KANSAS CITY KANSAS PUBLIC SCHOOLS NEW HIRE GUIDE 2021
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2021
KANSAS CITY
KANSAS PUBLIC
SCHOOLS
NEW HIRE
GUIDE
KCKPS | 2021 Employee Benefits Guide 1
2021 BENEFITS OVERVIEW
We recognize the importance of benefits within the
overall compensation package provided to all of our
eligible employees. At Kansas City Kansas Public
Schools, we focus not only on providing quality medical
plans but also on controlling the cost and financial risk
for our employees. PERSONAL INFORMATION
UPDATES
You can make updates to your
address by simply logging on to
NOT SURE HOW TO GET STARTED? employee online at the District’s
website. To correct a misspelled
As a new employee, in order to enroll in your benefits,
name, date of birth or gender,
you are required to speak with a benefits counselor.
please contact HR at 913-279-
Following are some tips to help you prepare for this
2262
call:
Review your benefits in this guide
If you have a name change,
please submit documentation
When you are ready to enroll please call 877-523- (court document, marriage
0176. license, driver's license, etc.) to
HR.
Have your employee id number, dependent date of
birth and Social security numbers for yourself, your
spouse, and dependent children ready
No appointment is necessary.
We value you as a member of the Kansas City Kansas
Public Schools family and look forward to a healthy and
safe 2021.
2 KCKPS | 2021 Employee Benefits Guide
TABLE
TABLE
OFOF
CONTENTS
CONTENTS
Welcome .................................................... 2 CONTACT INFORMATION
Contact Information & Table of Contents.............. 3 MEDICAL
Enrollment Information .................................. 4 BlueKC
www.mybluekc.com
Medical Insurance ......................................... 5 866.811.4589
Spira Care .................................................. 7 KCK Dedicated Customer Service Line: 816.395.2270
Your Medical Insurance Plan Options and Costs ....... 9 DENTAL
Care Options and When to Use Them ................ 13 Guardian
www.guardiananytime.com
RX Savings Solutions .................................... 14 800.541.7846
Virtual Care App ......................................... 15
VOLUNTARY VISION
Plan Scenarios ........................................... 16 Superior Vision
Wellness .................................................. 18 www.superiorvision.com
800.507.3800
Blue KC Mindful.......................................... 19
Health Savings Account (HSAs) ........................ 20 VOLUNTARY LIFE AND
SHORT-TERM DISABILITY
Flexible Spending Accounts (FSAs) .................... 22 OneAmerica
Dental Insurance ........................................ 23 www.oneamerica.com
800.553.5318
Vision Insurance ......................................... 25
Voluntary Term Life ..................................... 26 KPERS LONG-TERM DISABILITY
State of Kansas
Short-Term Disability ................................... 27 www.kpers.org
Long-Term Disability .................................... 27 888.275.5737
Voluntary Coverages .................................... 28 HEALTH SAVINGS ACCOUNT
Identity Theft ............................................ 31 UMB Bank
www.hsa.umb.com
Additional Voluntary Coverage ........................ 32
866.520.4472
Important Notices ....................................... 33
FLEXIBLE SPENDING ACCOUNTS
CBIZ
www.myplans.cbiz.com
800.815.3023
Throughout this guide you will find video and ACCIDENT AND CANCER
link icons that will take you to resources that provide Prosperity
additional information on the benefits available to you.
https://www.prosperitylife.com/
844.801.6238
EMPLOYEE ASSISTANCE PROGRAM HOSPITAL INDEMNITY
New Directions Reliance Standard CRITICAL ILLNESS
www.ndbh.com www.reliancestandard.com/ Reliance Standard
800.624.5544 home/ www.reliancestandard.com/home/
Email: customer.service@rsli.com Email: customer.service@rsli.com
LEGAL PLAN 800.351.7500 800.351.7500
MetLaw
https://www.legalplans.com/ COBRA/RETIREE
800.821.6400 KCKSD BENEFITS TEAM CBIZ Payroll
Crystal Primers Email: cbizcobra@cbiz.com
UNIVERSAL LIFE / LTC Sr. Benefits Clerk 800.815.3023
Transamerica Email: Crystal.Primers@kckps.org
http//www.transamerica.com/ 913.279.2200 IDENTITY THEFT
Email:tii.customerservice@transa InfoArmor
merica.com Rachel Swartz www.benefits-direct.com
800.251.7254 Total Rewards Advisor 877.523.0176
Email: rachel.swartz@kckps.org
913-601-0658
KCKPS | 2021 Employee Benefits Guide 3
ENROLLMENT
INFORMATION
WHO IS ELIGIBLE?
All certified and full-time classified employees
working 30 hours or more per week are considered
eligible to participate. Please discuss with Human
Resources your employment status to determine
eligibility and your benefit effective date.
Dependents of eligible employees may also be
eligible for coverage under many of these benefit
plans. Once you have enrolled you should receive a benefits
confirmation to your email from KCKPS Benefit
Eligible dependents include:
Enrollment. Please review, save and file for your
Your spouse records. You can also review your benefit elections at
Unmarried children through the end of the year
www.cbizesc.com/kckps.
(December 31) in which they turn 26 Login: 4 or 5 digit employee id number
Unmarried dependent children over age 26 who Password: Your date of Birth (mmddyyyy)
are incapable of supporting themselves because
of mental or physical handicaps (upon approval).
HOW DO I MAKE CHANGES?
Unless you have a qualified change in status, you cannot make changes to the benefits you elect until
the next annual enrollment period. Qualified changes in status include birth of a child, adoption, marriage,
death, divorce, a court order requiring provision of insurance to a dependent, loss of coverage (if you or
your spouse/dependents are covered under another plan and then lose that coverage), Medicare eligibility,
going from part-time to full-time, move or transfer out of the plan’s service area, or a reduction in hours
that makes you ineligible for coverage.
Should you wish to make changes to your elections due to a qualifying event, you have 31 days from the event
to notify the Employee Service Center at www.cbizesc.com/kckps. If the Employee Service Center is not
notified within this time frame, you must wait until the next open enrollment period to adjust your
benefits.
If you are eligible to enroll in the Federal Marketplace (Exchange) due to a Special Enrollment during the year,
you will be permitted to drop coverage under this plan.
If you or your dependents become ineligible for Medicaid or CHIP, you may be able to enroll in USD #500’s plan;
you must request enrollment within 60 days. Additionally, if you or your dependents become eligible for
premium assistance from Medicaid or CHIP, you may be able to enroll yourself and your dependents in USD
#500’s plan; you must request enrollment within 60 days.
What is a Qualifying Event?
4 KCKPS | 2021 Employee Benefits Guide
MEDICAL INSURANCE HOW TO GET STARTED
1. SELECT YOUR
YOUR HEALTH PLAN OPTIONS MEDICAL PLAN
As a full-time employee of Kansas City Kansas Public Schools,
you have the choice between ten medical plan options: HMO,
EPO, Preferred-Care Blue $500, $1,000, $2,500, HDHP,
BlueSelect Plus $2,500, HDHP, Spira Care $ 2,800 HDHP and
Spira Care $3,500 EPO.
