2022 Employee Benefits

2022

Employee Benefits

Human Resources & Benefits Coordinators Carol Lewis 816-525-1480 x 402 clewis@sca-kc.org

Mary Thiel 816-525-1480 x 405 mthiel@sca-kc.org

Summit Christian Academy Employee Benefits Table of Contents Health Insurance (1/1 – 12/31)............................................................ 2 Life Insurance (1/1 – 12/31)............................................................... 17 Dental Insurance (Flexible Enrollment) ............................................. 20 Teladoc (Flexible Enrollment) ............................................................ 23 Flexible Spending Account (8/1 – 7/31) ............................................. 30 403 (b) Retirement Plan (Flexible Enrollment) .................................. 37

1

SUMMIT CHRISTIAN ACADEMY Medical Benefits Financial Analysis Effective Date: 1/1/2022

Carrier Name Name of Plan Type of Plan Annual Deductible Individual Family Coinsurance Annual Out of Pocket Individual Family Professional Services Physician/Specialist Routine Preventive Care Urgent Care In-Patient/Out-Patient Emergency Pharmacy Retail Copay

Employee Only Employee + Spouse Employee + Child (ren) Family

BLUE CROSS & BLUE SHIELD OF KC Fully Insured Spira Care $1,500 Preferred Care Blue (PCB PPO) BlueSelect Plus EPO

Spira Care $3,500 BlueSelect Plus EPO

$3,000 $6,000 80%

$1,500 $3,000 100%

$3,500 $7,000 100%

$5,000 $10,000

$1,500 $3,000

$3,500 $7,000

$40 Covered at 100% 40 Deductible + 20% $100 + 20% after Ded

$0 at Spira Care Facility Covered at 100% Deductible Deductible Deductible

$0 at Spira Care Facility Covered at 100% Deductible Deductible Deductible

$15/$70/$110 Employee Full Premium Share $631.85 $1,263.70 $1,200.52 $2,021.92

$211.95 $843.80 $780.62 $1,602.02

$15/$50/Deductible Employee Full Premium Share $623.85 $1,247.71 $1,185.32 $1,996.33

2

$203.95 $827.81 $765.42 $1,576.43

$15/$50/Deductible Employee Full Premium Share $559.87 $1,119.74 $1,063.75 $1,791.58

$139.97 $699.84 $643.85 $1,371.68

An Independent Licensee of the Blue Cross and Blue Shield Association

Health Benefit Plan Summary - PCB PPO $3000 (OOPM $5000) MO This Benefit Summary provides only highlights of the services covered by Blue Cross and Blue Shield of Kansas City (Blue KC). For Additional details, exclusions and limitations refer to your member certificate available at MyBlueKC.com.

General Plan Information Preferred Provider Organization (PPO)

Plan Type

Members can receive services from any hospital or physician, but receive greater benefits when using in-network providers.

In Area: Preferred-Care Blue Out-of-Area: BlueCard PPO/EPO

Medical Network(s) A complete listing of network hospitals and physicians is available on MyBlueKC.com.

Deductible – Embedded You must pay all the costs up to the Deductible amount before this plan begins to pay for covered services.

Coinsurance The amount the plan pays for covered services is based on the allowed amount. If an outof-network provider charges more than the allowed amount, you may have to pay the difference.

Out-of-Pocket Limits – Embedded The Out-of-Pocket Limit is the most you could pay during the Calendar Year for your share of the cost of covered services.

These cost shares apply to the Out-of-Pocket Limit: Coinsurance, Deductibles, Copays Applies to: All Medical and Rx Cost Sharing

In-Network Individual: $3,000 Family: $6,000

Out-of-Network Individual: $3,000 Family: $6,000

In-Network Member Pays: 20% Plan Pays: 80%

Out-of-Network Member Pays: 40% Plan Pays: 60%

In-Network Individual: $5,000 Family: $10,000

Out-of-Network Individual: $10,000 Family: $20,000

26

Dependent Limiting Age Customer Service

PH: 888-989-8842

Plan Benefits - Medical When you visit a health care provider’s office or clinic…

In-Network

Out-of-Network

Primary Care Physician (PCP) - An internist, family practitioner, general practitioner, or pediatrician.

$40 Copay/Visit, no Deductible

40% Coinsurance after Deductible

Specialist - Doctors of Medicine (MD), Doctors of Osteopathy (DO), except Primary Care Physicians, and other medical practitioners such as optometrists, psychologists and chiropractors.

$40 Copay/Visit, no Deductible

40% Coinsurance after Deductible

Other Services & Procedures performed in a provider's office and not included with an office visit

20% Coinsurance after Deductible

40% Coinsurance after Deductible

Physician

ID: 2932300854, Marketing Code: L21PB

3

Urgent Care Center

$40 Copay/Visit, no Deductible

40% Coinsurance after Deductible

Blue KC Virtual Care - Office Visit

$10 Copay/Visit, no Deductible

Not applicable

$10 Copay/Visit, no Deductible

Not applicable

No member cost share

40% Coinsurance after Deductible

No member cost share

40% Coinsurance after Deductible

20% Coinsurance after Deductible

40% Coinsurance after Deductible

Allergy Treatment When you need radiology services…

X-Ray

20% Coinsurance after Deductible

40% Coinsurance after Deductible

In-Network

Out-of-Network

20% Coinsurance after Deductible

40% Coinsurance after Deductible

Other Radiology Procedures (MRI, CT/PET Scans, MRA)

20% Coinsurance after Deductible

40% Coinsurance after Deductible

In-Network

Out-of-Network

20% Coinsurance after Deductible

40% Coinsurance after Deductible

20% Coinsurance after Deductible

40% Coinsurance after Deductible

In-Network

Out-of-Network

Urgent Care Center Office Visit

$40 Copay/Visit, no Deductible

40% Coinsurance after Deductible

Emergency Services

$100 Copay/Visit, then Deductible, then 20% Coinsurance

$100 Copay/Visit, then In-Network Deductible, then 20% Coinsurance

20% Coinsurance after Deductible

20% Coinsurance after In-Network Deductible

20% Coinsurance after Deductible

20% Coinsurance after In-Network Deductible

Virtual Care provided by Blue KC virtual care partner(s). All other virtual care services subject to applicable cost sharing.

Blue KC Virtual Care - Behavioral Health Therapy Virtual Care provided by Blue KC virtual care partner(s). All other virtual care services subject to applicable cost sharing.

Preventive Screenings & Immunizations (Children & Adults) Blue KC health plans include routine preventive benefits that are consistent with the guidelines developed by the United States Preventive Services Task Force (USPSTF), Health Resources and Services Administration (HRSA), and the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. Services must be billed with a primary diagnosis of preventive to be covered at 100%. Refer to your member certificate for additional details.

Labs Performed in a Provider’s Office/Independent Lab/Urgent Care Facility Allergy Allergy Testing

Prior Authorization Policy Applies

When you have out-patient surgery…

Outpatient Surgery Facility Fees Prior Authorization Policy Applies

Physician (Surgeon) Services If you need immediate medical attention…

Copay Waived if Admitted Out-of-Network benefits are subject to the plan's allowable charge. Out-of-Network providers may bill the member for the remaining balance. See Certificate for details.

Ground Ambulance Out-of-Network benefits are subject to the plan's allowable charge. Out-of-Network providers may bill the member for the remaining balance. See Certificate for details.

