Benefit Contact Information
WORLD
Higginbotham Public Sector (800) 583-6908
www.mybenefitshub.com/ worldcompassacademy
Chubb (866) 324-8222 www.chubb.com
EyeMed (866) 939-3633 www.eyemed.com
Chubb (866) 324-8222 www.chubb.com
Kaiser Permanente (303) 338-3800
https://about.kaiserpermanente.org/
Kaiser Permanente (800) 632-9700
https://healthy.kaiserpermanente.org/
Recuro Health (844) 979-0313 www.recurohealth.com
The Hartford (860) 547-5000 www.thehartford.com
The Hartford (860) 547-5000 www.thehartford.com
MetLife (800) 638-5433 www.metlife.com
New York Life (800) 225-5695 www.newyorklife.com
1
2
3
4
www.mybenefitshub.com/ worldcompassacademy
CLICK LOGIN
5
Enter your Information
• Last Name
• Date of Birth
• Last Four (4) of Social Security Number
NOTE: THEbenefitsHUB uses this information to check behind the scenes to confirm your employment status.
Once confirmed, the Additional Security Verification page will list the contact options from your profile. Select either Text, Email, Call, or Ask Admin options to receive a code to complete the final verification step.
Enter the code that you receive and click Verify. You can now complete your benefits enrollment!
Annual Benefit Enrollment
Annual Enrollment
During your annual enrollment period, you have the opportunity to review, change or continue benefit elections each year. Changes are not permitted during the plan year (outside of annual enrollment) unless a Section 125 qualifying event occurs.
• Changes, additions or drops may be made only during the annual enrollment period without a qualifying event.
• Employees must review their personal information and verify that dependents they wish to provide coverage for are included in the dependent profile. Additionally, you must notify your employer of any discrepancy in personal and/or benefit information.
• Employees must confirm on each benefit screen (medical, dental, vision, etc.) that each dependent to be covered is selected in order to be included in the coverage for that particular benefit.
New Hire Enrollment
All new hire enrollment elections must be completed in the online enrollment system within the first 30 days of benefit eligibility employment. Failure to complete elections during this timeframe will result in the forfeiture of coverage.
Q&A
Who do I contact with Questions?
For supplemental benefit questions, you can contact your Benefits Office or you can call Higginbotham Public Sector at (866) 914-5202 for assistance.
Where can I find forms?
For benefit summaries and claim forms, go to your benefit website: www.mybenefitshub.com/ worldcompassacademy. Click the benefit plan you need information on (i.e., Dental) and you can find the forms you need under the Benefits and Forms section.
How can I find a Network Provider?
For benefit summaries and claim forms, go to the World Compass Academy benefit website: www.mybenefitshub.com/worldcompassacademy. Click on the benefit plan you need information on (i.e., Dental) and you can find provider search links under the Quick Links section.
When will I receive ID cards?
If the insurance carrier provides ID cards, you can expect to receive those 3-4 weeks after your effective date. For most dental and vision plans, you can login to the carrier website and print a temporary ID card or simply give your provider the insurance company’s phone number and they can call and verify your coverage if you do not have an ID card at that time. If you do not receive your ID card, you can call the carrier’s customer service number to request another card.
If the insurance carrier provides ID cards, but there are no changes to the plan, you typically will not receive a new ID card each year.
Annual Benefit Enrollment
Section 125 Cafeteria Plan Guidelines
A Cafeteria plan enables you to save money by using pre-tax dollars to pay for eligible group insurance premiums sponsored and offered by your employer. Enrollment is automatic unless you decline this benefit. Elections made during annual enrollment will become effective on the plan effective date and will remain in effect during the entire plan year.
CHANGES IN STATUS (CIS):
Marital Status
Change in Number of Tax Dependents
Change in Status of Employment Affecting Coverage Eligibility
Gain/Loss of Dependents’ Eligibility Status
Judgment/ Decree/Order
Eligibility for Government Programs
Changes in benefit elections can occur only if you experience a qualifying event. You must present proof of a qualifying event to your Benefit Office within 30 days of your qualifying event and meet with your Benefits Office to complete and sign the necessary paperwork in order to make a benefit election change. Benefit changes must be consistent with the qualifying event.
QUALIFYING EVENTS
A change in marital status includes marriage, death of a spouse, divorce or annulment (legal separation is not recognized in all states).
A change in number of dependents includes the following: birth, adoption and placement for adoption. You can add existing dependents not previously enrolled whenever a dependent gains eligibility as a result of a valid change in status event.
Change in employment status of the employee, or a spouse or dependent of the employee, that affects the individual’s eligibility under an employer’s plan includes commencement or termination of employment.
An event that causes an employee’s dependent to satisfy or cease to satisfy coverage requirements under an employer’s plan may include change in age, student, marital, employment or tax dependent status.
If a judgment, decree, or order from a divorce, annulment or change in legal custody requires that you provide accident or health coverage for your dependent child (including a foster child who is your dependent), you may change your election to provide coverage for the dependent child. If the order requires that another individual (including your spouse and former spouse) covers the dependent child and provides coverage under that individual’s plan, you may change your election to revoke coverage only for that dependent child and only if the other individual actually provides the coverage.
Gain or loss of Medicare/Medicaid coverage may trigger a permitted election change.
Annual Benefit Enrollment
Employee Eligibility Requirements
Medical and Supplemental Benefits: Eligible employees must work 30 or more regularly scheduled hours each work week.
Eligible employees must be actively at work on the plan effective date for new benefits to be effective, meaning you are physically capable of performing the functions of your job on the first day of work concurrent with the plan effective date. For example, if your 2025 benefits become effective on January 1, 2025, you must be actively-at-work on January 1, 2025 to be eligible for your new benefits.
Dependent Eligibility Requirements
Dependent Eligibility: You can cover eligible dependent children under a benefit that offers dependent coverage, provided you participate in the same benefit, through the maximum age listed below. Dependents cannot be double covered by married spouses within the district as both employees and dependents.
Please note, limits and exclusions may apply when obtaining coverage as a married couple or when obtaining coverage for dependents.