While all plans, except the HMO and EPO plans, give you the
option of using out-of-network providers, you can save money HMO : With an HMO, there’s no
by using in-network providers because Blue Cross Blue Shield of deductible. Your share of the costs includes
copayments for many services. You choose a
Kansas City has negotiated significant discounts with them. If primary care physician (PCP) who will
you choose to go out-of-network, you’ll be responsible for the provide most of your care and recommend
difference between the actual charge and BlueKC Allowable specialists as needed. To visit a specialist
charge, plus your out-of-network deductible and coinsurance. who participates in the Blue-Care Network,
simply select the specialist and make an
FREQUENTLY ASKED QUESTIONS appointment. No referral is required. An
HMO generally does not cover any services
How many hours do I need to work to be eligible for insurance benefits?
? from non-participating providers, except for
emergencies.
You must be a full-time employee working a minimum of 30 hours per
week on a regular basis. The HMO plan utilizes the Blue-Care
Network.
? Will I receive a new Medical ID card?
Preventive care covered at 100%.
After your enrollment has been processed by Blue KC, you will receive an Higher Premiums/No deductible.
ID card. The ID card will not be effective until your Blue KC coverage
effective date. Do not give this ID card to a physician or hospital prior to
that effective date as Blue KC will not yet have a record of you as a new
member.
Does the deductible run on a calendar year or policy
? year basis?
EPO : Like an HMO, the EPO has no
A calendar year basis.
deductible to meet. Your share of the costs
includes copayments for many services. You
? How long can I cover my dependent children? must receive all care from in-network
providers. The only exception to this is for
Dependent children are eligible until the end of the year in which emergency services. Non-emergency services
they turn age 26. received out-of-network will not be covered.
The EPO plan utilizes the BlueSelect Plus
? I just got hired. When will my benefits become effective? Network.
Your medical insurance coverage will begin on the 1st of the month Preventive care covered at 100%.
following your date of hire. Higher Premiums/No deductible.
What is an HMO?
KCKPS | 2021 Employee Benefits Guide 5
MEDICAL INSURANCE
PPO : A PPO allows you to see participating and non-
participating providers.
PROVIDER SEARCH
Three of the PPO plans utilize the Preferred-Care Blue
Network and one utilizes the BlueSelect Plus Network.
To find a participating provider before
Preventive Care is covered at 100%.
making your enrollment decision follow
First Dollar Coverage: Three of the District's PPO plans include these steps:
first dollar coverage (both $2500 PPOs as well as the $1000
Go to www.bluekc.com
PPO). For each covered person, the plan pays the first $250 of
eligible expenses for covered services from participating Click “Find Care”
providers. The First Dollar benefit does not apply to
copayments, office visits, prescription drugs, or any services Next, click “Search”
from non-participating providers. Once the plan has paid the
First Dollar Amount, you pay all other expenses until you Before you begin your search, select
reach your deductible. “Your Plan” under the “All Plans” link
at the top of the page
These plans are good options if you rarely visit the doctor or
take prescription medications. These plans also include a Then, choose the “BlueSelect Plus” or
safety net to cover a catastrophic health event, such as “Preferred-Care Blue” medical
serious illness or injury. network
What is a PPO? Now, you can search for a specific
provider, specialty, clinic, etc.
HDHP : An HDHP allows you to contribute towards a Health Once located, click on the provider’s
Savings Account. The District offers three HDHPs for you to name, if it appears
choose from. These plans offer lower monthly premiums in
exchange for higher deductibles. Finally, click “Plans Accepted” inside
the box with the provider’s
A Health Savings Account (HSA) is a tax exempt account used in
information to verify that the provider
conjunction with the high deductible health plan. It provides
is in the network you identified.
funding to pay for qualified medical expenses NOT covered by
the insurance. The HSA account is provided by UMB Bank and is Once you are enrolled and benefits are
available as an option ONLY to those who enroll in either of the effective, you can log in to search for a
BlueSaver HDHPs. Please refer to section 2 of this guide for provider. Your network will automatically
additional information on Health Savings Accounts. be selected for you.
What is a High Deductible Health Plan?
Learn more about a HDHP with a Health
Savings Account!
6 KCKPS | 2021 Employee Benefits Guide
SPIRA CARE
BLUE CROSS BLUE SHIELD OF KANSAS CITY
WHAT IS SPIRA CARE?
Blue KC is collaborating with one of the highest-
performing Blue KC Medical Homes to create Spira
Care – an innovative offering centered on a
reimagined primary care experience.
WHERE ARE THE CLINICS LOCATED?
Spira members will benefit from the network’s lower SHAWNEE
OLATHE
overall costs and convenient access to local providers 15710 West 135th St 10824 Shawnee Mission Pkwy
across the metro area. Spira membership and care Olathe, KS 66062 Shawnee, KS 66203
locations are exclusive to those employer groups LEE’S SUMMIT LIBERTY
enrolled. 760 NW Blue Pkwy 8350 N Church Rd
Lee’s Summit, MO 64086 Kansas City, MO 64158
WHAT SERVICES ARE INCLUDED IN SPIRA CARE? CROSSROADS WYANDOTTE
1916 Grand Blvd 9800 Troup Ave
All primary care and behavioral health services provided Kansas City, MO 64108 Kansas City, KS 66111
at the care center are covered for either no or low out
DEER CREEK WOODS
of pocket cost to members (depending on which Spira TIFFANY SPRINGS
8765 N Ambassador Drive BUSINESS CENTER
care plan you elect.) Kansas City, Missouri 64154 7341 W. 133rd St.
Overland Park, KS 66223
For more information on locations:
Chronic Digital Routine
condition x-rays preventative https://www.spiracare.com/care-centers.html
management care
Specialist
referrals &
scheduling WHAT IF I NEED CARE OUTSIDE THE CENTER?
Behavioral
Lab draws health For all needs outside the Care Centers*, you’ll have access
Extended Common sciences to the BlueSelect Plus network (hospitals shown below)
full service Prescriptions
hours within the Kansas City metro area.
filled on-site
Your dedicated care guide can help you navigate where to
go - see the following page to learn more about care
guides.
● Children’s Mercy Hospital
● Children’s Mercy Hospital - South
● Liberty Hospital
● North Kansas City Hospital
● Olathe Medical Center
● Advent Health
● Truman Medical Center - Hospital Hill
● Truman Medical Center - Lakewood
● University of Kansas Hospital
● Cameron Hospital
*If you are out of area and need access to care you can utilize the
Blue Card network.
KCKPS | 2021 Employee Benefits Guide 7
SPIRA CARE
BLUE CROSS BLUE SHIELD OF KANSAS CITY
SPIRA CARE OPTIONS
The District offers two Spira Care plans – the $2,800 HDHP and the $3,500 EPO. Both plans will allow you to take advantage of all of
the features of the Care Centers. The difference between the two plans is what you will pay for those services you receive at the Care
Center as well as the type of savings account you can make additional pre-tax contributions to in order to help pay for your medical
care. Below are a few key points for each plan.
