increased demand for diseases, conditions, and prescription drugs.
for care (resulting in higher prices for premiums ‹ Member Payment Estimator: With the Member
and prescription drugs) and an increase in chronic Payment Estimator, you can get real-time,
illnesses. The Company wants to help keep you personalized cost estimates based on your health
healthy, so we do what we can to keep your benefits plan so you’ll know what you can expect
healthcare costs reasonable. Make sure you’re to pay for healthcare services. By planning ahead,
informed about your options so you can make the you can get the most for your money without
best healthcare choices for you and your family. sacrificing the quality of your care.
Placing an importance on preventive care, making
‹ Links to Reliable, Up-to-Date Information:
healthy choices, and managing costs will help keep
your health — and wallet — in control in the long run. • Health Decision Support from Emmi: Learn
more about health conditions, treatment
options, and surgeries in minutes. Check for
recommendations, or simply choose a topic to
begin.
• Healthwise Knowledgebase: An online reference
and decision support tool that provides reliable
information on a variety of healthcare topics
and issues.
• PatientsLikeMe: An online resource that helps
you connect to a network of support. It unites
240,000 members like you, so you’re likely
to find someone who has a similar health
condition. You can visit message boards, send
private messages to other members, and more.
14PREVENTIVE CARE
Kleinfelder’s health plans cover a set of preventive services at no cost to you when
utilizing In-Network providers.
Screening tests and routine checkups are considered preventive, which means they’re often paid at 100%.
Keep up to date with your primary care physician to save time and money and keep yourself healthier in
the long run. Under the U.S. Patient Protection and Affordable Care Act (PPACA), some common covered
services include:
Screenings for blood Pediatric screenings for
Wellness visits, pressure, cancer, hearing, vision, obesity
physicals and standard cholesterol, depression, and developmental
immunizations obesity and diabetes disorders
Anemia screenings, breastfeeding
Iron supplements (for children ages 6
support and pumps for pregnant and
to 12 months at risk for anemia)
nursing women
Take advantage of these covered services. However, remember that diagnostic care to identify health risks is
covered according to plan benefits, even if done during a preventive care visit. This means if your doctor finds
a new condition or potential risk during your appointment, the services may be billed as diagnostic medicine
and result in some out-of-pocket costs. Read over your benefit summary to see what specific preventive
services are provided to you.
15VIRTUAL MEDICINE
When you’re sick, the last thing you want to do is leave the cozy comfort of your home.
Or sometimes you’re just too on the go to pop in for a visit. Virtual medicine is a convenient
and easy way to talk to a doctor fast.
TELADOC
Kleinfelder provides a telemedicine benefit through
Teladoc to you and your dependents. Teladoc
offers on-demand access to board-certified doctors
through online video, telephone or secure email. You
and your family can be treated for general health
issues at home for a $47 consultation fee or 20%
coinsurance after you have met your deductible.
Telemedicine is useful for after-hours non-
emergency care, when your primary care doctor is
unavailable, if you need prescriptions or refills
or if you’re traveling. Please note that some states
do not allow physicians to prescribe medications
via telemedicine.
Teladoc doctors can treat many medical
conditions, including:
‹ Cold & flu ‹ Respiratory infection
‹ Bronchitis ‹ Sinus problems
‹ Urinary tract infection
Go online to Teladoc.com/Aetna or call Teladoc directly at 855-Teladoc (855-835-2362) to
schedule your consultation.
NEW! MENTAL HEALTHCARE NEW! DERMATOLOGY
Talk to a therapist seven days a week Upload images of a skin issue online (such as
(7 a.m. to 9 p.m. local time) eczema, acne and rashes) and get a custom
treatment plan within two days.
‹ Therapist visit: $85 or less
‹ Consult: $75 or less.
‹ First psychiatrist visit: $190 or less
‹ Ongoing psychiatrist visit: $95 or less
16WHERE TO GO FOR CARE
You think you may be sick, but your primary care physician is booked through the end of the
month. You have a question about the side effects of a new medication, but the pharmacy is
closed. Instead of immediately choosing an expensive trip to the emergency room or relying
on questionable information from the internet. Take a look below at various care centers and
resources and the types of care they provide.