Potential Spouse Coverage Limitations: When enrolling in coverage, please keep in mind that some benefits may not allow you to cover your spouse as a dependent if your spouse is enrolled for coverage as an employee under the same employer. Review the applicable plan documents, contact Higginbotham Public Sector, or contact the insurance carrier for additional information on spouse eligibility.
FSA/HSA Limitations: Please note, in general, per IRS regulations, married couples may not enroll in both a Flexible Spending Account (FSA) and a Health Savings Account (HSA). If your spouse is covered under an FSA that reimburses for medical expenses then you and your spouse are not HSA eligible, even if you would not use your spouse’s FSA to reimburse your expenses. However, there are some exceptions to the general limitation regarding specific types of FSAs. To obtain more information on whether you can enroll in a specific type of FSA or HSA as a married couple, please reach out to the FSA and/or HSA provider prior to enrolling or reach out to your tax advisor for further guidance.
Potential Dependent Coverage Limitations: When enrolling for dependent coverage, please keep in mind that some benefits may not allow you to cover your eligible dependents if they are enrolled for coverage as an employee under the same employer. Review the applicable plan documents, contact Higginbotham Public Sector, or contact the insurance carrier for additional information on dependent eligibility.
25
Disclaimer: You acknowledge that you have read the limitations and exclusions that may apply to obtaining spouse and dependent coverage, including limitations and exclusions that may apply to enrollment in Flexible Spending Accounts and Health Savings Accounts as a married couple. You, the enrollee, shall hold harmless, defend, and indemnify Higginbotham Public Sector from any and all claims, actions, suits, charges, and judgments whatsoever that arise out of the enrollee’s enrollment in spouse and/or dependent coverage, including enrollment in Flexible Spending Accounts and Health Savings Accounts.
If your dependent is disabled, coverage may be able to continue past the maximum age under certain plans. If you have a disabled dependent who is reaching an ineligible age, you must provide a physician’s statement confirming your dependent’s disability. Contact your Benefits Office to request a continuation of coverage.
Helpful Definitions
Actively-at-Work
You are performing your regular occupation for the employer on a full-time basis, either at one of the employer’s usual places of business or at some location to which the employer’s business requires you to travel. If you will not be actively at work beginning 1/1/2025 please notify your benefits administrator.
Annual Enrollment
The period during which existing employees are given the opportunity to enroll in or change their current elections.
Annual Deductible
The amount you pay each plan year before the plan begins to pay covered expenses.
Calendar Year
January 1st through December 31st
Co-insurance
After any applicable deductible, your share of the cost of a covered health care service, calculated as a percentage (for example, 20%) of the allowed amount for the service.
Guaranteed Coverage
The amount of coverage you can elect without answering any medical questions or taking a health exam. Guaranteed coverage is only available during initial eligibility period. Actively-at-work and/or preexisting condition exclusion provisions do apply, as applicable by carrier.
In-Network
Doctors, hospitals, optometrists, dentists and other providers who have contracted with the plan as a network provider.
Out-of-Pocket Maximum
The most an eligible or insured person can pay in coinsurance for covered expenses.
Plan Year
January 1st through December 31st
Pre-Existing Conditions
Applies to any illness, injury or condition for which the participant has been under the care of a health care provider, taken prescriptions drugs or is under a health care provider’s orders to take drugs, or received medical care or services (including diagnostic and/or consultation services).
Description
Health Savings Account (HSA) (IRC Sec. 223)
Approved by Congress in 2003, HSAs are actual bank accounts in employee’s names that allow employees to save and pay for unreimbursed qualified medical expenses tax-free.
Employer Eligibility A qualified high deductible health plan.
Contribution Source Employee and/or employer
Account Owner Individual
Underlying Insurance Requirement High deductible health plan
Minimum Deductible
Maximum Contribution
Permissible Use Of Funds
Cash-Outs of Unused Amounts (if no medical expenses)
Year-to-year rollover of account balance?
$1,650 single (2025)
$3,300 family (2025)
$4,300 single (2025)
$8,550 family (2025)
55+ catch up +$1,000
Employees may use funds any way they wish. If used for nonqualified medical expenses, subject to current tax rate plus 20% penalty.
Permitted, but subject to current tax rate plus 20% penalty (penalty waived after age 65).
Yes, will roll over to use for subsequent year’s health coverage.
Does the account earn interest? Yes
Portable?
Yes, portable year-to-year and between jobs.
Medical Insurance
website: www.mybenefitshub.com/worldcompassacademy
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan . The SBC shows you how you and the plan would share the cost for covered health care services.
NOTE: Information about the cost of this plan (called the premium ) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage see https://kp.org/plandocuments or call 18552495005 (TTY:711). For general definitions of common terms, such as allowed amount , balance billing , coinsurance , copayment , deductible , provider , or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbcglossary/ or call 18552495005 (TTY:711) to request a copy.
Why this Matters:
Important Questions Answers
Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan , each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible . Are there services covered before you meet your deductible ? Yes. Preventive care and services indicated in chart starting on page 2.
$7,500 Individual / $15,000 Family
What is the overall deductible ?
You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services.
Yes. $50 Individual for Pediatric Dental in network . There are no other specific deductibles .
This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible . See a list of covered preventive services at https://www.healthcare.gov/coverage/preventivecarebenefits/ . Are there other deductibles for specific services?
$7,500 Individual / $15,000 Family
What is the outofpocket limit for this plan ?
Premiums , health care this plan doesn’t cover, and services indicated in chart starting on page 2. Even though you pay these expenses, they don't count toward the outofpocket limit .
The outofpocket limit is the most you could pay in a year for covered services. If you have other family members in this plan , they have to meet their own outofpocket limits until the overall family outofpocket limit has been met. What is not included in the outofpocket limit ?
This plan uses a provider network . You will pay less if you use a provider in the plan’s network . You will pay the most if you use an outofnetwork provider , and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays ( balance billing ). Be aware, your network provider might use an outofnetwork provider for some services (such as lab work). Check with your provider before you get services.
Will you pay less if you use a network provider ? Yes. See www.kp.org or call 18552495005 (TTY: 711) for a list of network providers .
This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist .
Do you need a referral to see a specialist ? Yes, but you may selfrefer to certain specialists
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
You may have to pay for services that aren't preventive . Ask your provider if the services needed are preventive . Then check what your plan will pay for. If you have a
Up to a 30day supply (retail); up to a 90day supply (mail order). Prescription refills of ongoing maintenance medications must be filled at a Kaiser Permanente Pharmacy. Subject to formulary guidelines. Formulary preventive and contraceptive drugs in all tiers are no charge, deductible does not apply.
Up to a 30day supply (retail); up to a 90day supply (mail order). Subject to formulary guidelines.
to a 30day supply (retail); up to a 90day supply (mail order). Subject to formulary guidelines, when approved through the exception process.
to a 30day supply (retail). Subject to formulary guidelines, when approved through the exception process.
Exceptions
Annual Wellness Visit: No charge, deductible does not apply. Virtual Care Services: No charge.
Depending on the type of services, a copayment , coinsurance , or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.)
Outpatient: 20 visit limit / therapy / year (autism spectrum disorders are not subject to visit limit). Virtual Care Services: No charge. Inpatient: Limited to 60 days / condition / year.
20 visit limit / therapy / year (autism spectrum disorders are not subject to visit limit). Virtual Care Services: No charge.
100day limit / year.
Subject to formulary guidelines.
Event Services You May Need What You Will Pay Plan Provider (You will pay the least) What You Will Pay NonPlan Provider (You will pay the most)
Limited to members up to the end of the year in which the member turns 19. Children's glasses No charge Not covered
Limited to members up to the end of the year in which the member turns 19. One pair of frames and lenses or contact lenses / 24 months.
Limitations, Exceptions & Other Important Information If your child needs dental or eye care Children's eye exam No charge Not covered
Limited to members up to the end of the month in which the member turns 19; limited coverage for diagnostic and preventive service s, minor restorative (fillings), simple extractions and crowns.
Routine foot care
Children's dental checkup No charge for preventive / diagnostic services after pediatric dental deductible . 50% coinsurance for basic / major services after pediatric dental deductible . Not covered
Longterm care
Cosmetic surgery
Weight loss programs the U.S.
Nonemergency care when traveling outside
Hearing aids (Adult)
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
Infertility treatment
Privateduty nursing (Inpatient)
Chiropractic care (20 visit limit/year)
Dental care (Adult)
Abortion
Acupuncture (10 visit limit/year)
Hearing aids (Up to age 18)
Bariatric surgery
Routine eye care (Adult) Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services .)
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is shown in the chart below. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace . For more information about the Marketplace , visit www.HealthCare.gov or call 18003182596.
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim . This complaint is called a grievance or appeal . For more information about your rights, look at the explanation of benefits you will receive for that medical claim . Your plan documents also provide complete information on how to submit a claim , appeal , or a grievance for any reason to your plan . For more information about your rights, this notice, or assistance, contact the agencies in the chart below. Contact Information for Your Rights to Continue Coverage & Your
and Appeals
Oversight 18772672323 x61565 or www.cciio.cms.gov
Department of Health & Human Services, Center for Consumer Information & Insurance
Colorado Division of Insurance 3038947490 (instate, tollfree: 8009303745) or insurance@dora.state.co.us
Does this plan provide Minimum Essential Coverage? Yes. Minimum Essential Coverage generally includes plans , health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage , you may not be eligible for the premium tax credit . Does this plan meet the Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standards , you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace .
Language Access Services: SPANISH (Español): Para obtener asistencia en Español, llame al 18552495005 (TTY: 711)
TAGALOG (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 18552495005 (TTY: 711)
TRADITIONAL CHINESE (中文 ): 如果需要中文的帮助，请拨打这个号码 18552495005 (TTY : 711)
PENNSYLVANIA DUTCH (Deitsch): Fer Hilf griege in Deitsch, ruf 18552495005 (TTY: 711) uff
NAVAJO (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 18552495005 (TTY: 711)
SAMOAN (Gagana Samoa): Mo se fesoasoani i le Gagana Samoa, vala’au mai i le numera telefoni 18552495005 (TTY: 711)
CAROLINIAN (Kapasal Falawasch): ngere aukke ghut alillis reel kapasal Falawasch au fafaingi tilifon ye 18552495005 (TTY: 711)
CHAMORRO (Chamoru): Para un ma ayuda gi finu Chamoru, ȧ 'gang 18552495005 (TTY: 711)
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
Mia's Simple Fracture (innetwork
and follow up care)
Managing Joe's Type 2 Diabetes (a year of routine innetwork care of a wellcontrolled condition) Peg is Having a Baby (9 months of innetwork prenatal care and a hospital delivery) This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts ( deductibles , copayments and coinsurance ) and excluded services under the plan . Use this information to compare the portion of costs you might pay under different health plans . Please note these coverage examples are based on selfonly coverage.
Colorado Supplement to the Summary of Benefits and Coverage Form
7500/100% HSA
5. OutofPocket Maximum EMBEDDED OUTOFPOCKET INDIVIDUAL –The amount that each member of the family must meet prior to claims being paid at 100%. Claims will not be paid at 100% for any other individual until their individual outofpocket or the family outofpocket has been met. INSURANCE COMPANY NAME
1. Type of Policy
Employer Group Policy 2. Type of plan Health maintenance organization (HMO) 3. Areas of Colorado where plan is available. Plan is available only in the following counties: Adams, Arapahoe, Boulder, Broomfield, Clear Creek, Denver, Douglas, El Paso, Elbert, Fremont, Gilpin, Jefferson, Larimer, Park, Pueblo, Teller, and Weld KP Select Plan: El Paso and Teller
SUPPLEMENTAL INFORMATION REGARDING BENEFITS
Important Note: The contents of this form are subject to the provisions of the policy, which contains all terms, covenants and conditions of coverage. It provides additional information meant to supplement the Summary of Benefits of Coverage you have received for this plan. This plan may exclude coverage for certain treatments, diagnoses, or services not specifically noted. Consult the actual policy to dete rmine the exact terms and conditions of coverage.
INTERESTED POLICYHOLDERS, CERTIFICATE HOLDERS, AND ENROLLEES ARE HEREBY GIVEN NOTICE THAT THIS SMALL GROUP POLICY REQUIRES THAT AN INSURED TRAVEL OUTSIDE OF THE GEOGRAPHIC AREA TO RECEIVE COVERED HEALTH BENEFITS.