Air Ambulance If you have a hospital stay…

Hospital Facility Fees Prior Authorization Policy Applies

ID: 2932300854, Marketing Code: L21PB

4

In-Network

Out-of-Network

20% Coinsurance after Deductible

40% Coinsurance after Deductible

Physician (Surgeon) Services

20% Coinsurance after Deductible

40% Coinsurance after Deductible

In-Network

Out-of-Network

20% Coinsurance after Deductible

40% Coinsurance after Deductible

20% Coinsurance after Deductible

40% Coinsurance after Deductible

20% Coinsurance after Deductible

40% Coinsurance after Deductible

20% Coinsurance after Deductible

40% Coinsurance after Deductible

20% Coinsurance after Deductible

40% Coinsurance after Deductible

20% Coinsurance after Deductible

40% Coinsurance after Deductible

20% Coinsurance after Deductible

40% Coinsurance after Deductible

20% Coinsurance after Deductible

40% Coinsurance after Deductible

20% Coinsurance after Deductible

40% Coinsurance after Deductible

20% Coinsurance after Deductible

40% Coinsurance after Deductible

In-Network

Out-of-Network

Office Visit

$40 Copay/Visit, no Deductible

40% Coinsurance after Deductible

Therapy

20% Coinsurance after Deductible

40% Coinsurance after Deductible

20% Coinsurance after Deductible

40% Coinsurance after Deductible

20% Coinsurance after Deductible

40% Coinsurance after Deductible

In-Network

Out-of-Network

No member cost share

40% Coinsurance after Deductible

No member cost share

40% Coinsurance after Deductible

If you need help recovering or have other special health needs…

Skilled Nursing Care Prior Authorization Policy Applies Maximum benefit of 30 Day(s)/Calendar Year for In-Network and Out-of-Network

Home Health Services Prior Authorization Policy Applies Maximum benefit of 60 Visit(s)/Calendar Year for In-Network and Out-of-Network

Physical Therapy Maximum benefit of 60 Visit(s)/Calendar Year for In-Network and Out-of-Network

Occupational Therapy Combined with Physical Therapy Limits

Skeletal Manipulation performed in a Chiropractic Office Prior Authorization Policy Applies Out-of-Network

Speech Therapy Maximum benefit of 20 Visit(s)/Calendar Year for In-Network and Out-of-Network

Hearing Therapy Combined with Speech Therapy Limits

Durable Medical Equipment Prior Authorization Policy Applies

Inpatient Hospice Services Prior Authorization Policy Applies Maximum benefit of 14 Day(s)/Lifetime for In-Network and Out-of-Network

Home Hospice Services If you have behavioral health, or substance abuse needs…

Outpatient Mental Health, Behavioral Health, and Substance Abuse Services

Inpatient Mental Health, Behavioral Health, and Substance Abuse Services (Facility Fees) Prior Authorization Policy Applies

Inpatient Mental Health, Behavioral Health, and Substance Abuse Services (Physician) Includes: Therapy & Other Services, partial hospitalizations

Family Planning & Pregnancy…

Contraceptive Devices, Implants, and Injections See also pharmacy benefits.

Elective Sterilization – Women ID: 2932300854, Marketing Code: L21PB

5

Elective Sterilization – Men

No member cost share

40% Coinsurance after Deductible

Maternity

Covered

Covered

Not covered

Not covered

Dependent Daughters are not covered for maternity services

Infertility and Impotency Diagnosis and Treatment Pharmacy Coverage: See Member Certificate for more details.

Routine Vision Care…

Routine Eye Exam

In-Network

Out-of-Network

$20 Copay/Visit, no Deductible

$20 Copay/Visit, no Deductible Limited to $45 Benefit Max per Calendar Year.

Maximum benefit of 1 Exam(s)/Calendar Year for In-Network and Out-of-Network Provided by Vision Service Plan (VSP)

General Pharmacy Information Retail Pharmacy Network(s)

RxPremier

Prescription Drug List

Blue KC Preferred Formulary

Learn more about the drugs covered by your plan, drug category/tier, prior authorization and step therapy by reviewing your prescription drug list at MyBlueKC.com

Specialty Pharmacy A Specialty Pharmacy is one that provides specialized care for patients with complex chronic health conditions. Learn more about the drugs covered by your plan, drug category/ tier, prior authorization and step therapy by reviewing your prescription drug list at MyBlueKC.com

Outpatient Prescription Drug Out-of-Pocket Limits The Out-of-Pocket Limit is the most you could pay during the Calendar Year for your share of the cost of covered services.

Rx Savings Solutions

OptumRx Specialty Services PH: 855-427-4682

In-Network

Out-of-Network

Combined with Medical Out-of-Pocket Limits

Combined with Medical Out-of-Pocket Limits

Register online at MyBlueKC.com and stay up-to-date on cost saving opportunities.

Email: info@rxsavingsllc.com PH: 1-800-268-4476

A team of pharmacists and pharmacy technician will help you make sure you’re getting the best possible pricing for your medicines. Member support is available Monday – Friday, 7 a.m. to 7 p.m. CST.

Plan Benefits – Pharmacy When you use a retail or specialty pharmacy...

In-Network

Out-of-Network

Drug Tier 1: Generic / Generic Specialty

RxPremier: $15 Copay/Fill Contraceptives – No member cost share

$15 Copay/Fill, then 50% Coinsurance

Drug Tier 2: Preferred Brand / Non-Preferred Generic

RxPremier: $70 Copay/Fill

$70 Copay/Fill, then 50% Coinsurance

Drug Tier 3: Non-Preferred Brand / Preferred Brand Specialty

RxPremier: $110 Copay/Fill

$110 Copay/Fill, then 50% Coinsurance

Drug Tier 4: Non-Preferred Brand Specialty

RxPremier: $200 Copay/Fill

$200 Copay/Fill, then 50% Coinsurance

When you use a mail order pharmacy…

In-Network

Out-of-Network

Drug Tier 1: Generic

$37.50 Copay/Fill Contraceptives – No member cost share

$37.50 Copay/Fill, then 50% Coinsurance

Drug Tier 2: Preferred Brand / Non-Preferred Generic

$175 Copay/Fill

$175 Copay/Fill, then 50% Coinsurance

Retail Pharmacy (Short-term supply: Up to 34 Days)

Mail Order Pharmacy (Mail Order supply: Between 35-102 Days)

ID: 2932300854, Marketing Code: L21PB

6

An Independent Licensee of the Blue Cross and Blue Shield Association

Health Benefit Plan Summary - BlueSelect Plus Spira Care EPO $1,500 MO This Benefit Summary provides only highlights of the services covered by Blue Cross and Blue Shield of Kansas City (Blue KC). For Additional details, exclusions and limitations refer to your member certificate available at MyBlueKC.com.

General Plan Information Exclusive Provider Organization (EPO)

Plan Type

Members receive all care from in-network providers except for emergency services. Nonemergency services received out-of-network will not be covered.

In Area: BlueSelect Plus Out-of-Area: BlueCard PPO/EPO

Medical Network(s) A complete listing of network hospitals and physicians is available on MyBlueKC.com.

Deductible – Embedded You must pay all the costs up to the Deductible amount before this plan begins to pay for covered services.

Coinsurance Applies only as specified in your contract. Coinsurance is noted in this summary where applicable.

Out-of-Pocket Limits – Embedded The Out-of-Pocket Limit is the most you could pay during the Calendar Year for your share of the cost of covered services.