When would I use this? What type of care would What are the costs and
You need routine care or they provide?* time considerations?**
treatment for a current
‹ Routine checkups ‹ Subject to your
health issue. Your primary deductible and
doctor knows you and your ‹ Immunizations
PRIMARY CARE coinsurance.
health history, can access ‹ Preventive services
CENTER your medical records,
‹ ormally requires an
N
‹ anage your general
M appointment.
provide routine care, and health
manage your medications. ‹ Usually little wait
time with scheduled
appointment.
When would I use this? What type of care would What are the costs and
You need a quick answer they provide?* time considerations?**
to a health issue that does Answers to questions regarding: ‹ Aetna’s Informed Health
not require immediate Line is available 24 hours
‹ Symptoms
medical treatment or a a day, 7 days a week.
physician visit. ‹ Medications and side
effects ‹ This service is free as part
Call 1-800-556-1555 to reach of your medical insurance. HEALTH LINE
Aetna’s Informed Health Line. ‹ Self‑care home
treatments
‹ When to seek care
When would I use this? What type of care would What are the costs and
You need care for minor they provide?* time considerations?**
illnesses and ailments, but ‹ Cold & flu symptoms ‹ $47 consultation fee
would prefer not to leave or 20% coinsurance
‹ Allergies
home. These services are after you’ve met your
available by phone and ‹ Bronchitis deductible.
TELADOC online (via webcam). ‹ Urinary tract infection ‹ ccess to care is usually
A
immediate.
‹ Sinus problems
‹ ome states may not
S
allow for prescriptions
through telemedicine or
virtual visits.
17WHERE TO GO FOR CARE
When would I use this? What type of care would What are the costs and
You need care quickly, they provide?* time considerations?**
but it is not a true ‹ Strains, sprains ‹ Subject to your
emergency. Urgent care deductible and
‹ inor broken bones
M
centers offer treatment for coinsurance and is usually
URGENT CARE non‑life‑threatening injuries
(e.g., finger)
higher than an office visit.
CENTER or illnesses. ‹ Minor infections
‹ alk‑in patients welcome,
W
‹ Minor burns but waiting periods may
be longer as patients with
‹ X‑rays
more urgent needs will be
treated first.
What may seem like an urgent
care center could actually
be a standalone ER. These
newer facilities come with DO YOUR
a higher price tag, so ask
for clarification if the word
HOMEWORK
"emergency" appears in
the company name.
When would I use this? What type of care would What are the costs and
You need immediate they provide?* time considerations?**
treatment for a serious
‹ Heavy bleeding ‹ Subject to your
life‑threatening condition. deductible and
If a situation seems life ‹ Chest pain coinsurance and is much
EMERGENCY threatening, call 911 or ‹ Major burns higher than an office visit
your local emergency or urgent care visit.
ROOM number right away.
‹ Spinal injuries
‹ pen 24/7, but waiting
O
‹ Severe head injury periods may be longer
‹ Broken bones because patients
with life‑threatening
emergencies will be
treated first.
*This is a sample list of services and may not be all‑inclusive.
**Costs and time information represent averages only and are not tied to a specific condition or treatment.
18PHARMACY BENEFITS
PRESCRIPTION DRUG COVERAGE FOR MEDICAL PLANS
Our Prescription Drug Program is coordinated through Aetna. That means you will only have one ID card for
both medical care and prescriptions. Information on your benefits coverage and a list of network pharmacies
is available online at aetna.com or by calling the Customer Care number on your ID Card. Your cost is
determined by the tier assigned to the prescription drug product. Products are assigned as Generic, Preferred
Brand, Non-Preferred Brand, Preferred Specialty and Non-Preferred Specialty Drugs.
AETNA HDHP 2000 AETNA HDHP 3000
IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK
RETAIL RX (30-DAY SUPPLY)
GENERIC $15 Copay* 50%* after Copay $15 Copay* 50%* after Copay
PREFERRED $60 Copay* 50%* after Copay $60 Copay* 50%* after Copay
NON-PREFERRED $90 Copay* 50%* after Copay $90 Copay* 50%* after Copay
PREFERRED SPECIALTY $95 Copay* Not Covered $95 Copay* Not Covered
NON-PREFERRED SPECIALTY $115 Copay* Not Covered $115 Copay* Not Covered
MAIL ORDER RX (90-DAY SUPPLY)
GENERIC $30 Copay* Not Covered $30 Copay* Not Covered
PREFERRED $120 Copay* Not Covered $120 Copay* Not Covered
NON-PREFERRED $180 Copay* Not Covered $180 Copay* Not Covered
*After Deductible
AETNA MAIL ORDER PROGRAM
Maintenance Choice gives members a choice to fill a 90-day supply of their maintenance medicine at either
Aetna Rx Home Delivery® mail-order pharmacy or CVS Pharmacy retail locations. You pay the same out-of-
pocket costs either way. After two retail fills, members are required to fill a 90-day supply of maintenance
drugs at CVS Pharmacy, unless you call Aetna to opt out.