This means if you live or work outside of the service area where this plan is available, you will have to travel into this service area to receive nonemergency or nonurgent covered services.
Description
4. Annual Deductible Type EMBEDDED DEDUCTIBLE INDIVIDUAL –The amount that each member of the family must meet prior to claims being paid. Claims will not be paid for any other individual until their individual deductible or the family deductible has been met. FAMILY –The maximum amount that the family will pay for the year. The family deductible can be met by [2] or more individuals.
6. What is included in the InNetwork OutofPocket Maximum? Deductibles, coinsurance and copayments.
7. Is pediatric dental covered by this plan? Yes, pediatric dental is subject to a separate $50 deductible.
8. What cancer screenings are covered? Breast Cancer (clinical breast exam, screening and/or imaging, genetic testing for inherited susceptibility for breast cancer); Colon and Rectal Cancer (fecal occult blood test (FIT), flexible sigmoidoscopy, barium enema, colonoscopy); Cervical Cancer (Pap test); Prostate Cancer (digital rectal exam, serum prostatic specific antigen (PSA))
INNETWORK OUTOFNETWORK
Yes, members may be responsible for any amounts over eligible Charges, except when Emergency Services are received in an OutofPlan Facility or from an OutofPlan Provider in a Plan Facility.
10. Does the plan have a binding arbitration clause? No FAMILY –The maximum amount that the family will pay for the year. The family outofpocket can be met by 2 or more individuals.
USING THE PLAN
No
9. If the provider charges more for a covered service than the plan normally pays, does the enrollee have to pay the difference?
Questions: Call 18552495005 (TTY 711 ) or visit us at www.kp.org . SPANISH (Español): Para obtener asistencia en Español, llame al 18552495005 (TTY 711 ). This document is available for free in Spanish. Please contact our Member Services number at 3033383800 or toll free 18006329700 (TTY 711 ). Este documento está disponible de forma gratuita en español. Si desea información adicional, por favor llame al número de nuestro Servicio a los Miembros al 3033383800 or toll free 18006329700 . (Los usuarios de la línea TTY deben llamar al 711 ). If you are not satisfied with the resolution of your complaint or grievance, contact:
Colorado Division of Insurance Consumer Services, Life and Health Section 1560 Broadway, Suite 850, Denver, CO 80202
Call: 3038947490 (instate, tollfree: 8009303745)
Email: dora_insurance@state.co.us
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan . The SBC shows you how you and the plan would share the cost for covered health care services.
NOTE: Information about the cost of this plan (called the premium ) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage see https://kp.org/plandocuments or call 18552495005 (TTY:711). For general definitions of common terms, such as allowed amount , balance billing , coinsurance , copayment , deductible , provider , or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbcglossary/ or call 18552495005 (TTY:711) to request a copy.
Why this Matters:
Important Questions Answers
Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan , each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible . Are there services covered before you meet your deductible ? Yes. Preventive care and services indicated in chart starting on page 2.
This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible . See a list of covered preventive services at https://www.healthcare.gov/coverage/preventivecarebenefits/
$1,875 Individual / $3,750 Family
What is the overall deductible ?
Yes. $50 Individual for Pediatric Dental in network . There are no other specific deductibles . You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services.
Are there other deductibles for specific services?
The outofpocket limit is the most you could pay in a year for covered services. If you have other family members in this plan , they have to meet their own outofpocket limits until the overall family outofpocket limit has been met.
$8,700 Individual / $17,400 Family
What is the outofpocket limit for this plan ?
Premiums , health care this plan doesn’t cover, and services indicated in chart starting on page 2. Even though you pay these expenses, they don't count toward the outofpocket limit .
What is not included in the outofpocket limit ?
This plan uses a provider network . You will pay less if you use a provider in the plan’s network . You will pay the most if you use an outofnetwork provider , and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays ( balance billing ). Be aware, your network provider might use an outofnetwork provider for some services (such as lab work). Check with your provider before you get services.
Will you pay less if you use a network provider ? Yes. See www.kp.org/cooption or call 18552495005 (TTY: 711) for a list of network providers .
Do you need a referral to see a specialist ? Yes, but you may selfrefer to certain specialists . This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist .
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
Limitations, Exceptions & Other
Services You May Need What You Will Pay Plan Provider (You will pay the least) What You Will Pay NonPlan Provider (You will pay the most)
Primary care visit to treat an injury or illness No charge, deductible does not apply Not covered
Virtual Care Services: No charge, deductible does not apply
Virtual Care Services: No charge, deductible does not apply Specialist visit $50 / visit, deductible does not apply. 30% coinsurance for other covered services received during a visit. Not covered
If you visit a health care provider's office or clinic
You may have to pay for services that aren't preventive . Ask your provider if the services needed are preventive . Then check what your plan will pay for.
Preventive care / screening / immunization No charge, deductible does not apply No charge
If you have a test Diagnostic test (xray, blood work) 30% coinsurance Not
You Will Pay NonPlan Provider (You will pay the most)
You May Need What You Will Pay Plan Provider (You will pay the least)
Up to a 30day supply (retail); up to a 90day supply (mail order). Prescription refills of ongoing maintenance medications must be filled at a Kaiser Permanente Pharmacy. Subject to formulary guidelines. Formulary preventive and contraceptive drugs in all tiers are no charge, deductible does not apply. Preferred brand drugs
$10 retail and $20 mail order / prescription , deductible does not apply. Not covered
$50 retail and $100 mail order / prescription , deductible does not apply. Not covered
Up to a 30day supply (retail); up to a 90day supply (mail order). Subject to formulary guidelines. Nonpreferred drugs
Up to a 30day supply (retail); up to a 90day supply (mail order). Subject to formulary guidelines, when approved through the exception process.
Up to a 30day supply (retail). Subject to formulary guidelines, when approved through the exception process.
$200 retail and $400 mail order / prescription , deductible does not apply. Not covered
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at http:// www.kp.org/formulary Generic drugs
drugs $600 retail / prescription , deductible does not apply Not covered
NonPlan Providers are not covered when inside the service area.