Spira Care $2,800 HDHP
A member will incur a charge of $60 for a diagnostic office visit at a Care Center. Diagnostic care includes but is not limited to
office visit charges, labs, x-rays and prescriptions dispensed on-site and follow-up care. This charge will apply to the member’s
deductible and out-of-pocket maximum which are noted on the following page.
Once the out-of-pocket maximum is reached, a member will have no additional fees for the rest of the calendar year for services
received either at a Care Center or from a provider in the BlueSelect Plus network.
Preventive services are covered at 100% with no deductible or copayment.
Employees enrolled in this plan can make pre-tax contributions to a Health Savings Account (HSA) to help pay for qualified medical
expenses.
Spira Care $3,500 EPO
All services, both preventive and diagnostic, that are received at a Care Center are covered at 100% with no deductible or
copayments. The only exception is a minimal copayment for generic prescription medications that are available and dispensed on-
site at the Care Center.
Tier 1 and 2 prescription medications that are purchased through a retail pharmacy or through the mail order program are covered
at 100% after the appropriate copayment.
Care received outside of the Care Center but from a BlueSelect Plus provider is subject to the deductible shown on the following
page. Once the deductible has been met, the plan will pay 100% for the rest of the calendar year.
Employees enrolled in this plan can make pre-tax contributions to a flexible spending account (FSA) to help pay for qualified
medical expenses.
WHAT IS A CARE GUIDE?
As a member of either of the District's Spira Care plans, you will have access to first-class doctors and nurses, as well as a
committed Care Guide Team dedicated to simplifying and enhancing your health journey.
Care Guides are real people and personal guides, many with nursing and benefit backgrounds, to help you on your health journey.
They can coordinate care, answer questions and explain benefits. Spira Care members have a single point of contact for both care
and coverage questions.
UNDERSTANDING COSTS COORDINATING CARE EXPLAINING BENEFITS
● Your doctor prescribed a ● Imagine you’ve recently You need to visit a specialist
blood test and a CT scan, but been discharged from the outside of your Spira Care
how much will it cost? And hospital. Your Care Guide Center.
where should you go to have calls to see how you’re feeling
them done? and follow up on treatment
Naturally, you have
questions. Is the specialist you
● Your Care Guide is ready to needs.
chose in-network?
provide you with answers to ● It’s a little something we call
these questions and more,
● Have you reached your
proactive outreach, and it
ensuring you have the deductible? Your Care Guide
can be a big help.
information you need to make is available to answer your
smart healthcare choices for benefit questions.
you and your wallet.
8 KCKPS | 2021 Employee Benefits Guide
MEDICAL INSURANCE
HMO EPO $500 PPO $1,000 PPO
Blue-Care BlueSelect Plus Preferred-Care Blue Preferred-Care Blue
Employee Cost Per Month
Costs are based on completed wellness requirements. If not completed add $20 per month to the listed cost.
Employee Only $200.54 $109.58 $198.14 $61.46
Employee & Spouse $1,105.12 $905.88 $1,099.80 $798.98
Employee & Child(ren) $924.20 $746.60 $919.44 $651.46
Employee & Family $1,678.02 $1,410.16 $1,670.80 $1,266.10
Special Family $1,114.16 $846.30 $1,106.94 $702.24
Out-of- Out-of-
In-Network In-Network In-Network In-Network
Network Network
$250 per
First Dollar Coverage N/A N/A N/A member per No benefit
calendar year
Deductible
$500 $1,000 $1,000 $3,000
Individual None None
$1,500 $3,000 $3,000 $9,000
Family
Member Coinsurance 0% 0% 10% 30% 20% 30%
Out-of-Pocket Maximum
Individual
$4,000 $4,000 $5,750 $11,500 $5,800 $11,600
Family $10,000 $10,000 $11,500 $23,000 $11,600 $23,200
(includes deductible, coinsurance &
copays)
Office Visit $25 / $50 $25 / $50 copay
30% after 30% after
Primary Physician/ $25 / $50 copay $25 / $50 copay copay (office (office visit
deductible deductible
Specialist visit only) only)
No copay (contract lists No copay (contract lists Covered at 30% after 30% after
Preventive Care Covered at 100%
covered services) covered services) 100% deductible deductible
$50 copay (if services are $50 copay (if services are $50 copay $50 copay
30% after 30% after
Urgent Care received in an urgent care received in an urgent care (office visit
deductible
(office visit and
deductible
center) center) and lab only) lab only)
$200 copay then $200 copay then
$200 copay $200 copay
deductible then 10% deductible then 20%
Emergency Room (Copay waived if (Copay waived if admitted
(Copay waived if admitted to (Copay waived if admitted to
admitted to a hospital) to a hospital)
a hospital) a hospital)
$300 copay per $300 copay per occurrence 10% after 20% after
occurrence (Up to $1,500 (Up to $1,500 per calendar deductible (if 30% after deductible (if in 30% after
Outpatient Surgery per calendar year year combined with in outpatient deductible outpatient deductible
combined with inpatient) inpatient) facility) facility)
$400
$300 copay per $400
$300 copay per occurrence copay per
occurrence (Up to $1,500 copay per
(Up to $1,500 per calendar admission, 30% after 30% after
Inpatient Hospital Services per calendar year admission, then
year combined with then deductible deductible
combined with 10% after
outpatient) 100% after
outpatient) deductible
deductible
Prescription Drug
$15 / $40 / $60 $15 / $40 / $60
Retail (at participating pharmacies) (Tier 1 generic (Tier 1 generic $15 / $40 / $60 $15 / $40 / $60
(Tier 1, Tier 2, Tier 3) contraceptives covered at contraceptives covered at (Tier 1 generic contraceptives (Tier 1 generic contraceptives
100%) 100%) covered at 100%) covered at 100%)
Mail Order (90-day supply)
(Tier 1, Tier 2, Tier 3) $30 / $80/ $120 $30 / $80/ $120 $30 / $80/ $120 $30 / $80/ $120
(Tier 1 generic contraceptives (Tier 1 generic contraceptives
(Tier 1 generic (Tier 1 generic covered at 100%) covered at 100%)
Out-of-Network: Refer to Plan Out-of-Network: Refer to Plan
contraceptives covered at contraceptives covered at Summary for details Summary for details
100%) 100%)
All plans are detailed in BCBS 2021 Certificate of Coverage (COC). This is a brief summary only. For exact terms and conditions, please refer to your certificate.
KCKPS | 2021 Employee Benefits Guide 9
MEDICAL INSURANCE
$2,500 PPO $2,500 PPO
Preferred-Care Blue BlueSelect Plus
Employee Cost Per Month
Costs are based on completed wellness requirements. If not completed add $20 per month
to the listed cost.