19GENERIC VS. BRAND-NAME PRESCRIPTIONS HERE’S HOW TO GET STARTED WITH 90-DAY
Did you know that a generic drug is made with REFILLS
the same active ingredients and in the same Getting 90-day refills for the medications you take
dosage form as a brand-name drug? Some are regularly is easier than ever. And whichever choice
even manufactured by the same pharmaceutical you make, it’s the same low price.
companies that make brand-name drugs.
1. Choose delivery or pickup
You will pay less when you choose generic drugs. Aetna Rx Home Delivery® pharmacy can deliver
Taking a generic is an easy way to reduce your out- your 90-day supply to your home, or you can pick
of-pocket costs. They are safe, effective and often it up at your local CVS Pharmacy®.
cost less than their brand-name counterparts. Your 2. Choose from two easy ways to order your
plan requires you to use a generic drug, when one is 90-day refills:
available, in order to get the best coverage.
– Call the Customer Care number at
Your pharmacy will usually fill your prescription with a 1-888-RX-AETNA (1-888-792-3862). We’ll
generic, if one is available.
contact your doctor for a new prescription
Most times, your doctor will let you take a generic and handle all the details.
version of a drug. For that reason, your pharmacist
will usually substitute a generic for the brand-name – Refill order online. Visit the website that’s
drug. This helps you save money every time you fill a on your member ID card and sign in to your
prescription. account to submit your order.
You can still get the brand-name version of your drug if If you call to opt out, you may continue to fill 30-day
you want, but you may pay more. supplies at any retail pharmacy in the network without
You and your doctor may still decide that you want to penalty. If you do not call and do not switch to a 90-
get the brand-name version of a drug. If so, your doctor day supply, you will be responsible for 100% of the
will write “DAW” on your prescription. This stands for cost-share. Opt-out is required annually.
“Dispense as Written.” In this case, your pharmacist will
only fill your prescription with the brand-name drug.
Please know that if a generic is available, and you
choose to get the brand instead, you’ll pay the
difference in cost between the brand and the generic,
plus the applicable brand copay for your plan. This
could result in a significant increase in your out-of-
pocket expenses. The out-of-pocket cost difference
between the generic and brand may not be applied to
the deductible.
20AETNA SPECIALTY PHARMACY
Members are required to fill specialty medicine on
the first fill through an Aetna Specialty Network
Pharmacy. This includes Aetna Specialty Pharmacy
medicine and support services or other in-network
specialty pharmacies. Required use of Aetna
Specialty Pharmacy Network on the first fill helps
to connect members to the high-touch support
and follow up they get when they use Aetna
Specialty Pharmacy.
Always have the medicine and supplies you need.
It is important to take your medicine just how your
doctor prescribed it. Missing a dose could harm
you. Aetna Specialty Pharmacy® will make sure you
always have the medicine and supplies you need on
hand. They will call you one week before your refill
is due, prepare your next order and check that you
stay on track with your treatment.
You get a personal care plan and ongoing support.
‹ Nurses and pharmacists can answer your questions
24 hours a day, every day.
‹ Care coordinators work with you to help your order
process quickly.
‹ Insurance and claims specialists help you to
maximize your benefits plan.
‹ Service representatives call you or your doctor to
set up your refills.
21HEALTH SAVINGS ACCOUNT
Need funds to help cover out-of-pocket healthcare expenses? Consider a Health Savings
Account (HSA). An HSA is a personal healthcare bank account used to pay for qualified
medical expenses and is funded by you and Kleinfelder. HSA contributions and withdrawals for
qualified healthcare expenses are tax-free. You must be enrolled in a HDHP to participate.
Tax-free Interest
Your HSA can be used for qualified expenses for
you, your spouse/domestic partner and/or tax Employer Contributions
dependent(s). If you are not currently enrolled in (pre-tax)
a HDHP but you have unused HSA funds from a
previous account, those funds can still be used for
qualified expenses.