$50 / visit, deductible does not apply
$50 / visit, deductible does not
None
Annual Wellness Visit and Virtual Care Services: No charge, deductible does not apply.
Depending on the type of services, a copayment , coinsurance , or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.)
Outpatient: 20 visit limit / therapy / year (autism
disorders not subject to visit limit). Autism spectrum disorders: No charge, deductible does not apply. Virtual Care Services: No charge, deductible does not apply. Inpatient: Limited to 60 days / condition / year.
20 visit limit / therapy / year (autism spectrum disorders not subject to visit limit). Autism spectrum disorders: No charge, deductible does not apply. Virtual Care Services: No charge, deductible does not apply.
100day limit / year.
Subject to formulary guidelines.
None
Limitations, Exceptions & Other Important Information
What You Will Pay NonPlan Provider (You will pay the most)
Limited to members up to the end of the year in which the member turns 19.
Limited to members up to the end of the year in which the member turns 19. One pair of frames and lenses or contact lenses / 24 months.
Limited to members up to the end of the month in which the member turns 19; limited coverage for diagnostic and preventive service s, minor restorative (fillings), simple extractions and crowns.
What You Will Pay Plan Provider (You will pay the least)
Services You May Need
Common Medical Event
Children's eye exam No charge, deductible does not apply Not covered
Children's glasses 50% coinsurance , deductible does not apply Not covered
Children's dental checkup No charge for preventive / diagnostic services after pediatric dental deductible . 50% coinsurance for basic / major services after pediatric dental deductible . Not covered
If your child needs dental or eye care
Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services
● Routine foot care
● Weight loss programs
Nonemergency care when traveling outside
● Hearing aids (Adult) the U.S.
● Routine eye care (Adult)
● Longterm care
Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
Infertility treatment
Chiropractic care (20 visit limit/year)
Dental care (Adult)
Hearing aids (Up to age 18)
Abortion
Acupuncture (10 visit limit/year)
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is shown in the chart below. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace . For more information about the Marketplace , visit www.HealthCare.gov or call 18003182596.
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim . This complaint is called a grievance or appeal . For more information about your rights, look at the explanation of benefits you will receive for that medical claim . Your plan documents also provide complete information on how to submit a claim , appeal , or a grievance for any reason to your plan . For more information about your rights, this notice, or assistance, contact the agencies in the chart below.
Contact Information for Your Rights to Continue Coverage & Your Grievance and Appeals
Oversight 18772672323 x61565 or www.cciio.cms.gov
Department of Health & Human Services, Center for Consumer Information & Insurance
Colorado Division of Insurance 3038947490 (instate, tollfree: 8009303745) or insurance@dora.state.co.us
Does this plan provide Minimum Essential Coverage? Yes. Minimum Essential Coverage generally includes plans , health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage , you may not be eligible for the premium tax credit . Does this plan meet the Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standards , you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace .
Language Access Services: SPANISH (Español): Para obtener asistencia en Español, llame al 18552495005 (TTY: 711)
TAGALOG (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 18552495005 (TTY: 711)
TRADITIONAL CHINESE (中文 ): 如果需要中文的帮助，请拨打这个号码 18552495005 (TTY : 711)
PENNSYLVANIA DUTCH (Deitsch): Fer Hilf griege in Deitsch, ruf 18552495005 (TTY: 711) uff
NAVAJO (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 18552495005 (TTY: 711)
SAMOAN (Gagana Samoa): Mo se fesoasoani i le Gagana Samoa, vala’au mai i le numera telefoni 18552495005 (TTY: 711)
CAROLINIAN (Kapasal Falawasch): ngere aukke ghut alillis reel kapasal Falawasch au fafaingi tilifon ye 18552495005 (TTY: 711)
CHAMORRO (Chamoru): Para un ma ayuda gi finu Chamoru, ȧ 'gang 18552495005 (TTY: 711)
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
Managing Joe's Type 2 Diabetes (a year of routine innetwork care of a wellcontrolled condition) Peg is Having a Baby (9 months of innetwork prenatal care and a hospital delivery) This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts ( deductibles , copayments and coinsurance ) and excluded services under the plan . Use this information to compare the portion of costs you might pay under different health plans . Please note these coverage examples are based on selfonly coverage.
Mia's Simple Fracture (innetwork emergency room visit and follow up care)
Colorado Supplement to the Summary of Benefits and Coverage Form
Plan is available only in the following counties: Adams, Arapahoe, Boulder, Broomfield, Clear Creek, Denver, Douglas, El Paso, Elbert, Fremont, Gilpin, Jefferson, Larimer, Park, Pueblo, Teller, and Weld
SUPPLEMENTAL INFORMATION REGARDING BENEFITS
Important Note: The contents of this form are subject to the provisions of the policy, which contains all terms, covenants and conditions of coverage. It provides additional information meant to supplement the Summary of Benefits of Coverage you have received for this plan. This plan may exclude coverage for certain treatments, diagnoses, or services not specifically noted. Consult the actual policy to dete rmine the exact terms and conditions of coverage.
INTERESTED POLICYHOLDERS, CERTIFICATE HOLDERS, AND ENROLLEES ARE HEREBY GIVEN NOTICE THAT THIS SMALL GROUP POLICY REQUIRES THAT AN INSURED TRAVEL OUTSIDE OF THE GEOGRAPHIC AREA TO RECEIVE COVERED HEALTH BENEFITS. This means if you live or work outside of the service area where this plan is available, you will have to travel into this service area to receive nonemergency or nonurgent covered services.
Description
4. Annual Deductible Type EMBEDDED DEDUCTIBLE INDIVIDUAL –The amount that each member of the family must meet prior to claims being paid. Claims will not be paid for any other individual until their individual deductible or the family deductible has been met. FAMILY –The maximum amount that the family will pay for the year. The family deductible can be met by [2] or more individuals. 5. Outof -
EMBEDDED OUTOFPOCKET INDIVIDUAL –The amount that each member of the family must meet prior to claims being paid at 100%. Claims will not be paid at 100% for any other individual until their individual outofpocket or the family outofpocket has been met. FAMILY –The maximum amount that the family will pay for the year. The family outofpocket can be met by 2 or more individuals.