Employee Only $0.00 $0.00
Employee & Spouse $655.18 $598.94
Employee & Child(ren) $523.28 $473.10
Employee & Family $1,072.86 $997.26
Special Family $509.00 $433.40
In-Network Out-of-Network In-Network Out-of-Network
$250 per member per $250 per member per
First Dollar Coverage N/A N/A
calendar year calendar year
Deductible
$2,500 $5,000 $2,500 $5,000
Individual
$7,500 $15,000 $7,500 $15,000
Family
Member Coinsurance 10% 30% 10% 40%
Out-of-Pocket Maximum
Individual $5,400 $10,800 $5,400 $27,000
Family $10,800 $21,600 $10,800 $54,000
(includes deductible, coinsurance & copays)
Office Visit
$25 / $50 copay (office visit $25 / $50 copay (office visit
Primary Physician/ Deductible then 30% Deductible then 40%
only) only)
Specialist
Preventive Care Covered at 100% Deductible then 30% Covered at 100% Deductible then 40%
$50 copay(office visit and $50 copay (office visit and
Urgent Care lab only)
Deductible then 30%
lab only)
Deductible then 40%
$200 copay then $200 copay then $200 copay then $200 copay then
Emergency Room deductible then 10% deductible then 10% deductible then 10% deductible then 10%
(Copay waived if admitted to (Copay waived if admitted (Copay waived if admitted to a (Copay waived if
a hospital) to a hospital) hospital) admitted to a hospital)
10% after deductible 10% after deductible
Outpatient Surgery (if in outpatient facility)
Deductible then 30%
(if in outpatient facility)
Deductible then 40%
$600 copay per admission, $600 copay per admission,
Inpatient Hospital Services then 10% after deductible
Deductible then 30%
then10% after deductible
Deductible then 40%
Prescription Drug
Retail (at participating pharmacies) $15 / $40 / $60
(Tier 1, Tier 2, Tier 3) $15 / $40 / $60
(Tier 1 generic contraceptives
(Tier 1 generic contraceptives
covered at 100%)
covered at 100%) Out-of-Network: Refer Out-of-Network: Refer
Mail Order (90-day supply) to Plan Summary for to Plan Summary for
$30 / $80/ $120
(Tier 1, Tier 2, Tier 3) $30 / $80/ $120 details (Tier 1 generic contraceptives
details
(Tier 1 generic contraceptives
covered at 100%)
covered at 100%)
Out-of-Network: Refer to
Plan Summary for details
All plans are detailed in BCBS 2021 Certificate of Coverage (COC). This is a brief summary only. For exact terms and conditions, please refer to your certificate.
10 KCKPS | 2021 Employee Benefits GuideMEDICAL INSURANCE
Blue Saver HDHP Blue Saver HDHP
Preferred-Care Blue BlueSelect Plus
Employee Cost Per Month
Costs are based on completed wellness requirements. If not completed add $20 per month to
the listed cost.
Employee Only $0.00 $0.00
Employee & Spouse $655.18 $598.94
Employee & Child(ren) $523.28 $473.10
Employee & Family $1,072.86 $997.26
Special Family $509.00 $433.40
In-Network Out-of-Network In-Network Out-of-Network
First Dollar Coverage N/A N/A N/A
Deductible
$2,800 $2,800 $2,800 $5,600
Individual
$5,600 $5,600 $5,600 $11,200
Family
Member Coinsurance 0% 20% 0% 30%
Out-of-Pocket Maximum
Individual
$2,800 $5,600 $2,800 $14,000
Family
$5,600 $11,200 $5,600 $28,000
(includes deductible, coinsurance &
copays)
Office Visit
30% after
Primary Physician/ 0% after deductible 20% after deductible 0% after deductible
deductible
Specialist
30% after
Preventive Care Covered at 100% 20% after deductible Covered at 100%
deductible
30% after
Urgent Care 0% after deductible 20% after deductible 0% after deductible
deductible
Emergency Room 0% after deductible 0% after deductible
30% after
Outpatient Surgery 0% after deductible 20% after deductible 0% after deductible
deductible
30% after
Inpatient Hospital Services 0% after deductible 20% after deductible 0% after deductible
deductible
Prescription Drug
Retail (at participating pharmacies) 0% after Deductible 0% after Deductible
(Tier 1, Tier 2, Tier 3)
Mail Order (90-day supply)
(Tier 1, Tier 2, Tier 3)
0% after Deductible 0% after Deductible
All plans are detailed in BCBS 2021 Certificate of Coverage (COC). This is a brief summary only. For exact terms and conditions, please refer to your certificate.
KCKPS | 2021 Employee Benefits Guide 11MEDICAL INSURANCE
Spira Care $2,800 HDHP Spira Care EPO $3,500
Employee Cost Per Month
Costs are based on completed wellness requirements. If not completed add $20 per
month to the listed cost.
Employee Only $0.00 $0.00
Employee & Spouse $598.94 $598.94
Employee & Child(ren) $473.10 $473.10
Employee & Family $997.26 $997.26
Special Family $433.40 $433.40
Spira Care BlueSelect Out-of- Spira Care BlueSelect Out-of-
Center Plus Network Center Plus Network
Deductible
$2,800 $3,500
Individual Not covered None Not covered
$5,600 $7,000
Family
Member Coinsurance 0% 0% Not covered 0% 0% Not covered
Out-of-Pocket Maximum
Individual
$2,800 Not $3,500
Family Not covered Not covered
$5,600 applicable $7,000
(includes deductible, coinsurance &
copays)
Office Visit
0% after 0% after 0% after
Primary Physician / Not covered No Charge Not covered
deductible deductible deductible
Specialist
Preventive Care No Charge No Charge Not covered No Charge No Charge Not covered
0% after 0% after 0% after
Lab and X-ray Not covered No Charge Not covered
deductible deductible deductible
Major Diagnostics Not 0% after Not 0% after
Not covered Not covered
(MRI, CT, PET…) applicable deductible applicable deductible
0% after 0% after 0% after
Urgent Care Not covered No Charge Not covered
deductible deductible deductible
Not 0% after Not 0% after
Emergency Room Not covered Not covered
applicable deductible applicable deductible
Outpatient Surgery Not 0% after Not 0% after
Not covered Not covered
applicable deductible applicable deductible
Inpatient Hospital Services Not 0% after Not 0% after
Not covered Not covered
applicable deductible applicable deductible
Prescription Drug
Retail (at participating pharmacies) 0% after 0% after $15 copay $15/$50/0%
Deductible Deductible (Tier 1 only; after
(Tier 1 only; All other tiers deductible
All other tiers not available)
not available) Not covered Not covered
Not 0% after Not $15/$125/0%
Mail Order (90-day supply) Applicable Deductible Applicable after
deductible
All plans are detailed in BCBS 2021 Certificate of Coverage (COC). This is a brief summary only. For exact terms and conditions, please refer to your certificate.
12 KCKPS | 2021 Employee Benefits GuideCARE OPTIONS & WHEN TO USE THEM
YOUR CARE OPTIONS
While we recommend that you seek routine medical care from your primary care physician whenever possible, there are
alternatives available to you. Services may vary, so it’s a good idea to visit the care provider’s website. Be sure to check
that the facility is in-network by calling the toll-free number on the back of your medical ID card, or by visiting
www.mybluekc.com
PRIMARY CARE
Routine, primary/preventive care For routine, primary/ preventive care or non-urgent treatment, we
Non-urgent treatment recommend going to your doctor’s office. Your doctor knows you and your
health history and has access to your medical records. You may also pay
Chronic disease management the least amount out of pocket.