Voluntary
Contributions
HealthEquity will issue you a debit card, giving you
direct access to your account balance. Use your
debit card to pay for qualified medical expenses,
with no need to submit receipts for reimbursement.
You must have a balance in your HSA account to use
the card.
HSA
Eligible expenses include doctors’ visits, eye exams, Tax-free
prescription expenses, laser eye surgery and more. Payments
Check out IRS Publication 502 on irs.gov for a
complete list of eligible expenses.
(for qualified medical
expenses)
22ELIGIBILITY PLAN. SPEND. SAVE.
You are eligible to contribute to an HSA if: Contributions to an HSA can be made through
payroll deduction on a pre-tax basis when you
‹ You are enrolled in an HSA-eligible High Deductible
open an account with HealthEquity. The money in
Health Plan (HDHP).
this account (including interest and investment
‹ You are not covered by your spouse’s or domestic earnings) grows tax-free. When the funds are used
partner’s non-HDHP health plan. for qualified medical expenses, they are spent
‹ Your spouse or domestic partner does not have a tax-free.
healthcare Flexible Spending Account or Health Per IRS regulations, if HSA funds are used for
Reimbursement Account. purposes other than qualified medical expenses and
‹ You are not eligible to be claimed as a dependent you are younger than age 65, you must pay federal
on someone else’s tax return. income tax on the amount withdrawn, plus a 20%
penalty tax.
‹ You are not enrolled in Medicare or TRICARE.
‹ You have not received Department of Veterans
Affairs medical benefits in the past 90 days for
non-service-related care. (Service-related care will
not be taken into consideration.)
YOUR MONEY. YOUR ACCOUNT.
Your HSA is a personal bank account that you
own and administer. It’s up to you how much you
contribute, when to use the money for medical
services, and when to reimburse yourself. You can
save and roll over HSA funds to the next year if you
don’t spend them all in the calendar year. You can
even let funds accumulate year-over-year to use
in retirement. HSA funds are also portable if you
change jobs. There are no vesting requirements or
forfeiture provisions.
HOW TO ENROLL
To enroll in the company-sponsored HSA, you
must elect one of the High Deductible Health
Plans through Aetna. Complete all HSA enrollment
materials and designate the amount to contribute
on a pre-tax basis. Kleinfelder will establish an HSA
account in your name and send in your contribution
once bank account information has been provided
and verified.
23HSA FUNDING LIMITS HSA contributions in excess of the IRS annual
contribution limits are not tax deductible and are
The IRS places an annual limit on the maximum
generally subject to a 6% excise tax.
amount that can be contributed to HSAs. For
2021, contributions (which include Kleinfelder’s If you’ve contributed too much to your HSA this
contribution) are limited to the following: year, you have two options:
‹ Remove the excess contributions and the net
HSA FUNDING LIMITS income attributable to the excess contribution
EMPLOYEE $3,600 before you file your federal income tax return
(including extensions). You’ll pay income taxes on
FAMILY $7,200
the excess removed from your HSA.
CATCH-UP CONTRIBUTION
$1,000
(AGES 55+) ‹ Leave the excess contributions in your HSA and
pay 6% excise tax on excess contributions. Next
EMPLOYER CONTRIBUTION year consider contributing less than the annual limit
Kleinfelder provides an HSA employer contribution to your HSA to make up for the excess contribution
that will be deposited on a bi-weekly basis. Funds during the previous year.
are deposited into your HealthEquity HSA based on The Kleinfelder HSA is established with
your medical coverage tier selected during Open HealthEquity. You may be able to roll over funds
Enrollment, within the new hire eligibility window, or from another HSA. For more enrollment information,
during a qualifying life event. You must open your contact Human Resources or visit healthequity.com.
HSA bank account through the enrollment system
within 60 days of your benefit eligibility date to
receive the Kleinfelder contribution.
EMPLOYER HSA CONTRIBUTION
EMPLOYEE $750
FAMILY $1,500
24FLEXIBLE SPENDING ACCOUNTS
Flex your spending power! A Flexible Spending Account (FSA) is a special tax-free
account you put money into to pay for certain out-of-pocket expenses.