6. What is included in the InNetwork OutofPocket Maximum? Deductibles, coinsurance and copayments.
7. Is pediatric dental covered by this plan? Yes, pediatric dental is subject to a separate $50 deductible.
8. What cancer screenings are covered? Breast Cancer (clinical breast exam, screening and/or imaging, genetic testing for inherited susceptibility for breast cancer); Colon and Rectal Cancer (fecal occult blood test (FIT), flexible sigmoidoscopy, barium enema, colonoscopy); Cervical Cancer (Pap test); Prostate Cancer (digital rectal exam, serum prostatic specific antigen (PSA))
INNETWORK OUTOFNETWORK
Yes, members may be responsible for any amounts over eligible Charges, except when Emergency Services are received in an OutofPlan Facility or from an OutofPlan Provider in a Plan Facility.
USING THE PLAN
9. If the provider charges more for a covered service than the plan normally pays, does the enrollee have to pay the difference? No
10. Does the plan have a binding arbitration clause? No
Questions: Call 18552495005 (TTY 711 ) or visit us at www.kp.org . SPANISH (Español): Para obtener asistencia en Español, llame al 18552495005 (TTY 711 ). This document is available for free in Spanish. Please contact our Member Services number at 3033383800 or toll free 18006329700 (TTY 711 ). Este documento está disponible de forma gratuita en español. Si desea información adicional, por favor llame al número de nuestro Servicio a los Miembros al
Colorado Division of Insurance
3033383800 or toll free 18006329700 . (Los usuarios de la línea TTY deben llamar al 711 ). If you are not satisfied with the resolution of your complaint or grievance, contact:
Consumer Services, Life and Health Section 1560 Broadway, Suite 850, Denver, CO 80202
Call: 3038947490 (instate, tollfree: 8009303745)
Email: dora_insurance@state.co.us
Summary of Benefits and Coverage: What this Plan Covers & What You Pay for
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan . The SBC shows you how you and the plan would share the cost for covered health care services.
NOTE: Information about the cost of this plan (called the premium ) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage see https://kp.org/plandocuments or call 18552495005 (TTY:711). For general definitions of common terms, such as allowed amount , balance billing , coinsurance , copayment , deductible , provider , or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbcglossary/ or call 18552495005 (TTY:711) to request a copy.
Why this Matters:
Important Questions Answers
Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan , each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible . Are there services covered before you meet your deductible ? Yes. Preventive care and services indicated in chart starting on page 2.
You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services.
$500 Individual / $1,000 Family
What is the overall deductible ?
This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible . See a list of covered preventive services at https://www.healthcare.gov/coverage/preventivecarebenefits/ . Are there other deductibles for specific services? Yes. $300 Individual for prescription drugs . $50 Individual for Pediatric Dental in Network . There are no other specific deductibles .
$7,500 Individual / $15,000 Family
What is the outofpocket limit for this plan ?
Premiums , health care this plan doesn’t cover, and services indicated in chart starting on page 2. Even though you pay these expenses, they don't count toward the outofpocket limit .
The outofpocket limit is the most you could pay in a year for covered services. If you have other family members in this plan , they have to meet their own outofpocket limits until the overall family outofpocket limit has been met. What is not included in the outofpocket limit ?
This plan uses a provider network . You will pay less if you use a provider in the plan’s network . You will pay the most if you use an outofnetwork provider , and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays ( balance billing ). Be aware, your network provider might use an outofnetwork provider for some services (such as lab work). Check with your provider before you get services.
Will you pay less if you use a network provider ? Yes. See www.kp.org or call 18552495005 (TTY: 711) for a list of network providers .
You may have to pay for services that aren't
. Ask your provider if the services needed are preventive . Then check what your plan will pay for.
You Will Pay NonPlan Provider (You will pay the most) Limitations, Exceptions & Other
Up to a 30day supply (retail); up to a 90day supply (mail order). Prescription refills of ongoing maintenance medications must be filled at a Kaiser Permanente Pharmacy. Subject to formulary guidelines. Formulary preventive and contraceptive drugs in all tiers are no charge, deductible does not apply.
Up to a 30day supply (retail); up to a 90day supply (mail order). Subject to formulary guidelines.
Up to a 30day supply (retail); up to a 90day supply (mail order). Subject to formulary guidelines, when approved through the exception process.
Up to a 30day supply (retail). Subject to formulary guidelines, when approved through the exception process.
None
None
You May Need What You Will Pay Plan Provider (You will pay the least)
$15 retail and $30 mail order / prescription , deductible does not apply. Not covered
$75 retail and $150 mail order / prescription , deductible does not apply. Not covered
Generic drugs
Preferred brand drugs
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at http:// www.kp.org/formulary
If you have outpatient surgery Facility fee (e.g., ambulatory surgery center)
$750 / visit, deductible does not apply
$750 / visit, deductible does not apply
20% coinsurance
Emergency room copayment waived if admitted directly to the hospital as an inpatient. Emergency medical transportation 20% coinsurance
NonPlan Providers are not covered when inside the service area.
Emergency room care
None Urgent care
If you need immediate medical attention
$75 / visit, deductible does not apply
$75 / visit, deductible does not apply
Cost sharing does not apply for preventive service s. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.)
You Will Pay NonPlan Provider (You will pay the most)
Less than 8 hours / day and 28 hours / week.
Services You May Need What You Will Pay Plan Provider (You will pay the least)
Outpatient: 20 visit limit / therapy / year (autism spectrum disorders not subject to visit limit). Autism spectrum disorders: $25 / visit, deductible does not apply. Virtual Care Services: No charge, deductible does not apply. Inpatient: Limited to 60 days / condition / year. Habilitation services
Outpatient services: $40 / visit, deductible does not apply. Inpatient service: 20% coinsurance . Not covered
Rehabilitation services
20 visit limit / therapy / year (autism spectrum disorders not subject to visit limit). Autism spectrum disorders: $25 / visit, deductible does not apply. Virtual Care Services: No charge, deductible does not apply.
day limit / year.
Subject to formulary guidelines.