These cost shares apply to the Out-of-Pocket Limit: Coinsurance, Deductibles, Copays Applies to: All Medical and Rx Cost Sharing

In-Network Individual: $1,500 Family: $3,000

Out-of-Network Not covered

In-Network Member Pays: 0% Plan Pays: 100%

Out-of-Network Not covered

In-Network Individual: $1,500 Family: $3,000

Out-of-Network Not covered

26

Dependent Limiting Age Customer Service & Care Guide Services

Local: 913-29-SPIRA (77472) Toll Free: 877-33-SPIRA (77472)

Plan Benefits - Medical When you visit a Spira Care Center…

ID: 0419540625, Marketing Code: L25PP

In-Network

7

Out-of-Network

Visits to a Spira Care Center include: • Office Visit – Routine • Office Visit – Urgent/Acute • Chronic Disease Care (excluding drugs & equipment) • Outpatient Mental Health, Behavioral Health, and Substance Abuse Services

No member cost share

Not covered

No member cost share

Not covered

Included as part of office visit and no member cost share: • Labs • X-ray (basic diagnostic x-rays for fracture and other injuries or illness) Workers’ Comp Your health coverage through any of the Blue Cross and Blue Shield of Kansas City plans, including Spira Care and Spira Care (HSA Eligible), cannot be used for an onthe-job or work-related injury or illness. However, members may have access to workers’ compensation insurance paid for by their employers which may provide monetary benefits and/or medical care coverage for a work related injury or illness.

Please speak with your human resources representative for more information.

Preventive Screenings & Immunizations (Children & Adults) Blue KC health plans include routine preventive benefits that are consistent with the guidelines developed by the United States Preventive Services Task Force (USPSTF), Health Resources and Services Administration (HRSA), and the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. Services must be billed with a primary diagnosis of preventive to be covered at 100%. Refer to your member certificate for additional details.

When you visit another Physician’s Office…

In-Network

Out-of-Network

Primary Care Physician (PCP) - An internist, family practitioner, general practitioner, or pediatrician.

Deductible, then no charge

Not covered

Specialist - Doctors of Medicine (MD), Doctors of Osteopathy (DO), except Primary Care Physicians, and other medical practitioners such as optometrists, psychologists and chiropractors.

Deductible, then no charge

Not covered

Other Services & Procedures performed in a provider's office and not included with an office visit

Deductible, then no charge

Not covered

Urgent Care Center

Deductible, then no charge

Not covered

Blue KC Virtual Care - Office Visit

No member cost share

Not applicable

No member cost share

Not applicable

No member cost share

Not covered

Deductible, then no charge

Not covered

Physician

Virtual Care provided by Blue KC virtual care partner(s). All other virtual care services subject to applicable cost sharing.

Blue KC Virtual Care - Behavioral Health Therapy Virtual Care provided by Blue KC virtual care partner(s). All other virtual care services subject to applicable cost sharing.

Preventive Screenings & Immunizations (Children & Adults) Blue KC health plans include routine preventive benefits that are consistent with the guidelines developed by the United States Preventive Services Task Force (USPSTF), Health Resources and Services Administration (HRSA), and the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. Services must be billed with a primary diagnosis of preventive to be covered at 100%. Refer to your member certificate for additional details.

Labs Performed in a Provider’s Office/Independent Lab/Urgent Care Facility ID: 0419540625, Marketing Code: L25PP

8

Allergy Deductible, then no charge

Not covered

Allergy Treatment When you need radiology services…

X-Ray

Deductible, then no charge

Not covered

In-Network

Out-of-Network

Deductible, then no charge

Not covered

Other Radiology Procedures (MRI, CT/PET Scans, MRA)

Deductible, then no charge

Not covered

In-Network

Out-of-Network

Deductible, then no charge

Not covered

Deductible, then no charge

Not covered

In-Network

Out-of-Network

Urgent Care Center Office Visit

Deductible, then no charge

Not covered

Emergency Services

Deductible, then no charge

In-Network Deductible, then no charge

Deductible, then no charge

In-Network Deductible, then no charge

Deductible, then no charge

In-Network Deductible, then no charge

In-Network

Out-of-Network

Deductible, then no charge

Not covered

Deductible, then no charge

Not covered

In-Network

Out-of-Network

Deductible, then no charge

Not covered

Deductible, then no charge

Not covered

Deductible, then no charge

Not covered

Deductible, then no charge

Not covered

Skeletal Manipulation performed in a Chiropractic Office

Deductible, then no charge

Not covered

Speech Therapy

Deductible, then no charge

Not covered

Allergy Testing

Prior Authorization Policy Applies In-Network

When you have out-patient surgery…

Outpatient Surgery Facility Fees Prior Authorization Policy Applies In-Network

Physician (Surgeon) Services If you need immediate medical attention…

Out-of-Network benefits are subject to the plan's allowable charge. Out-of-Network providers may bill the member for the remaining balance. See Certificate for details.

Ground Ambulance Out-of-Network benefits are subject to the plan's allowable charge. Out-of-Network providers may bill the member for the remaining balance. See Certificate for details.

Air Ambulance If you have a hospital stay…

Hospital Facility Fees Prior Authorization Policy Applies In-Network

Physician (Surgeon) Services If you need help recovering or have other special health needs…

Skilled Nursing Care Prior Authorization Policy Applies In-Network Maximum benefit of 30 Day(s)/Calendar Year for In-Network

Home Health Services Prior Authorization Policy Applies In-Network Maximum benefit of 60 Visit(s)/Calendar Year for In-Network

Physical Therapy Maximum benefit of 60 Visit(s)/Calendar Year for In-Network

Occupational Therapy Combined with Physical Therapy Limits

Maximum benefit of 20 Visit(s)/Calendar Year for In-Network ID: 0419540625, Marketing Code: L25PP

9

Hearing Therapy

Deductible, then no charge

Not covered

Deductible, then no charge

Not covered

Deductible, then no charge

Not covered

Deductible, then no charge

Not covered

In-Network

Out-of-Network

Office Visit

Deductible, then no charge

Not covered

Therapy

Deductible, then no charge

Not covered

Deductible, then no charge

Not covered

Deductible, then no charge

Not covered

In-Network

Out-of-Network

No member cost share

Not covered

Elective Sterilization – Women

No member cost share

Not covered

Elective Sterilization – Men

No member cost share

Not covered

Maternity

Covered

Not covered

Not covered

Not covered

Combined with Speech Therapy Limits

Durable Medical Equipment Prior Authorization Policy Applies In-Network

Inpatient Hospice Services Prior Authorization Policy Applies In-Network Maximum benefit of 14 Day(s)/Lifetime for In-Network

Home Hospice Services If you have behavioral health, or substance abuse needs…

Outpatient Mental Health, Behavioral Health, and Substance Abuse Services

Inpatient Mental Health, Behavioral Health, and Substance Abuse Services (Facility Fees) Prior Authorization Policy Applies In-Network

Inpatient Mental Health, Behavioral Health, and Substance Abuse Services (Physician) Includes: Therapy & Other Services, partial hospitalizations

Family Planning & Pregnancy…

Contraceptive Devices, Implants, and Injections See also pharmacy benefits.

Dependent Daughters are not covered for maternity services

Infertility and Impotency Diagnosis and Treatment Pharmacy Coverage: See Member Certificate for more details.