HEALTHCARE FLEXIBLE DEPENDENT CARE FLEXIBLE
SPENDING ACCOUNT SPENDING ACCOUNT
The contribution limit for the Health FSA in 2021 In addition to the Healthcare FSA, you may opt to
is $2,750 (subject to change per IRS regulations). participate in the Dependent Care FSA — whether
You can use these funds for qualified medical or not you elect any other benefits. You can set
expenses (deductibles, copays and coinsurance) aside pre-tax funds into a Dependent Care FSA
with pre-tax dollars, reducing your taxable income for expenses associated with caring for elderly
and increasing your take-home pay. You can even or child dependents. Unlike the Healthcare FSA,
pay for eligible expenses with an FSA debit card at reimbursement from your Dependent Care FSA is
the same time you receive them without waiting for limited to the total amount in your account at that
reimbursement. time.
Please note: Over-the-counter (OTC) drugs are not ‹ With the Dependent Care FSA, you can set
eligible for reimbursement through an FSA unless aside up to $5,000 to pay for child or elder care
you have a prescription for them. expenses on a pre-tax basis.
‹ Eligible dependents include children under 13
LIMITED PURPOSE FLEXIBLE and a spouse or other individual who is physically
SPENDING ACCOUNT or mentally incapable of self-care and has the
A Limited Purpose Flexible Spending Account principal place of residence as the employee
(LPFSA) works alongside a Health Savings Account for more than half the year may be a qualifying
(HSA) and allows for reimbursement of eligible individual.
dental and vision expenses. You must decide how
‹ Expenses are reimbursable if the provider is not
much to set aside for this account. The contribution
your dependent.
for the LPFSA in 2021 is $2,750 (subject to change
per IRS regulations). ‹ You must provide the tax identification number or
Social Security number of the party providing care
to be reimbursed.
NOTE
For a list of eligible expenses, visit UltiPro
Benefits at Kleinfelder.ultipro.com.
25This account covers dependent day care expenses GENERAL RULES AND RESTRICTIONS
that are necessary for you and your spouse to work
The IRS has the following rules and restrictions for
or attend school full-time. Examples of eligible
Healthcare and Dependent Care FSAs:
dependent care expenses include:
‹ Expenses must be incurred during the 2021 plan
‹ In-Home Baby-Sitting Services (not provided by a
year.
tax dependent)
‹ Dollars cannot be transferred between FSAs.
‹ Care of a Preschool Child by a Licensed Nursery or
Day Care Provider ‹ You cannot participate in a Dependent Care FSA
and claim a dependent care tax deduction at the
‹ Before- and After-School Care
same time.
‹ Day Camp
‹ You must “use it or lose it” — any unused funds will
‹ In-House Dependent Day Care be forfeited.
Due to federal regulations, expenses for your ‹ You cannot change your FSA election in the middle
domestic partner and your domestic partner’s of the plan year unless you experience a qualifying
children may not be reimbursed under the FSA life event.
programs. Check with your tax advisor to determine
‹ Those considered highly compensated employees
if any exceptions apply.
(family gross earnings were $125,000 or more last
year) may have different FSA contribution limits.
HOW TO USE THE ACCOUNT
Visit irs.gov for more information.
You can use your FSA debit card at doctor or
dentist offices, pharmacies and vision service
providers. It cannot be used at locations that
do not offer services under the plan, unless the
provider has also complied with IRS regulations. The
transaction will be denied if you attempt to use the
card at an ineligible location.
Once you incur an eligible expense, submit a claim
form along with the required documentation.
Contact PayFlex with reimbursement questions. If
you need to submit a receipt, you will be notified by
PayFlex. Always retain a receipt for your records.
While FSA debit cards allow you to pay for
services at point of sale, they do not remove the
IRS regulations for substantiation. Always keep
receipts and Explanation of Benefits (EOBs) for any
debit card charges. Without proof that an expense
was valid, your card could be turned off and your
expense deemed taxable.
26FSA VS HSA
Flexible Spending Accounts (FSAs) and Health Savings Accounts (HSAs) are both ways to save
pre-tax money to pay for your eligible healthcare costs. Which one is right for you?
FSA HSA
Your employer owns your FSA. If you leave your You own your HSA. It is a savings account in your name
OWNERSHIP employer, you lose access to the account unless you and you always have access to the funds, even if you
have a COBRA right. change jobs.
1. You must be enrolled in a Qualified High Deductible Health Plan to
You’re eligible for an FSA if it’s offered by your employer. You can elect
be eligible to contribute money to your HSA. You cannot be covered
a Healthcare FSA even if you waive other coverage. You cannot make
ELIGIBILITY & by a spouse’s non-High Deductible plan or eligible for a spouse’s FSA
changes to your contribution during the Plan Year without a Qualifying
ENROLLMENT Life Event. You cannot be enrolled in both a Healthcare FSA and
or enrolled in Medicare or TRICARE.
an HSA.