CONVENIENCE CARE
Common Pregnancy These providers are a good alternative when you are not able to get to
infections tests your doctor’s office and your condition is not urgent or an emergency.
(ear infections, They are often located in malls or retail stores (such as CVS Caremark,
Vaccines
pink eye, strep Walgreens, Wal-Mart and Target), and generally serve patients 18 months
throat & Rashes of age or older without an appointment. Services may be provided at a
bronchitis) lower out-of-pocket cost than an urgent care center.
Screenings
Flu shots
URGENT CARE
Sprains Sore throats Sometimes you need medical care fast, but a trip to the emergency room
may not be necessary. During office hours, you may be able to go to your
Small cuts Mild asthma
doctor’s office. Outside regular office hours — or if you can’t be seen by
attacks
Strains your doctor immediately — you may consider going to an Urgent Care
Back pain or Center where you can generally be treated for many minor medical
Minor
strains problems faster than at an emergency room.
infections
EMERGENCY ROOM
Heavy bleeding Difficulty An emergency medical condition is any condition (including severe pain)
breathing which you believe that, without immediate medical care, may result in
Large open
serious injury or is life threatening. Emergency services are always
wounds Major burns
considered in-network. If you receive treatment for an emergency in a
Chest pain Severe head non-network facility, you may be transferred to an in-network facility
injuries once your condition has been stabilized.
Spinal injuries
If you believe you are experiencing a medical emergency,
go to the nearest emergency room or call 9-1-1, even if Primary Care vs. Urgent Care vs. ER
your symptoms are not described here.
KCKPS | 2021 Employee Benefits Guide 13RX SAVINGS SOLUTIONS
RX SAVINGS SOLUTIONS HELPS YOU
SAVE ON PRESCRIPTIONS
BlueKC has partnered with Rx Savings Solutions to
bring cutting-edge technology that will notify you via
text message and/or email when you and your
family can save at the pharmacy.
DID YOU KNOW?
Some of the ways you might save Rx Savings Solutions was created by a
include: pharmacist who found ways to help
Switching pharmacies consumers save money. Prescription prices
can vary widely, even within the same ZIP
Trying a generic or a different generic code.
medication
Trying therapeutic alternatives
DON’T WANT TO WAIT?
STEP 1: Get text and email alerts You don’t have to wait for a savings
notification. Take a look for yourself and start
How to set up alerts:
saving today.
A. Visit MyBlueKC.com. If you are a first-time
visitor, click Register Now. Please have your
BlueKC ID card available to reference. Log in to MyBlueKC.com
Click on Plan Benefits on the left, then click
B. Once logged in, click on Plan Benefits. Then
the Pharmacy Plan Info and Spend Less at
click Pharmacy Plan Info and then Spend Less
the Pharmacy.
at the Pharmacy.
Check your Rx Savings Solutions home page
C. Once on the Rx Savings page, fill in your email for savings opportunities or use the search
address and mobile phone number. feature to view different medications.
STEP 2: review your savings options and
share with your doctor.
Example: Example:
Switch from Switch from
Pharmacy A to Medication A
Pharmacy B to
STEP 3: Start saving on prescriptions
For more information call the Customer Service
number listed on your member ID Card.
14 KCKPS | 2021 Employee Benefits GuideBLUEKC VIRTUAL CARE
APP
Blue Cross and Blue Shield of Kansas City (Blue
KC) members have affordable access to 24/7
healthcare. NEW - Blue KC Virtual Care offers the
same on demand sick visits under a new app.
BLUE KC VIRTUAL CARE HIGHLIGHTS:
In addition to sick care, members can now schedule
video visits with behavioral health therapists right Access a virtual care provider to obtain
from their smartphones, tablets or computers. Blue treatment for common conditions like: sinus
KC Virtual Care is convenient for everyday medical pain, mild asthma, mild allergic reactions,
and behavioral health care needs. Always private, minor headaches, cold sores, sprains, pink
secure and affordably priced, members can register eye, nausea, vomiting, bumps, cuts, scrapes,
now at bluekcvirtualcare.com or download the Blue coughs, sore throat, eye irritation, minor
KC Virtual Care app in the Apple App Store or in fever, colds, rashes and minor burns.
Google Play. No appointment necessary
Maximum charge of $59 per visit (with the
Spira Care EPO $3,500 and Spira Care $2,800 HDHP
exception of Spira Care $3500 EPO
members only should use service key SPIRA when
members who will have a $0 cost per visit)
registering.
You may also access a virtual care provider for
treatment for conditions such as anxiety,
WHAT IF A MEMBER CURRENTLY USES bereavement/grief, bipolar disorder,
AMWELL? depression, OCD, PTSD/trauma, panic attacks.
All members who previously utilized the Amwell Psychologists and counselors are available
app should now download the new Blue KC Virtual for scheduled sessions
Care app to enjoy the same great benefits. Those Visits start at $85 but vary by provider
members who have used Amwell in the past will type, and may be less based on your plan’s
receive an email with additional information about cost share
transitioning to the new platform.
Therapy services are provided by a network of
For additional assistance please contact doctoral level psychologists and master’s
virtualcare@bluekc.com. degree level therapists trained and licensed in
virtual care prevention and therapy
techniques.
KCKPS | 2021 Employee Benefits Guide 15MEDICAL INSURANCE PLAN
SCENARIO #1
The following scenarios illustrate the amount of out-of-pocket expense an individual would pay
according to each medical plan option. For simplicity, each scenario assumes the member is
enrolled in Employee Only coverage, is using in-network providers and that the employee has
met all of the criteria required to earn the wellness discount.
SCENARIO #1
Karen usually goes to her primary care physician (PCP) once a year for her routine physical and
recommended screenings. In January, her PCP recommended she have some moles removed from
her back. She had the outpatient service done at her PCP office. They billed for an office visit
and removal of the mole. Her PCP is in-network. Karen still has to meet her deductible. Following
is an estimate of Karen’s out-of-pocket costs:
HDHP $2,800 SPIRA CARE
PPO $1,000 PCB PPO $2,500 BSP
PCB $3,500 EPO
1. PCP Office Visit
A. Total Cost $100 $100 $100 $100
B. Karen’s Cost $25 $100 $25 $0
C. BCBS Paid $75 $0 $75 $100
2. Outpatient Surgery Total Cost $1,400 $1,400 $1,400 $1,400
A. 1st dollar coverage paid by BCBS $250 $0 $250 0
B. Deductible paid by Karen $1,000 $1,400 $1,150 $1,400
C. Coinsurance paid by Karen $30 $0 $0 $0
D. Coinsurance paid by BCBS $120 $0 $0 $0
3. Total paid by BCBS (1c+2b+2c) $445 $0 $325 $100
4. Summary of Karen’s Costs
A. Medical Expenses (1b+2b+2c) $1,055 $1,500 $1,175 $1,400
B. Annual Premium $737.52 $0 $0 $0
5. Karen’s Total Annual Cost (4a+4b) $1,792.52 $1,500 $1,175 $1,400
16 KCKPS | 2021 Employee Benefits GuideMEDICAL INSURANCE PLAN
SCENARIO #2
The following scenarios illustrate the amount of out-of-pocket expense an individual would pay
according to each medical plan option. For simplicity, each scenario assumes the member is
enrolled in Employee Only coverage, is using in-network providers and that the employee has met
all of the criteria required to earn the wellness discount.