Routine Vision Care…

Routine Eye Exam

In-Network

Out-of-Network

Not covered

Not covered

General Pharmacy Information Retail Pharmacy Network(s)

RxPremier

Prescription Drug List

Blue KC Preferred Formulary

Learn more about the drugs covered by your plan, drug category/tier, prior authorization and step therapy by reviewing your prescription drug list at MyBlueKC.com

ID: 0419540625, Marketing Code: L25PP

10

Specialty Pharmacy A Specialty Pharmacy is one that provides specialized care for patients with complex chronic health conditions. Learn more about the drugs covered by your plan, drug category/ tier, prior authorization and step therapy by reviewing your prescription drug list at MyBlueKC.com

Outpatient Prescription Drug Deductible You must pay all the costs up to the Deductible amount before this plan begins to pay for covered services.

Outpatient Prescription Drug Out-of-Pocket Limits The Out-of-Pocket Limit is the most you could pay during the Calendar Year for your share of the cost of covered services.

Rx Savings Solutions

OptumRx Specialty Services PH: 855-427-4682

In-Network

Out-of-Network

Combined with Medical Deductible

Not covered

In-Network

Out-of-Network

Combined with Medical Out-of-Pocket Limits

Not covered

Register online at MyBlueKC.com and stay up-to-date on cost saving opportunities.

Email: info@rxsavingsllc.com PH: 1-800-268-4476

A team of pharmacists and pharmacy technician will help you make sure you’re getting the best possible pricing for your medicines. Member support is available Monday – Friday, 7 a.m. to 7 p.m. CST.

Plan Benefits – Pharmacy When you use a retail or specialty pharmacy...

In-Network

Out-of-Network

Drug Tier 1: Generic / Generic Specialty

RxPremier: $15 Copay/Fill, no Deductible Contraceptives – No member cost share

Not covered

Drug Tier 2: Preferred Brand / Non-Preferred Generic / Preferred Brand Specialty

RxPremier: $50 Copay/Fill, no Deductible

Not covered

Drug Tier 3: Non-Preferred Brand / Non-Preferred Brand Specialty

RxPremier: Deductible, then no charge

Not covered

When you use a mail order pharmacy…

In-Network

Out-of-Network

Drug Tier 1: Generic

$15 Copay/Fill, no Deductible Contraceptives – No member cost share

Not covered

Drug Tier 2: Preferred Brand / Non-Preferred Generic

$125 Copay/Fill, no Deductible

Not covered

Drug Tier 3: Non-Preferred Brand

Deductible, then no charge

Not covered

Retail Pharmacy (Short-term supply: Up to 34 Days)

Mail Order Pharmacy (Mail Order supply: Between 35-102 Days)

ID: 0419540625, Marketing Code: L25PP

11

An Independent Licensee of the Blue Cross and Blue Shield Association

Health Benefit Plan Summary - BlueSelect Plus Spira Care EPO $3,500 MO This Benefit Summary provides only highlights of the services covered by Blue Cross and Blue Shield of Kansas City (Blue KC). For Additional details, exclusions and limitations refer to your member certificate available at MyBlueKC.com.

General Plan Information Exclusive Provider Organization (EPO)

Plan Type

Members receive all care from in-network providers except for emergency services. Nonemergency services received out-of-network will not be covered.

In Area: BlueSelect Plus Out-of-Area: BlueCard PPO/EPO

Medical Network(s) A complete listing of network hospitals and physicians is available on MyBlueKC.com.

Deductible – Embedded You must pay all the costs up to the Deductible amount before this plan begins to pay for covered services.

Coinsurance Applies only as specified in your contract. Coinsurance is noted in this summary where applicable.

Out-of-Pocket Limits – Embedded The Out-of-Pocket Limit is the most you could pay during the Calendar Year for your share of the cost of covered services.

These cost shares apply to the Out-of-Pocket Limit: Coinsurance, Deductibles, Copays Applies to: All Medical and Rx Cost Sharing

In-Network Individual: $3,500 Family: $7,000

Out-of-Network Not covered

In-Network Member Pays: 0% Plan Pays: 100%

Out-of-Network Not covered

In-Network Individual: $3,500 Family: $7,000

Out-of-Network Not covered

26

Dependent Limiting Age Customer Service & Care Guide Services

Local: 913-29-SPIRA (77472) Toll Free: 877-33-SPIRA (77472)

Plan Benefits - Medical When you visit a Spira Care Center…

ID: 0402540415, Marketing Code: L26PP

In-Network

12

Out-of-Network

Visits to a Spira Care Center include: • Office Visit – Routine • Office Visit – Urgent/Acute • Chronic Disease Care (excluding drugs & equipment) • Outpatient Mental Health, Behavioral Health, and Substance Abuse Services

No member cost share

Not covered

No member cost share

Not covered

Included as part of office visit and no member cost share: • Labs • X-ray (basic diagnostic x-rays for fracture and other injuries or illness) Workers’ Comp Your health coverage through any of the Blue Cross and Blue Shield of Kansas City plans, including Spira Care and Spira Care (HSA Eligible), cannot be used for an onthe-job or work-related injury or illness. However, members may have access to workers’ compensation insurance paid for by their employers which may provide monetary benefits and/or medical care coverage for a work related injury or illness.

Please speak with your human resources representative for more information.

Preventive Screenings & Immunizations (Children & Adults) Blue KC health plans include routine preventive benefits that are consistent with the guidelines developed by the United States Preventive Services Task Force (USPSTF), Health Resources and Services Administration (HRSA), and the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. Services must be billed with a primary diagnosis of preventive to be covered at 100%. Refer to your member certificate for additional details.

When you visit another Physician’s Office…

In-Network

Out-of-Network

Primary Care Physician (PCP) - An internist, family practitioner, general practitioner, or pediatrician.

Deductible, then no charge

Not covered

Specialist - Doctors of Medicine (MD), Doctors of Osteopathy (DO), except Primary Care Physicians, and other medical practitioners such as optometrists, psychologists and chiropractors.

Deductible, then no charge

Not covered

Other Services & Procedures performed in a provider's office and not included with an office visit

Deductible, then no charge

Not covered

Urgent Care Center

Deductible, then no charge

Not covered

Blue KC Virtual Care - Office Visit

No member cost share

Not applicable

No member cost share

Not applicable

No member cost share

Not covered

Deductible, then no charge

Not covered

Physician

Virtual Care provided by Blue KC virtual care partner(s). All other virtual care services subject to applicable cost sharing.

Blue KC Virtual Care - Behavioral Health Therapy Virtual Care provided by Blue KC virtual care partner(s). All other virtual care services subject to applicable cost sharing.

Preventive Screenings & Immunizations (Children & Adults) Blue KC health plans include routine preventive benefits that are consistent with the guidelines developed by the United States Preventive Services Task Force (USPSTF), Health Resources and Services Administration (HRSA), and the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. Services must be billed with a primary diagnosis of preventive to be covered at 100%. Refer to your member certificate for additional details.