2. You can change your contribution at any time during the Plan Year.
For Federal tax purposes, the money in the account is “triple tax-
free,” meaning:
Contributions are tax-free via payroll deduction. However, the funds
TAXATION 1. Contributions are tax-free.
spent are not tax-free.
2. The account grows tax-free.
3. Funds are spent tax-free (if used for qualified expenses).
Both you and your employer can contribute to the account according
You can contribute to the account according to IRS limits. The to IRS limits. The contribution limit for 2021 is $3,600 for individuals
CONTRIBUTIONS contribution limit for the Health FSA in 2021 is $2,750 (subject to and $7,200 for families. This amount includes the employer
change per IRS regulations). contribution. If you are 55 or older, you may make a “catch-up”
contribution of $1,000 per year.
Your HSA, through Health Equity, includes a debit card to pay for
qualified expenses directly. You can also use online bill payment
Some plans include an FSA debit card to pay for eligible expenses. If services from the HSA financial bank. You decide when to use the
PAYMENT
not, you pay up front and submit your receipts for reimbursement. money in your HSA to pay for qualified expenses, or if you want to
use another account to pay for services and save the money in your
HSA for future expenses or retirement.
You must use the money in the account by the end of the Plan
Year; however, Kleinfelder’s plan includes a 3-month run-out period.
The money in the account rolls over from year to year. Funds are
This run out period allows you to request reimbursement through
ROLL OVER always yours and may be used for future qualified expenses — even
March 31, 2022 for eligible expenses incurred from Jan 1, 2021 to
in retirement years.
December 31, 2021. Any unclaimed funds at the end of the run-out
period are forfeited.
Physician services, hospital services, prescriptions, dental care, vision
QUALIFIED Physician services, hospital services, prescriptions, dental care and
care, Medicare Part D plans, COBRA premiums and long-term care
EXPENSES vision care. A full listing of eligible expenses is available at irs.gov.
premiums. A full listing of eligible expenses is available at irs.gov.
Other types of FSAs include:
• Dependent Care FSA - Allows you to set aside pre-tax dollars for
elder or child dependent care and covers expenses such as day
care and before- and after-school care.
OTHER TYPES There is only one type of HSA.
• Limited Purpose FSA (LPFSA) - Covers eligible dental and vision
expenses. LPFSAs are typically offered in conjunction with an HSA
as the IRS does not allow someone to have a Healthcare FSA and
an HSA.
Please refer to your Summary Plan Description or plan certificate for your plan’s specific FSA or HSA benefits.
27SUPPLEMENTAL HEALTH BENEFITS
Kleinfelder offers several ways for you to supplement your medical plan coverage. This additional
insurance can help cover unexpected expenses, regardless of any benefit you may receive from
your medical plan. Coverage is available for yourself and your dependents and is paid on an
after-tax basis.
ACCIDENT COVERAGE ACCIDENT RATES
Accident coverage, available through Unum, MONTHLY CONTRIBUTIONS
provides cash benefits for you and your covered
EMPLOYEE ONLY $17.46
family members if you have expenses related to
an accidental injury that occurs on and off the job. EMPLOYEE + SPOUSE $29.06
Health insurance helps with medical expenses, but EMPLOYEE + CHILD(REN) $33.21
this coverage is an additional layer of protection
EMPLOYEE + FAMILY $44.81
that can help you pay deductibles, copays and even
typical day-to-day expenses such as a mortgage or
car payment. Coverage is offered on a guaranteed
basis, meaning no health questions are required.
You can even keep the coverage if you change jobs
or retire. This coverage is only available during your
A few examples of covered benefits are: New Hire or Open Enrollment. If you miss this
‹ Emergency room treatment - $150
window to enroll, you must wait until the next
Open Enrollment. To change your elections.
‹ Hospital admission - $1,500
Call the Unum Call Center at 800-635-5597
‹ Hospital ICU Admission - $2,250 where a Benefits Counselor will assist you.
‹ Hospital confinement - $200/day
‹ Injuries - varies (for a schedule of payments for
fractures, dislocations, lacerations, burns, etc.,
please visit Kleinfelder.ultipro.com)
NOTE: This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or
be unavailable in some states. The policy has exclusions and limitations that may affect any benefits payable. For complete details of coverage and
availability, refer to the Policy or contact Unum.