SCENARIO #2
Karen caught a very bad cold that progressed to pneumonia. She saw her PCP two times while ill,
had blood tests and a chest x-ray upon diagnosis and then additional blood tests and a chest x-ray
once she was feeling better. In this scenario, Karen had already met her deductible prior to these
services.
HDHP $2,800 SPIRA CARE
PPO $1,000 PCB PPO $2,500 BSP
PCB $3,500 EPO
1. PCP Office Visit
A. Total Cost $200 $200 $200 $200
B. Karen’s Cost $50 $0 $50 $0
C. BCBS Paid $150 $200 $150 $200
2. Outpatient Total Cost $1,200 $1,200 $1,200 $1,200
A. 1st dollar coverage paid by BCBS $250 $0 $250 $0
B. Deductible paid by Karen $0 $0 $0 $0
C. Coinsurance paid by Karen $190 $0 $95 $0
D. Coinsurance paid by BCBS $760 $1,200 $855 $1,200
3. Total paid by BCBS (1c+2b+2c) $910 $1,400 $1,255 $1,400
4. Summary of Karen’s Costs
A. Medical Expenses (1b+2b+2c) $240 $0 $145 $0
B. Annual Premium $737.52 $0 $0 $0
5. Karen’s Total Annual Cost (4a+4b) $977.52 $0 $145 $0
KCKPS | 2021 Employee Benefits Guide 17WELLNESS
MEDICAL SPENDING CONTRIBUTIONS AND A HEALTHIER
YOU
As an employee that was hired by school district 1/01/2021 or
after you have the opportunity to participate in the Blue KC
“A Healthier You wellness program.” The KCK wellness plan
year runs 9/1/2020 to 8/31/2021.
All KCK employees who reach 2,700 points in the BlueKC “A
Healthier You program” during the wellness plan year, will
receive a $200 contribution made by the district to their
Flexible Spending Account (FSA) or Health Savings Account DISCOVER YOUR A
(HSA) for the 2022 plan year. In addition they will also have HEALTHIER YOU TM PORTAL
an additional $20 monthly premium waived from their 2022
medical plan year premium. 1. Visit MyBlueKC.com or
download the Blue KC A
The 2,700 points have to be reached by August 31, 2021 in
Healthier You App.
order to be eligible for the $200 contribution to your 2022
*Use Google Chrome browser.
Flexible Spending account or Health Savings account and have
the $20 monthly premium waived from your 2022 medical
2. Enter your username and
plan.
password, and click LOG IN.
The “Healthier You wellness program” offers a number of If you are a first time visitor,
ways for participants to earn points and meet the 2,700 point click REGISTER NOW. Be sure
goal. Members can find the detailed list of point earning to have your member ID card
opportunities on the District Website under Wellness program, available to reference.
or request this information from the Wellness Coordinator.
If you were hired between April 1, 2021 through August 31, 3. Once logged in, click on A Healthier You
2021, you will automatically have the additional $20 monthly from the “My Home” page.
premium waived from your 2022 medical plan premium. You
will still need to earn the 2,700 points through the BlueKC “A 4. First time users will be prompted to
Healthier You wellness program” by August 31, 2021 to complete the onboarding personalization
receive the $200 contribution to your Flexible Spending questions.
account or Health Savings account for the 2022 plan year.
Take the Health Risk Assessment Use points to enter and redeem
monthly sweepstakes drawings
Connect and manage your fitness device
for more points Complete activities to earn points
View your Personalized Health Action Get answers or search symptoms with
plan and screening results the Personal Health Assistant
18 KCKPS | 2021 Employee Benefits GuideMINDFUL BY BLUE KC
Mindful by Blue KC is a behavioral health initiative dedicated to
reducing stigma around behavioral health in our communities
while making care accessible and affordable for our members.
Mindful by Blue KC is a commitment to covering the health needs
of the whole person. It is a set of tools and resources available to
help members cope with stress, depression, anxiety, substance
abuse and more. This ensures that you are able to access and
afford the behavioral healthcare you or your family members
may need.
SERVICES INCLUDED:
Well-Being resources and Online Therapy
Text, chat, phone and video therapy to help with conditions such
as depression, anxiety or stress or major life events such as di-
vorce, adoption or loss (up to three sessions per member per is-
sue).
Online Self-Guided Tools
Resources to manage stress, improve mood and more
Expedited Access Network
Team support to find a behavioral health appointment in the ear-
liest window possible for a member in crisis
LEARN MORE
Virtual Care
With therapists trained and licensed in Virtual Care therapy tech- 833-302-MIND
niques
www.mindfulbluekc.com
Managed Behavioral Health
Helping members identify in-network providers that best fit their
needs by type and specialty
*Members will pay for services as outlined in their plan benefits. Normal cost-
sharing and out-of-pocket maximum limits will apply.
KCKPS | 2021 Employee Benefits Guide 19HEALTH SAVINGS ACCOUNT (HSA)
UNDERSTANDING A HEALTH Annually contribute up to $3,600 Single or
SAVINGS ACCOUNT (HSA) $7,200 Family
THERE ARE TWO WAYS YOU CAN PUT
MONEY INTO YOUR HSA:
Regular payroll deductions on a pre-tax WHAT ARE THE RULES?
basis, and You must be covered under a Qualified High Deductible
Health plan (QHDP) in order to establish an HSA.
Lump-sum contributions of any amount, You cannot establish an HSA if you or your spouse also
anytime, up to the maximum limit. have a medical FSA, unless it is a Limited Purpose FSA.
You cannot be enrolled in Medicare or TRICARE due to
WHAT IS AN HSA? age or disability.
You cannot set up an HSA if you have insurance
A savings account where you can either direct
coverage under another plan, for example your
pre-tax payroll deductions or deposit money to
spouse’s employer, unless that secondary coverage is
be used to pay for current or future qualified
also a qualified high deductible health plan.
medical expenses for you and/or your
dependents. Once money goes into the account, You cannot be claimed as a dependent under someone
it’s yours to keep — the HSA is owned by you, just else’s tax return.
like a personal checking or savings account. WHAT ELSE SHOULD I KNOW?