Labs Performed in a Provider’s Office/Independent Lab/Urgent Care Facility ID: 0402540415, Marketing Code: L26PP

13

Allergy Deductible, then no charge

Not covered

Allergy Treatment When you need radiology services…

X-Ray

Deductible, then no charge

Not covered

In-Network

Out-of-Network

Deductible, then no charge

Not covered

Other Radiology Procedures (MRI, CT/PET Scans, MRA)

Deductible, then no charge

Not covered

In-Network

Out-of-Network

Deductible, then no charge

Not covered

Deductible, then no charge

Not covered

In-Network

Out-of-Network

Urgent Care Center Office Visit

Deductible, then no charge

Not covered

Emergency Services

Deductible, then no charge

In-Network Deductible, then no charge

Deductible, then no charge

In-Network Deductible, then no charge

Deductible, then no charge

In-Network Deductible, then no charge

In-Network

Out-of-Network

Deductible, then no charge

Not covered

Deductible, then no charge

Not covered

In-Network

Out-of-Network

Deductible, then no charge

Not covered

Deductible, then no charge

Not covered

Deductible, then no charge

Not covered

Deductible, then no charge

Not covered

Skeletal Manipulation performed in a Chiropractic Office

Deductible, then no charge

Not covered

Speech Therapy

Deductible, then no charge

Not covered

Allergy Testing

Prior Authorization Policy Applies In-Network

When you have out-patient surgery…

Outpatient Surgery Facility Fees Prior Authorization Policy Applies In-Network

Physician (Surgeon) Services If you need immediate medical attention…

Out-of-Network benefits are subject to the plan's allowable charge. Out-of-Network providers may bill the member for the remaining balance. See Certificate for details.

Ground Ambulance Out-of-Network benefits are subject to the plan's allowable charge. Out-of-Network providers may bill the member for the remaining balance. See Certificate for details.

Air Ambulance If you have a hospital stay…

Hospital Facility Fees Prior Authorization Policy Applies In-Network

Physician (Surgeon) Services If you need help recovering or have other special health needs…

Skilled Nursing Care Prior Authorization Policy Applies In-Network Maximum benefit of 30 Day(s)/Calendar Year for In-Network

Home Health Services Prior Authorization Policy Applies In-Network Maximum benefit of 60 Visit(s)/Calendar Year for In-Network

Physical Therapy Maximum benefit of 60 Visit(s)/Calendar Year for In-Network

Occupational Therapy Combined with Physical Therapy Limits

Maximum benefit of 20 Visit(s)/Calendar Year for In-Network ID: 0402540415, Marketing Code: L26PP

14

Hearing Therapy

Deductible, then no charge

Not covered

Deductible, then no charge

Not covered

Deductible, then no charge

Not covered

Deductible, then no charge

Not covered

In-Network

Out-of-Network

Office Visit

Deductible, then no charge

Not covered

Therapy

Deductible, then no charge

Not covered

Deductible, then no charge

Not covered

Deductible, then no charge

Not covered

In-Network

Out-of-Network

No member cost share

Not covered

Elective Sterilization – Women

No member cost share

Not covered

Elective Sterilization – Men

No member cost share

Not covered

Maternity

Covered

Not covered

Not covered

Not covered

Combined with Speech Therapy Limits

Durable Medical Equipment Prior Authorization Policy Applies In-Network

Inpatient Hospice Services Prior Authorization Policy Applies In-Network Maximum benefit of 14 Day(s)/Lifetime for In-Network

Home Hospice Services If you have behavioral health, or substance abuse needs…

Outpatient Mental Health, Behavioral Health, and Substance Abuse Services

Inpatient Mental Health, Behavioral Health, and Substance Abuse Services (Facility Fees) Prior Authorization Policy Applies In-Network

Inpatient Mental Health, Behavioral Health, and Substance Abuse Services (Physician) Includes: Therapy & Other Services, partial hospitalizations

Family Planning & Pregnancy…

Contraceptive Devices, Implants, and Injections See also pharmacy benefits.

Dependent Daughters are not covered for maternity services

Infertility and Impotency Diagnosis and Treatment Pharmacy Coverage: See Member Certificate for more details.

Routine Vision Care…

Routine Eye Exam

In-Network

Out-of-Network

Not covered

Not covered

General Pharmacy Information Retail Pharmacy Network(s)

RxPremier

Prescription Drug List

Blue KC Preferred Formulary

Learn more about the drugs covered by your plan, drug category/tier, prior authorization and step therapy by reviewing your prescription drug list at MyBlueKC.com

ID: 0402540415, Marketing Code: L26PP

15

Specialty Pharmacy A Specialty Pharmacy is one that provides specialized care for patients with complex chronic health conditions. Learn more about the drugs covered by your plan, drug category/ tier, prior authorization and step therapy by reviewing your prescription drug list at MyBlueKC.com

Outpatient Prescription Drug Deductible You must pay all the costs up to the Deductible amount before this plan begins to pay for covered services.

Outpatient Prescription Drug Out-of-Pocket Limits The Out-of-Pocket Limit is the most you could pay during the Calendar Year for your share of the cost of covered services.

Rx Savings Solutions

OptumRx Specialty Services PH: 855-427-4682

In-Network

Out-of-Network

Combined with Medical Deductible

Not covered

In-Network

Out-of-Network

Combined with Medical Out-of-Pocket Limits

Not covered

Register online at MyBlueKC.com and stay up-to-date on cost saving opportunities.

Email: info@rxsavingsllc.com PH: 1-800-268-4476

A team of pharmacists and pharmacy technician will help you make sure you’re getting the best possible pricing for your medicines. Member support is available Monday – Friday, 7 a.m. to 7 p.m. CST.

Plan Benefits – Pharmacy When you use a retail or specialty pharmacy...

In-Network

Out-of-Network

Drug Tier 1: Generic / Generic Specialty

RxPremier: $15 Copay/Fill, no Deductible Contraceptives – No member cost share

Not covered

Drug Tier 2: Preferred Brand / Non-Preferred Generic / Preferred Brand Specialty

RxPremier: $50 Copay/Fill, no Deductible

Not covered

Drug Tier 3: Non-Preferred Brand / Non-Preferred Brand Specialty

RxPremier: Deductible, then no charge

Not covered

When you use a mail order pharmacy…

In-Network

Out-of-Network

Drug Tier 1: Generic

$15 Copay/Fill, no Deductible Contraceptives – No member cost share

Not covered

Drug Tier 2: Preferred Brand / Non-Preferred Generic

$125 Copay/Fill, no Deductible

Not covered

Drug Tier 3: Non-Preferred Brand

Deductible, then no charge

Not covered

Retail Pharmacy (Short-term supply: Up to 34 Days)

Mail Order Pharmacy (Mail Order supply: Between 35-102 Days)

ID: 0402540415, Marketing Code: L26PP

16

17

18

19

DENTAL SOURCE DHMO Instructions in using the Provider Search Engine

1. Open your default internet browser – In the address bar, type in the address http://www.fcldental.com 2. Click on Find a Dentist 3. Searching for Providers – Please follow the directions below: a. In order to get a result in your search Select a “Network” Dental Source-DHMO that you are on from the drop down. b. Type in a “Zip Code” that you would like to find providers in. c. Select a “Radius” of 5 to 300 miles from the designated “Zip Code” you typed in.

The default is 5 miles. d. You can change how many providers you would like to be shown in your list by changing the “Display” between 10 and 50, the default is 10. e. Click on “Search” and your results will display. You can narrow your search down too, if you know your providers “Last name”, type that in for a more precise search.

If you would prefer to have assistance choosing a provider, you may call our Member Services (Customer Service) Department between the hours of 8 AM and 5 PM Monday through Friday.

To request help selecting a DHMO provider, please call 866-481-9473 and select the Member Services prompt.

20

21

22

Unlimited No Copay Model Health care made simple.

Timely access + Lower costs + Quality care Teladoc® was founded in 2002 with the vision of tackling the three biggest issues in health care.

Health care is in need of solutions.

Teladoc answers the call.

COVERAGE EXPANSION. National health care coverage is expected to increase from 86% to 94% adding approximately 30M more members into the system.+

24/7/365 ACCESS TO HEALTH CARE. Teladoc has the largest physician network in telehealth with a one-hour guaranteed response from a physician for phone consultations.