28CRITICAL ILLNESS COVERAGE MONTHLY PREMIUM
Unum’s Critical Illness coverage protects your FOR $1,000 OF COVERAGE
finances from the expense of a serious health ISSUE AGE NON-TOBACCO TOBACCO
problem, such as a stroke, heart attack or cancer.
You may choose a lump sum benefit of $5,000, 0-24 $0.49 $0.71
$10,000, $15,000, $20,000 or $30,000 for yourself 25-29 $0.54 $0.85
and $5,000, $10,000 or $15,000 for your spouse.
30-34 $0.79 $1.27
This benefit is paid directly to you at the first
35-39 $1.08 $1.87
diagnosis of a covered condition.
40-44 $1.54 $2.76
When you purchase Critical Illness coverage for
yourself, your child(ren) are automatically covered at 45-49 $2.12 $3.82
50% of your amount at no additional cost. 50-54 $2.82 $5.15
55-59 $3.72 $6.56
Covered Benefits
Examples of covered benefits are listed below and 60-64 $4.76 $7.86
paid at 100% of your elected benefit. 65-69 $5.40 $8.27
‹ Heart Attack ‹ End-Stage Kidney 70-99 $9.69 $13.33
Failure
‹ Blindness
‹ Benign Brain Tumor
‹ Major Organ Failure
‹ Cancer
MONTHLY WELLNESS BENEFIT
Employee and Child(ren) $1.60
Wellness Benefit Spouse $1.60
Every year, each family member who has Critical
Illness coverage can receive $50 for getting a health
screening test, such as: chest x-rays, stress tests,
colonoscopies, and others.
HOW TO CALCULATE YOUR MONTHLY PREMIUM
$ ÷ $1,000 = $ x Issue Age Rate = $ + $1.60 $
Estimated Monthly
Benefit Amount
Premium
NOTE: This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or
be unavailable in some states. The policy has exclusions and limitations that may affect any benefits payable. For complete details of coverage and
availability, refer to the Policy or contact Unum.
29DENTAL BENEFITS
Brushing your teeth and flossing are great, but don’t forget to visit the dentist too! Kleinfelder
offers its dental plan through United Concordia (UCCI) that encourages preventive care and
offers a wide range of services.
DENTAL PLAN SUMMARY UCCI DENTAL PPO PLAN
This chart summarizes the 2021 dental coverage MONTHLY CONTRIBUTIONS
provided by United Concordia.
EMPLOYEE ONLY $36.96
DENTAL PREMIUMS EMPLOYEE + SPOUSE $73.24
Premium contributions for dental are deducted EMPLOYEE + CHILD(REN) $80.24
from your paycheck on a pre-tax basis. Your tier of
EMPLOYEE + FAMILY $109.93
coverage determines your monthly premium.
DEDUCTIBLE
NETWORK DENTISTS
IN-NETWORK OUT-OF-NETWORK
Your dental network through United Concordia is
the Elite Plus Network. If you use a non-participating INDIVIDUAL $50 $50
provider, your out-of-pocket costs will be higher, and FAMILY $150 $150
you are subject to balance billing. To find a network MAXIMUM
dentist, visit unitedconcordia.com or download the PER PERSON $1,500 $1,500
app through the App Store or Google Play – just
search for “United Concordia.” COVERED SERVICES (PLAN PAYS)
PREVENTIVE SERVICES
100% 100%
SMILE FOR HEALTH® WELLNESS Oral Exams, Routine Cleanings,
deductible waived deductible waived
Bitewing X-rays, Fluoride
If you have been diagnosed with certain chronic
BASIC SERVICES
medical conditions (such as heart disease, diabetes,
Fillings, Root Canal, Simple 90%* 80%*
lupus, and more), you are eligible for enhanced Extractions
dental benefits through UCCI’s Smile for Health® MAJOR SERVICES
Wellness Program. Enhanced benefits include 100% Crowns, Implants, Dentures, 60%* 50%*
coverage for periodontal maintenance, scaling & Denture Repair
root planning and periodontal surgery, if necessary. ORTHODONTICS
50%
Child(ren) & Adults
You and any eligible dependent can register ORTHODONTIC LIFETIME
$1,500
to use Smile for Health® Wellness by visiting MAXIMUM
UnitedConcordia.com/GetMDB from your desktop or *After Deductible
mobile device.
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