Outpatient services: $40 / visit, deductible does not apply Not covered
Limitations, Exceptions & Other Important Information If you need help recovering or have other special health needs Home health care 20% coinsurance Not covered
No charge, deductible does not apply Not
Limited to members up to the end of the year in which the member turns 19. Children's glasses 50% coinsurance , deductible does not apply Not covered
Limited to members up to the end of the year in which the member turns 19. One pair of frames and lenses or contact lenses / 24 months.
None If your child needs dental or eye care
Children's eye exam $25 / visit, deductible does not apply Not covered
Limited to members up to the end of the month in which the member turns 19; limited coverage for diagnostic and preventive service s, minor restorative (fillings), simple extractions and crowns.
No charge for preventive care / diagnostic services after pediatric dental deductible . 50% coinsurance for basic / major services after pediatric dental deductible . Not covered
Children's dental checkup
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services .)
● Routine foot care
● Longterm care
● Weight loss programs the U.S.
● Nonemergency care when traveling outside
● Infertility treatment
● Privateduty nursing (Inpatient)
● Routine eye care (Adult)
● Cosmetic surgery
● Hearing aids (Adult)
● Chiropractic care (20 visit limit/year)
● Dental care (Adult)
● Hearing aids (Up to age 18)
● Abortion
● Acupuncture (10 visit limit/year)
● Bariatric surgery
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is shown in the chart below. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace . For more information about the Marketplace , visit www.HealthCare.gov or call 18003182596.
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim . This complaint is called a grievance or appeal . For more information about your rights, look at the explanation of benefits you will receive for that medical claim . Your plan documents also provide complete information on how to submit a claim , appeal , or a grievance for any reason to your plan . For more information about your rights, this notice, or assistance, contact the agencies in the chart below.
18552495005 (TTY: 711) or www.kp.org/memberservices
1866444EBSA (3272) or www.dol.gov/ebsa/healthreform
3038947490 (instate, tollfree: 8009303745) or insurance@dora.state.co.us Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
Contact Information for Your Rights to Continue Coverage & Your Grievance and Appeals Rights:
18772672323 x61565 or www.cciio.cms.gov
Kaiser Permanente Member Services
Department of Labor’s Employee Benefits Security Administration
Department of Health & Human Services, Center for Consumer Information & Insurance Oversight
Colorado Division of Insurance
Does this plan provide Minimum Essential Coverage? Yes.
Minimum Essential Coverage generally includes plans , health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage , you may not be eligible for the premium tax credit . Does this plan meet the Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standards , you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace
Language Access Services: SPANISH (Español): Para obtener asistencia en Español, llame al 18552495005 (TTY: 711)
TAGALOG (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 18552495005 (TTY: 711)
TRADITIONAL CHINESE (中文 ): 如果需要中文的帮助，请拨打这个号码 18552495005 (TTY : 711)
PENNSYLVANIA DUTCH (Deitsch): Fer Hilf griege in Deitsch, ruf 18552495005 (TTY: 711) uff
NAVAJO (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 18552495005 (TTY: 711)
SAMOAN (Gagana Samoa): Mo se fesoasoani i le Gagana Samoa, vala’au mai i le numera telefoni 18552495005 (TTY: 711)
CAROLINIAN (Kapasal Falawasch): ngere aukke ghut alillis reel kapasal Falawasch au fafaingi tilifon ye 18552495005 (TTY: 711)
CHAMORRO (Chamoru): Para un ma ayuda gi finu Chamoru, ȧ 'gang 18552495005 (TTY: 711)
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
Examples:
Managing Joe's Type 2 Diabetes (a year of routine innetwork care of a wellcontrolled condition) Peg is Having a Baby (9 months of innetwork prenatal care and a hospital delivery) This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts ( deductibles , copayments and coinsurance ) and excluded services under the plan . Use this information to compare the portion of costs you might pay under different health plans . Please note these coverage examples are based on selfonly coverage.
Mia's Simple Fracture (innetwork emergency room visit and follow up care)
$65 20% 20% This EXAMPLE event includes services like: Specialist office visits ( prenatal care ) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests ( ultrasounds and blood work ) Specialist visit ( anesthesia ) This EXAMPLE event includes services like: Primary care physician office visits ( including disease education ) Diagnostic tests ( blood work ) Prescription drugs Durable medical equipment ( glucose meter )
EXAMPLE event includes services like: Emergency room care ( including medical supplies ) Diagnostic test ( xray ) Durable medical equipment ( crutches ) Rehabilitation services ( physical therapy ) In this example, Peg would
Colorado Supplement to the Summary of Benefits and Coverage Form
INSURANCE COMPANY NAME Kaiser Foundation Health Plan of Colorado NAME OF PLAN KP CO Gold 500/25
Health maintenance organization (HMO)
1. Type of Policy Small Employer Group Policy 2. Type of plan
3. Areas of Colorado where plan is available. Plan is available only in the following counties: Adams, Arapahoe, Boulder, Broomfield, Clear Creek, Denver, Douglas, El Paso, Elbert, Fremont, Gilpin, Jefferson, Larimer, Park, Pueblo, Teller, and Weld KP Select Plan: El Paso and Teller
SUPPLEMENTAL INFORMATION REGARDING BENEFITS
Important Note: The contents of this form are subject to the provisions of the policy, which contains all terms, covenants and conditions of coverage. It provides additional information meant to supplement the Summary of Benefits of Coverage you have received for this plan. This plan may exclude coverage for certain treatments, diagnoses, or services not specifically noted. Consult the actual policy to dete rmine the exact terms and conditions of coverage.
INTERESTED POLICYHOLDERS, CERTIFICATE HOLDERS, AND ENROLLEES ARE HEREBY GIVEN NOTICE THAT THIS SMALL GROUP POLICY REQUIRES THAT AN INSURED TRAVEL OUTSIDE OF THE GEOGRAPHIC AREA TO RECEIVE COVERED HEALTH BENEFITS.
This means if you live or work outside of the service area where this plan is available, you will have to travel into this service area to receive nonemergency or nonurgent covered services.
Description
4. Annual Deductible Type EMBEDDED DEDUCTIBLE INDIVIDUAL –The amount that each member of the family must meet prior to claims being paid. Claims will not be paid for any other individual until their individual deductible or the family deductible has been met. FAMILY –The maximum amount that the family will pay for the year. The family deductible can be met by [2] or more individuals.