RISING CLAIMS COSTS. 45% of emergency room visits are considered to be non-emergent or non-urgent.++

SAVE TIME, SAVE MONEY. Teladoc is a lower-cost alternative to $131 doctor visits, $163 urgent care visits and $1,477 ER visits.

QUALITY OF CARE. Employers want to increase the access they provide to their members but not at the expense of quality.

EXPERIENCED PHYSICIANS. Teladoc physicians are U.S. board-certified, average 15 years of practice experience, and are credentialed every three years (meeting NCQA standards).

+ ++

New York Times, “Health Care Reform”, 17 October 2011 National Hospital Ambulatory Care Survey published by the CDC 2008

23

+

Teladoc reporting

Teladoc Overview

Founded in 2002, Teladoc is the first and largest provider of telehealth medical consultations in the U.S., allowing members 24/7/365 access to affordable healthcare via phone and video consults.

Today’s healthcare issues

Consumer Directed Health Plans (CDHPs)6

With the passage of the Patient Protection and Affordable Care Act (PPACA), organizations and individuals will face even greater challenges and costs as part of health coverage.

• 13% of all covered employees are enrolled in a CDHP (five years ago, CDHPs enrolled just 3% of covered employees).

National shortage of PCP’s1 • 78% of physicians believe there is a nationwide shortage of PCPs. • 49% of physicians state they will reduce their number of patients or stop practicing entirely.

Coverage expansion2 • National healthcare coverage is expected to increase from 86% to 94% resulting in approximately 30M more covered patients flooding into the healthcare system.

Medical cost3 • There is an increasing trend of emergency room over-utilization due to access to care barriers.

• Healthcare costs are expected to increase in 2012 well above inflation rate.

Misuse of the ER • 85% of Americans who went to the ER said they couldn’t wait to see their regular medical provider.4 • 79.7% of adults who visited the ER and were not admitted did so due to the lack of access to other providers.5

2009

2010

2011

2012

2013

208,000

456,000

794,000

1.7 MILLION

4.5 MILLION

All material proprietary and confidential

• The appeal of these plans to employers is clear. The cost of coverage in a CDHP with a health savings account is nearly 20% lower, on average, than the cost of PPO coverage – $7,787 per employee compared to $9,385.

As healthcare costs continue to rise, organizations are looking for smart, effective ways to reduce their benefit-related costs. As a result, there has been an increased focus on technology to connect patients to different modes of care, including telephone consultations and virtual encounters.

“The strategy that seems poised to become mainstream the most quickly is telemedicine generally, phone or web-based physician consultations.”

Mercer National Survey of Employer-Sponsored Health Plans, 2011

Teladoc offers a solution Teladoc provides a value-added benefit that reduces healthcare costs and gives members 24/7/365 access to U.S. board-certified physicians through phone and video consultations, as opposed to more expensive and less productive settings like an urgent care center or emergency department (ED).

Teladoc is not designed to replace the primary care physician (PCP). It simply allows members to resolve their non-emergency medical issues at a fraction of the time and cost when their PCP is unavailable.

Telehealth has become an attractive option for healthcare, as seen in Teladoc’s membership.

24

Today 7.5 MILLION

What is Teladoc?

Simple. Teladoc provides members access to U.S. board-certified physicians who can resolve many medical issues via phone or online video consultations, 24/7/365, from wherever they are.

How it works

Step 1

Step 4

Medical Record

Resolve the Issue

The member completes their medical history when they set up their account.

The physician recommends the right treatment for the member. If a prescription is necessary, it is sent to the member’s pharmacy of choice.

Step 2

Contact Teladoc The member logs into their account or calls Teladoc, 24/7/365, to request a phone or video consultation. The Benefit Intelligence Unlimited Program has NO CO-PAY.

Step 5

Continuity of Care The physician documents the results of the consultation in the member’s medical history. With the member’s consent, this information is sent to their primary care physician.

Step 3

Talk with a Physician

Step 6

Complete Consultation A U.S. board-certified physician licensed in their state reviews their medical history and provides a consultation over the phone or through video, just like an in-person visit.

+

At the end of every call, the physician checks to make sure all questions are answered. A secure Message Center enables our physicians to send additional information to patient and the patient can ask follow up questions for up to 72 hours.

Teladoc member survey

25

What can Teladoc be used for?

Teladoc is a convenient alternative to urgent care or ER visits. U.S. board-certified physicians and pediatricians are available anytime, anywhere, and can resolve many medical issues.

Conditions treated

•

Sore throat & stuffy nose Sinus problems

•

Bronchitis

•

Allergies

•

Cold & flu symptoms

•

Urinary tract infection

•

Respiratory infection

•

Pink eye

•

Ear infection

•

Pediatric care

•

Dermatology

•

Behavioral health

•

And more!

•

Short-term Prescriptions Teladoc physicians can prescribe medication for a wide range of conditions, when necessary.* * Teladoc physicians do not prescribe substances controlled by the DEA, non-therapeutic, and/or certain other drugs which may be harmful because of their potential for abuse.

When it can be used

After normal office hours

Non-emergency medical assistance

On vacation or a business trip

Lab results

When a doctor is not available

Pediatric care for any age

Refill of recurring prescription (short term only)

Explanation or second opinion

26

Happy members or lower costs?

Why not both? Members love Teladoc because it saves them money and time otherwise spent on urgent care or ER visits. But it also significantly lowers costs and improves access to care.

For members: Access to affordable health care

For employers: Lower costs

Teladoc members enjoy the convenience of 24/7/365 access to U.S. board-certified physicians no matter where they happen to be: work, home, vacation, business trip. The results:+

If they hadn’t gone to Teladoc, where would they have gone? +

Patient Issues Resolved

Member Satisfaction

Physician Satisfaction

Average Consult Duration

Would Use Teladoc Again

+

Teladoc reporting

90% 95% 96% 17min 92%

42% Urgent Care

8% ER Visit 1% Specialist Visit

11% Did Nothing

38% PCP Visit

What would it have cost?

SAVINGS

PCP / $131

$131

Specialist / $196

$196

Urgent Care / $163

$163

ER / $1,477

$1,477

Avg. savings per consult with Teladoc

$198.36 +

Cost of lost productivity++

$ 86.96 +

Total savings per consult

$285.32

++

27

Approx. 4 hrs lost @ avg. wage of $21.74/hr

Why choose Teladoc?

Teladoc is the first, largest and fastest growing provider of telehealth medical consultations, serving millions of members nationwide.

The telehealth leader

Quality physicians

•

U.S. board-certified in internal medicine, family practice, emergency medicine or pediatrics

•

U.S. residents, state-licensed in their respective states

•

Average of 15 years of experience

•

Verified through the National Practitioner Data Bank and the American Medical Association

•

Strictly credentialed meeting NCQA standards

1ST & LARGEST

provider of telehealth medical consultations in the U.S. FOUNDED IN 2002

7.5MILLION

members and growing

Driving utilization Teladoc’s low per-member fee helps health plans realize ROI quickly. And the more members use Teladoc, the greater the ROI. That’s why Teladoc targets high utilizers of urgent care and ER visits, and provides marketing materials to redirect usage to Teladoc, saving money for health plans while providing better access to care.

Employer experience and integration Teladoc has significant experience working with thousands of employers of all sizes, locations, occupations, and demographics. Teladoc services can be intergrated in 30 days.