THE HSA CAN ALSO BE AN You can invest up to the IRS’s annual contribution
INVESTMENT OPPORTUNITY. limit. Contributions are based on a calendar year. The
contribution limits for 2021 are $3,600 for Single and
Depending upon your HSA account balance, your $7,200 for Family coverage. If you’re age 55 or older,
account can grow tax-free in an investment of you are allowed to make extra contributions each year.
your choice (like an interest-bearing savings
The contributions grow tax-free and come out tax-free
account, a money market account, a wide variety
as long as you utilize the funds for approved services
of mutual funds — or all three). Of course, your
based on the IRS Publication 502 (medical, dental,
funds are always available if you need them for
vision expenses and over-the-counter medications with
qualified health care expenses.
a physician’s prescription).
YOUR FUNDS CAN CARRY OVER Your unused contributions roll over from year to year
AND EVEN GROW OVER TIME. and can be taken with you if you leave your current
job.
The money always belongs to you, even if you
If you use the money for non-qualified expenses, then
leave the District, and unused funds carry over
the money becomes taxable and subject to a 20%
from year to year. You never have to worry about
excise tax penalty (like in an IRA account).
losing your money. That means if you don’t use a
lot of health care services now, your HSA funds There is no penalty for distributions following death,
will be there if you need them in the future — disability (as defined in IRC 72), or attainment of
even after retirement. Medicare eligibility age, but taxes would apply for non-
qualified distributions.
HSA FUNDS CAN BE USED FOR YOUR FAMILY. If your healthcare expenses are more than your HSA
balance, you need to pay the remaining cost another
You can use your HSA for your spouse and tax way, such as a credit card or personal check. But save
dependents for their eligible expenses — even if your receipts in case you are ever audited! You can
they’re not covered by your medical plan. request reimbursement later, after you have
accumulated more money in your account.
What Is A Health Savings Account?
20 KCKPS | 2021 Employee Benefits GuideHEALTH SAVINGS ACCOUNT (HSA)
YOU CAN USE HSA FUNDS FOR
IRS-APPROVED ITEMS SUCH AS: FREQUENTLY ASKED
Doctor's office visits QUESTIONS
Dental services
Eye exams, eyeglasses, laser surgery, contact lenses and solution
WHAT WILL I PAY AT
Hearing aids THE PHARMACY WITH
THE HSA QUALIFIED
Orthodontia, dental cleanings, and fillings PLAN OPTIONS?
Prescription drugs and some over-the-counter medications (with a
You will pay the actual
physician’s prescription) discounted cost of the drug
until you satisfy your calendar
Physical therapy, speech therapy, and chiropractic expenses
year deductible in full.
More information about approved items, plus additional details about the
HSA, is available at irs.gov.
WHAT WILL I PAY AT THE
Every time you use your HSA, save your receipt in case the IRS asks you to PHYSICIAN’S OFFICE WITH
prove your claim was for a qualified expense. If you use HSA funds for a THE HSA QUALIFIED PLAN?
non-qualified expense, you will pay tax and a penalty on those funds. You’ll provide your BlueKC ID card at
The HSA is your personal account and contains your personal funds. It can the time of the visit and the physician’s
office will submit the claim to
be considered an asset by a creditor and garnished as applicable.
BlueKC. You will not owe anything at
As an HSA account holder, you will be required to file a Form 8889 with the time of the visit. Later you’ll
receive an Explanation of Benefits
the IRS each year. This form identifies any contributions, distributions, or
(EOB) from BlueKC that shows the
earned interest associated with your account. charges discounted based on their
contract with the physician. When you
THIS MAY BE THE BEST PLAN OPTION FOR YOU IF ANY OF THE receive a bill from the physician’s
FOLLOWING IS TRUE: office, you pay the portion of the
discounted cost you are responsible
You do not incur a lot of medical and prescription medication for as shown on the EOB.
expenses.
You would like money in a savings account to pay for Qualified
Expenses permitted under Federal Law.
WHERE CAN I GET
You would like the opportunity to contribute pre-tax income to a A COPY OF AN EOB?
Health Savings Account.
You can access all of your
EOB information, as well as
CONTACT UMB BANK: obtain other important
information, by logging on to
www.hsa.umb.com
www.mybluekc.com
Phone: 866-520-4472
PLEASE NOTE: Accountholders will need their account number or card
number to set up online access for the first time, and from there they
will have a user ID and password to access their account.
KCKPS | 2021 Employee Benefits Guide 21FLEXIBLE SPENDING ACCOUNTS (FSA)
HEALTH CARE FLEXIBLE 2. SELECT YOUR
SPENDING ACCOUNT FSA ACCOUNTS
This account enables you to pay medical, dental, vision, and prescription
drug expenses that may or may not be covered under your insurance HEALTH CARE FLEXIBLE SPENDING
program (or your spouse’s) with pre-tax dollars. You can also pay for ACCOUNT
dependent health care expenses, even if you choose single (vs. family)
LIMITED FLEXIBLE SPENDING ACCOUNT
coverage. The total amount of your annual election is available to you up
front, reducing the chance of having a large out-of-pocket expense early DEPENDENT CARE EXPENSE ACCOUNT
in the plan year. Be aware—any unused portion of the account at the end
of the plan year is forfeited.
DEPENDENT CARE
LIMITED FLEXIBLE SPENDING ACCOUNT EXPENSE ACCOUNT
For those who enroll in the in one of the BlueSaver High Deductible
Health Plans and contribute to an HSA, IRS rules state you are not eligible This account gives you the opportunity to redirect a
to participate in the Health Care flexible spending account. You are, portion of your annual pay on a pre-tax basis to pay
however, eligible to participate in the Limited Flexible Account, allowing for dependent care expenses. An eligible dependent
you to pay for dental and vision care expenses, ONLY. All rules that apply is any member of your household for whom you can
to the traditional health care flexible spending account also apply to the claim expenses on your Federal Income Tax Form
Limited FSA, i.e. once you make your annual election your contributions 2441, “Credit for Child and Dependent Care
will remain unchanged unless you experience a qualifying event; you can Expenses.” Children must be under age 13. Care
file claims for any amount up to your total annual contribution at any centers which qualify include dependent care
time, even if you have not yet had the amount withheld from your pay
centers, preschool educational institutions, and
and any unused amounts at the end of the plan year are forfeited.
qualified individuals (as long as the caregiver is not a
How the Health Care Flexible Spending Account Works family member and reports income for tax
purposes). Before deciding to use the Dependent
When you have out-of-pocket expenses (such as copayments and
Care Expense Account, it would be wise to compare
deductibles), you can either use your FSA debit card to pay for these
expenses at qualified providers or submit an FSA claim form with your its tax benefit to that of claiming a child care tax
receipt to CBIZ Payroll. Reimbursement is issued to you through direct credit when filing your tax return. You may want to
deposit into your bank account, or if you prefer, a check can be issued to check with your tax advisor to determine which
you. method is best for you and your family. Any unused
portion of your account balance at the end of the
plan year is forfeited. Please note that this
2021 Maximum Contributions account cannot be used to pay for medical
expenses associated with your dependents.
Health Care Flexible Spending Account $2,750 max
CONTACT INFORMATION
Dependent Care Expense Account $5,000 max
You may request a full statement of your accounts at
any time by calling 800.815.3023 or logging on to
Click here for the full list of www.myplans.cbiz.com to review your FSA or
Healthcare FSA Eligible Expenses dependent care expense account balances. You can
also fax claims to CBIZ Payroll at 800.584.4185.