Case studies available at Teladoc.com.

28

200,000+ consultations annually

100 %

U.S. board-certified physicians credentialed to NCQA standards

Benefit Intelligence Unlimited Program Simple Pricing Model Benefit Intelligence provides a simple pricing model. Our Teladoc program features a low monthly Per Employee Per Month (PEPM) fee with unlimited consultations included and NO MEMBER CO-PAY. Our Unlimited Program provides services to ALL MEMBERS of the Employees household. The pricing structure is designed to realize ROI faster because, unlike traditional physician consultations, greater utilization leads to higher levels of ROI. FEE DESCRIPTION

COST

Per Employee Per Month (PEPM)*

$5.00

Managed by:

PEPM pricing includes: • Telephone and video consultations • Online registration and medical history disclosure (MHD) • Free portable electronic health record (EHR)

Benefit Intelligence, Inc.

• 1-800 call center support

4862 East Baseline Road, Suite 101

• Fulfillment of welcome kits to members

Mesa, AZ 85206

• Benefit Intelligence will provide marketing material

P 1-866-555-1020 F (480) 892-7184 Monthly billing and eligibility will be managed by Benefit Intelligence

• No Member Copay Plan • Monthly utililization report provided by Benefit Intelligence • 1-year contract minimum

For more information please contact Creative Planning Benefits, LLC 111350 Tomahawk Creek Parkway, Suite 200, Leawood, KS 66211 Direct: (913) 563-7908 | Fax: (913) 385-7007

Benefit Intelligence is an authorized reseller for Teladoc. Teladoc does not replace the primary care physician. Teladoc does not guarantee that a prescription will be written. Teladoc operates subject to state regulation and may not be available in certain states. Teladoc does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. Teladoc physicians reserve the right to deny care for potential misuse of services. Teladoc phone consultations are available 24 hours, 7 days a week while video consultations are available during the hours of 7am to 9pm, 7 days a week.

Disclaimer. © 2014 Teladoc, Inc. All rights reserved. Teladoc and the Teladoc logo are registered trademarks of Teladoc, Inc. and may not be used without written permission.

All material proprietary and confidential

29

Provide 24/7/365 access to quality healthcare and reduce medical costs | 15

FSAGUIDE

TAX SAVINGS FOR Medical and Dependent Care Expenses

basiconline.com 30

WHAT IS A

FLEXIBLE SPENDING Flexible Spending Accounts (FSA) are

A Medical FSA can be used to cover:

part of Section 125, established by the

• Insurance deductibles

IRS. Section 125 allows employees to

• Co-payments and coinsurance

set aside money for future medical and

• Prescriptions

child care costs on a pre-tax basis.

• Dental or vision expenses • Over-the-counter medicine • Menstrual products

SAVINGS

You save between 15%-40% by not having to pay federal, most state and local taxes, as well as Social Security and Medicare taxes for every dollar elected for an FSA.

The savings really add up.

Without an FSA

With an FSA

Gross taxable wage

$500.00 Gross taxable wage

Federal, FICA & State Tax

-113.25

Group Insurance premium contribution Take home pay

-40.00

Group Insurance premium contribution Average weekly out-of-pocket medical expenses

$346.75 Taxable wage

Average weekly out-of-pocket medical expenses Amount left to spend

-50.00 Federal, FICA & State Tax $296.75 Amount left to spend

FSA Tax Savings per week • Assuming 15% Federal tax, 7.65% FICA Tax (Social Security and Medicare)

31

$500.00 -40.00 -50.00 $410.00 -92.86 $317.14

$20.39

G ACCOUNT? MEDICAL FSA Below is an example of a how a current participant calculated the amount they elected for medical FSA. Be sure to base YOUR estimate on known expenses.

LIMITED PURPOSE FLEX

The full amount of your medical election is available for reimbursement upon the first day of your plan year.

DESIGNED FOR INDIVIDUALS WITH A HEALTH SAVINGS ACCOUNT (HSA)

When you incur an eligible out-of-pocket expense, submit your itemized documentation to BASIC and receive a tax free reimbursement.

IRS regulations do not allow you to contribute to an HSA and participate in a standard Medical FSA, however, you may enroll in a Limited Purpose FSA. If you or your spouse

Charges

Savings

Deductible

$500

$113

your Flex plan year and you are enrolled in a

Co-pays

$450

$101

standard Medical FSA, you are not allowed to

Prescriptions

$480

$108

make or receive HSA contributions or change

Contacts/Vision services

$220

$49

Dental

$100

$22

Over-the-counter items+

$75

$16

$1825

$409

Total

change to an HDHP option (with HSA) during

your FSA Plan type.

The difference between Medical FSA and a Limited Purpose FSA is eligible expenses. A Limited Purpose FSA plan is only for dental and vision expenses.

A Limited Purpose FSA works just like a regular

• Assuming 15% Federal tax, 7.65% FICA Tax (Social Security and Medicare)

+ Over-the-counter items require a letter of medical necessity

FSA, except for the limited type of eligible expenses. You designate a certain amount of

IRS regulations govern the eligibility of claims which include those that are not fully covered by a health care plan and are prescribed by a physician or other licensed professional, primarily for preventing, treating or mitigating a physical defect or illness. The IRS does not allow reimbursement for the following: cosmetic surgery, insurance premiums, teeth bleaching / whitening, nutritional supplements/vitamins, marriage counseling, debt counseling, eyeglass sun clips and prepayment of services. For more details, refer to IRS Publication No. 502.

money to be taken out of each paycheck to be deposited into your LPFSA account.

You cannot use funds from both your LPFSA and your HSA to cover the same eligible expense, even if the expense is considered eligible under both plans.

An HSA Account does not affect your

32

eligibility for a dependent care account.

QUALIFIED EXPENSES IRS regulations govern the eligibility of items and claims. As a Flex Administrator, BASIC helps ensure that you and your employer stay within these regulations.

MEDICAL, DENTAL & VISION Co-pays Co-insurance Deductibles

MEDICAL*

Acupuncture Chiropractor Podiatrist Doctor fees Office visit Prescriptions Hospital bills Laboratory fees Medic alert bracelet Dermatologist Immunizations Obstetrical expenses Routine physicals X-rays Well baby checkups

DIABETIC SUPPLIES* Insulin Glucometer Syringes/Needles Test Strips

HEARING*

Hearing exam Hearing aids Special batteries

THERAPY*

Physical therapy Learning disability Psychologist fees for medical care Psychiatric care

VISION*

Glasses Eye exam Contact lenses Contact solution Prescription sunglasses LASIK surgery Visine and eye drops Reading glasses Eyeglass repair kits Orthokeratology Seeing eye dog (buying, training, and maintaining)

DENTAL*

Orthodontic Dentures/bridge/crowns Fluoride treatments & seals Cleanings and fillings Root canals Extractions Dental x-rays Occlusal guards Reconstruction/implants

BIRTH CONTROL DEVICES* Condoms Prescriptions Sterilization

PHYSICAL IMPAIRMENTS*

Wheelchair Crutches Walker Custom made orthopedic shoes and inserts

SPECIAL NEEDS*

Transportation to and from doctor/hospital (call for current mileage rates and guidelines)

OVER-THE-COUNTER ITEMS* Acid controllers Acne medication Antibiotic products Anti-diarrheas/gas Anti-itch/insect bite Antiparasitic treatments Baby rash creams Band-aids Carpal tunnel wrist supports Cold sore remedies Cold/hot packs for injuries Cough, cold & flu Digestive aids Feminine anti-fungal/anti-itch Hemorrhoidal preps Home pregnancy tests Incontinence supplies Laxatives Liquid adhesive for small cuts Nasal strips Pain relief Sleep aids & sedatives Stomach remedies Stop smoking programs/ items Sunscreen

MENSTRUAL PRODUCTS* Tampons Pads and liners Menstrual cups

Visit www.basiconline.com/Medical-FSA-Election-Worksheet.pdf for a qualified expense worksheet to help you estimate your out of pocket costs.

33

EXPENSES THAT REQUIRE A LETTER OF MEDICAL NECESSITY

The IRS allows reimbursement of the following, with a copy of the physician’s statement of medical necessity, that includes the specific product/service and a diagnosis. Treatment cannot be for general health or well being. A copy needs to be submitted with every reimbursement request and a new letter needs to be reinstated every 12 months.

Health club fees/gym memberships Nutritional supplements/vitamins Massage therapy Weight loss programs (i.e. Weight Watchers and Jenny Craig) - Program fees are eligible but food portions are not.

* P LEASE NOTE: This list is a broad overview of eligible expenses; not all services provided by a provider or practitioner are eligible under the IRS regulations.

EXAMPLES OF INELIGIBLE EXPENSES The IRS does not allow reimbursement for the following: Cosmetic surgery Insurance premiums Marriage/debt counseling Eyeglass sun clips Eyeglass or contact warranty Prepayment of services Special (dietary) foods Personal care items Diapers Deodorant Chapstick Face cream or moisturizers Eye serums or wrinkle creams Teeth bleaching/whitening Toothbrushes/toothpaste Floss/flossing devices Mouthwash Protein shakes/meal replacement

Please call BASIC regarding your specific item or treatment, prior to election, to confirm eligibility.

CALCULATE SAVINGS Visit www.basiconline.com/fsasavingscalculator to use our calculator to estimate the size of your tax saving, annually or per pay check, when you choose to participate in BASIC Flex!

34

DEPENDENT CARE FSA A single parent or a married couple filing jointly can elect up to $5,000 per family, while a married person filing separately can elect up to $2,500 per person, but equal $5,000 for the family. Just as with Medical FSA, you save between 15%-40% by not having to pay federal, most state and local taxes, as well as Social Security and Medicare taxes for every dollar elected for Dependent Care FSA. Unlike a Medical FSA, Dependent Care FSA is a pay-as-you-go account. Funds are not advanced by your employer.

Without an FSA

With an FSA

Gross taxable wage

$500.00 Gross taxable wage

Federal, FICA & State Tax

-113.25

Take home pay

$386.75 Taxable wage

Average weekly out-of-pocket medical expenses Amount left to spend

$500.00 -96.15

Dependent care election ($5,000 divided by 52 weeks)

-96.15

$403.85 -91.47

Federal, FICA & State Tax

$290.60 Amount left to spend

FSA Tax Savings per week Annual Savings

$312.36

$21.78 $1132.56

• Assuming 15% Federal tax, 7.65% FICA Tax (Social Security and Medicare)

DEPENDENT ELIGIBILITY

SERVICE REQUIREMENTS

• Y ou and your spouse must be employed or actively seeking employment or attending school full time.

• Child must be a dependent under 13 years of age and be in your custodial care more than 50% of the calendar year. Once your child turns 13 during the plan year, expenses are no longer eligible for reimbursement.

• A spouse or dependent who is incapable of self-care and regularly spends at least eight hours per day in your home (i.e. an invalid parent).

• P rovider may not be a minor child or dependent for income tax purposes (i.e. an older child).

• Service provider must claim payments as income and comply with state regulations.

• Services must be for the physical care of the child, not for education, meals, etc.

• Overnight camps are not eligible for reimbursement.

• Expenses paid for Pre-K are eligible but kindergarten and higher is not.

If you qualify for the Child Care Credit, the same IRS rules apply. If you have 2 or more children and spend more than $5,000 for child care, you may have additional tax credits available to you. For more details, refer to IRS Publication No. 503

35

ADDITIONAL

DETAILS

PLAN RULES ARE COMPANY SPECIFIC While this booklet provides general information about a plan, a Summary Plan Description (SPD) containing further details is available. If you have specific questions regarding your particular situation, you may want to consult your company Benefits Coordinator, an attorney or accountant.

Refer to the Summary Plan Description (SPD) to find out how long you have to submit remaining claims after your plan year or coverage has ended.

CHANGES TO YOUR CONTRIBUTIONS You may change your annual election if you have a qualified change in status (marriage, birth, adoption, death or divorce).

The change in status must correlate with the event and be made within 30 days of the event. For example, if the event is a birth, you may increase your election, not decrease it.

END OF YEAR BALANCE According to the IRS, money left in your account may become the property of your employer and cannot be returned to you. Please see the Summary Plan Description (SPD) for further details. Most people use all their funds by good planning . . . such as getting a physical, dental checkup or new glasses. Rarely is there ever more than 5% left in the account, and the tax savings more than outweigh this amount.

ELIGIBILITY

Flex Benefits end upon termination of employment and/or participation.

Services must be rendered during your current period of coverage. For new employees entering the plan during the plan year, services must be rendered after your eligibility or election date, whichever is later.

FSA BENEFIT DEBIT CARD ELIMINATE PAYING OUT-OF-POCKET AND WAIT FOR REIMBURSEMENT. FSA Benefit Debit Cards can be used at qualified locations including hospitals, physician, dental offices, pharmacies and merchants with specific certification.

The IRS regulates the rules regarding eligible expenses; therefore, there will be some transactions that need to be substantiated for eligibility. At BASIC, we have an 87% auto substantiate rate for debit card purchases. There are, however, some instances when participants will be required to submit itemized documentation for their FSA Benefit Debit Card purchases.

In all cases, itemized documentation for transactions should be kept.

Debit Cards will be suspended if documentation is not provided.

Debit Card availability is determined by your employer. Please check with your benefits department to find out if a debit card is available.

If you have questions at anytime call 800-372-3539 and speak to a BASIC Flex Account Manager.

36

SUMMIT CHRISTIAN ACADEMY TAX SHELTERED ANNUITY BENEFIT INFORMATION As part of the benefit package for employees who work and/or are paid over 12 months, SCA offers an optional 403(b) plan. A 403(b) plan, also known as a taxsheltered annuity (TSA) plan. A TSA is a retirement plan for certain employees of public schools, employees of certain tax-exempt organizations, and certain ministries.

Employees may choose to set aside pre-tax dollars into a 403(b) through either Modern Woodmen of America or Vanguard.

We encourage you to speak with your tax accountant before choosing this option to verify that it is a wise decision for your family situation.

Employees are responsible for contacting the below companies for information on plans they offer. Once a decision is made and paperwork completed, employees should provide copies of their Vanguard or Modern Woodmen paperwork to the finance office, so contributions to the plan can be deducted from paychecks and transferred to the provider accordingly.

Modern Woodmen of America 1701 1st Avenue Rock Island, IL 61201 www.modern-woodmen.org 800-447-0369 & ask for Member Services Local Representative Stephen Million 816-525-2333 SCA Account No. 21064081001

Vanguard P. O. Box 1110 Valley Forge, PA 19482 www.vanguard.com 800-962-5068 SCA Plan ID 10208771

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Summit Christian Academy 2022 Employee Benefits SCA admits students of any race, color and national or ethnic origin.