What Is A Flexible Spending Account?
At www.myplans.cbiz.com you can:
● View account information and activity
● File claims
DISTRICT FSA CONTRIBUTION: ● Manage your profile
● View notifications
You are eligible for a $200 contribution if you complete all requirements of
● Access forms
the Wellness Program by the deadline.
22 KCKPS | 2021 Employee Benefits Guide3. REVIEW YOUR
DENTAL INSURANCE DENTAL PLAN
GUARDIAN IS THE DENTAL CARRIER FOR 2021.
Both dental plan options are PPO plans the provide in and out-of-network coverage. If you choose to go out-of-network, you will
be responsible for any cost exceeding Guardian’s negotiated fees, plus any deductible and coinsurance associated with your procedure.
Dependent children are eligible until the end of the year in which they turn age 26.
PREDETERMINATION
A predetermination of benefits is simply a notification to you and your dentist as to whether the procedures recommended are within
the services covered by the Guardian contract. By obtaining a predetermination from Guardian prior to receiving dental services, you
have the security of knowing in advance the percentage Guardian will pay, how much you will be responsible for out of pocket and
whether the services recommended by your dentist fall within the benefit maximums and procedure limitations. Guardian suggests
having a predetermination for all services that exceed $300. You or your dental provider can submit the predetermination by sending
Guardian an itemized bill or a completed claim form with the following information:
Patient name
Member name or Group Number
ID #
Procedure codes
Teeth #
Fee
Dentist’s name and address
The predetermination can be submitted directly to the Guardian Dental Claims Department via email: cru@glic.com , fax: (509) 465-
3404.
MAXIMUM ROLLOVER
Guardian will roll over a portion of each member’s unused annual maximum benefit into your Maximum Rollover Account (MRA). The
MRA can be used in future years if a member reaches the plan’s annual maximum. To qualify, you must submit a claim and not exceed
the paid claims threshold during the benefit year. You and each of your dependents maintain separate MRAs based on your own claim
activity. Each member’s MRA may not exceed the MRA limit. If you have questions about this benefit or your Maximum Rollover Account,
please contact Guardian directly.
FIND A DENTIST
To find a Guardian provider in your area, visit the website at www.guardiananytime.com
Click on “Find a Provider”
Click on “Find a Dentist”
Enter your ZIP Code
Select the “PPO network”
Click “Submit” for a comprehensive directory of dentists
KCKPS | 2021 Employee Benefits Guide 23DENTAL INSURANCE
CONTINUED
DENTAL INSURANCE PLAN OPTIONS AND COSTS
Guardian Employee Cost Per Month
Employee $25.82 $34.22
Employee & Spouse $47.00 $62.32 In-network Providers: Provider is
Employee & Child(ren) $55.74 $74.06 reimbursed based on contracted fees and
Employee & Family $84.22 $112.08 cannot balance bill you.
Out-of-Network Providers: Provider is reimbursed
Low Plan High Plan
based on Reasonable and Customary standards and
PPO In- Out-of- PPO In- Out-of- balance billing is possible.
Network Network Network Network
Deductible
Individual / Family Applied to Type B & C Services
$50 / $150 $50 / $150 $0 $25 / $75
Annual Maximum $1,000 $1,000 $2,000 $1,000 Applied to Type A, B & C Services
Oral Examination – every six months
Teeth Cleaning – every six months
X-Rays – four bitewings every twelve months;
Preventive Periodontal Maintenance Procedure – every six months
Services 100% 100% 100% 90% Emergency Palliative Treatment
(not subject to deductible)
Fluoride Treatments – every six months (to age 19)
Space Maintainers for Children (under age 16)
Topical Sealants for un-restored molar teeth – one
treatment for children under age 16 in a three year
period
Fillings – amalgam & anterior composites
X-Rays – full mouth series every five years
Periodontal Services (other than Periodontal
Maintenance Procedure)
Endodontic Services/Root Canal Therapy
Basic 80% 80% 80% 60%
Diagnostic Consultation – one per year
Services Crowns – stainless steel
General Anesthesia – surgical procedures only
Injectable Antibiotics – for treatment of a dental
condition only
Laboratory Test
Repairs of dentures, bridgework, crowns, etc.
Oral Surgery
Crowns – resin, metal
Major 40% 40% 60% 40%
Bridges Installation – fixed and removable
Services Dentures – full and partial
Inlays, Onlays, Posts
TMJ – annual limit of $200
Not subject to annual maximum rollover
Orthodontic Services 40% 40% 50% 40% Children under age 19 for Low Plan
Adult + Child for High Plan
$1,000
Orthodontia Maximum Diagnostics and treatment
lifetime maximum
24 KCKPS | 2021 Employee Benefits Guide4. REVIEW YOUR
VISION INSURANCE VISION PLAN
SUPERIOR VISION IS THE VOLUNTARY
VISION CARRIER FOR 2021.
The vision plan offers coverage both in-network and out-of-network. It is to your advantage to utilize a
network provider in order to achieve the greatest cost savings. If you go out-of-network, your benefit is based on a
reimbursement schedule.
Also, if you are considering Lasik surgery, there is a discount available with some providers. To find a participating provider,
go to www.superiorvision.com. Dependent children are eligible until the end of the year in which they turn age 26.
VISION INSURANCE PLAN OPTIONS AND COSTS
Employee Cost Per Month
Employee $10.30
Employee & Spouse $20.40
Employee & Child(ren) $20.00
Employee & Family $30.40
In-Network Out-of-Network
Examination Copay Reimbursement
$15 copay Up to $26 (Optometrist)
Up to $34 (Ophthalmologist)
Frequency of Service
Exam Every 12 months Every 12 months
Lenses Every 12 months Every 12 months
Frames Every 12 months Every 12 months
Contact Lenses Every 12 months Every 12 months
Lenses Reimbursement
Single Covered in full Up to $29
Bifocal Covered in full Up to $43
Trifocal Covered in full Up to $53
Standard Progressive Lenses Up to $165 retail Up to $53
Polycarbonate Covered in full (up to age 19) Not Covered
Photochromic Single Focal Covered in full Not Covered
Tints Covered in full Not Covered
$25 copay; $150 allowance, Reimbursement
Frames
20% off balance at participating providers Up to $65
Contact Lenses Fitting
$15 copay Not Covered
(Standard and Specialty)
Reimbursement
Conventional Contacts
$0 copay; $150 allowance,
(allowance includes materials only)
20% off balance at participating providers Up to $100
Medically Necessary Contacts
Paid-in-full Up to $210
FIND A PROVIDER:
Visit the website at www.superiorvision.com
Under the Member Tab you can quickly find a provider by clicking on “Locate a Provider”
Enter your location information and select the “Insurance Through Your Employer” option
Pick the Superior National network and choose your desired distance
Click the “Find Providers” button
OR, you can call 800.507.3800 to speak with a Customer Service representative
KCKPS | 2021 Employee Benefits Guide 25You can also read