5. OutofPocket Maximum EMBEDDED OUTOFPOCKET INDIVIDUAL –The amount that each member of the family must meet prior to claims being paid at 100%. Claims will not be paid at 100% for any other individual until their individual outofpocket or the family outofpocket has been met.
6. What is included in the InNetwork OutofPocket Maximum? Deductibles, coinsurance and copayments.
7. Is pediatric dental covered by this plan? Yes, pediatric dental is subject to a separate $50 deductible.
8. What cancer screenings are covered? Breast Cancer (clinical breast exam, screening and/or imaging, genetic testing for inherited susceptibility for breast cancer); Colon and Rectal Cancer (fecal occult blood test (FIT), flexible sigmoidoscopy, barium enema, colonoscopy); Cervical Cancer (Pap test); Prostate Cancer (digital rectal exam, serum prostatic specific antigen (PSA))
INNETWORK OUTOFNETWORK
Yes, members may be responsible for any amounts over eligible Charges, except when Emergency Services are received in an OutofPlan Facility or from an OutofPlan Provider in a Plan Facility.
10. Does the plan have a binding arbitration clause? No FAMILY –The maximum amount that the family will pay for the year. The family outofpocket can be met by 2 or more individuals.
USING THE PLAN
No
9. If the provider charges more for a covered service than the plan normally pays, does the enrollee have to pay the difference?
Questions: Call 18552495005 (TTY 711 ) or visit us at www.kp.org . SPANISH (Español): Para obtener asistencia en Español, llame al 18552495005 (TTY 711 ). This document is available for free in Spanish. Please contact our Member Services number at 3033383800 or toll free 18006329700 (TTY 711 ). Este documento está disponible de forma gratuita en español. Si desea información adicional, por favor llame al número de nuestro Servicio a los Miembros al 3033383800 or toll free 18006329700 . (Los usuarios de la línea TTY deben llamar al 711 ). If you are not satisfied with the resolution of your complaint or grievance, contact:
Colorado Division of Insurance Consumer Services, Life and Health Section 1560 Broadway, Suite 850, Denver, CO 80202
Call: 3038947490 (instate, tollfree: 8009303745)
Email: dora_insurance@state.co.us
Health Savings Account (HSA) Kaiser Permanente
ABOUT HSA
A Health Savings Account (HSA) is a personal savings account where the money can only be used for eligible medical expenses. Unlike a flexible spending account (FSA), the money rolls over year to year however only those funds that have been deposited in your account can be used. Contributions to a Health Savings Account can only be used if you are also enrolled in a High Deductible Health Care Plan (HDHP).
For full plan details, please visit your benefit website: www.mybenefitshub.com/worldcompassacademy
With a health savings account (HSA) plan,1 you can be prepared to spend on what matters most — your health. The money contributed to your HSA isn’t considered part of your wages, so you won’t be taxed on it as long as you use the money for qualified medical expenses.2 You also won’t pay taxes on HSA funds when you withdraw them to pay for qualified medical expenses. As a bonus, your HSA also might provide investment opportunities.
Using your HSA plan
With your Kaiser Permanente HSA-Qualified Deductible HMO Plan, your employer supports your well-being with an HSA.
How your HSA works
Once you’ve enrolled in your health plan, you can set up an HSA and contribute tax-free funds to it.3 You can use your HSA funds to pay for qualified medical expenses,4 including:
• Doctor and hospital visits
• Prescription drugs
It’s easy to get the care
you need
• Primary and specialty care visits
• X-rays and lab tests
• Choose your doctor. Select a Kaiser Permanente doctor or an affiliated plan doctor. As one of the largest multispecialty medical groups in Colorado, Kaiser Permanente physicians work together in one connected system to deliver better care. If your needs shift, you can make a change, anytime. Visit kp.org/locations to search for Kaiser Permanente physicians and affiliated plan providers near you.5
• Get care all in one stop. Visit one of our medical offices to see a doctor, or get lab work and X-rays done, all in the same place. In most locations, you can even pick up a prescription.6
• Connect to care wherever you are. No time for an appointment? No problem. Connect with your Kaiser Permanente care team through email, online chat, phone, or even video visits, without leaving home or work.6
• Stay healthy. With a focus on preventive care, physicals, adult screenings, well-woman care, well-child care, and certain immunizations are covered at no charge — and you don’t have to meet a deductible. We also provide online tools and resources to help you manage your health.
How it works
• Getting care. When you receive care, you’ll pay the full cost for most services until you reach a set amount known as your deductible.7
• Value. You’ll pay coinsurance for most services covered by your plan. Coinsurance helps limit your costs for many types of care, while your out-of-pocket maximum puts a cap on how much you’ll pay for covered services each plan year.
Health Savings Account (HSA)
Kaiser Permanente
Prescriptions
You can always fill or refill your prescriptions at any Kaiser Permanente pharmacy. Depending on the type of medication, you may also be able to fill your formulary prescriptions at an affiliated plan pharmacy, or have them delivered to your doorstep using mail-order pharmacy or our convenient same-day/next-day delivery service.8
New to Kaiser Permanente? Don’t worry. Our clinical pharmacists will work with you and your doctor to understand our formulary and transfer your prescriptions. Our formulary is listed online at kp.org/formulary, or you can contact our Clinical Pharmacy Call Center at 1 (866) 244-4119 (TTY 711), 8 a.m. to 6 p.m., weekdays.
Emergency and inpatient care
When it comes to urgent and emergency care, you’re covered anywhere in the world. For scheduled inpatient care, you’ll have a choice of hospitals close to home. Visit kp.org/locations to find a location near you.
Easy ways to manage your health
Personalized online wellness programs, webinars, and classes give you the tools to fit wellness into your schedule, no matter how busy you are.9 And, if you have a chronic condition such as asthma, heart disease, or diabetes, we provide extra coordinated support through our chronic care management programs, including assistance with complex care needs.
Questions?
Call Member Services at (303) 338-3800 or toll-free 1 (800) 632-9700. Representatives are available weekdays from 8 a.m. to 6 p.m. TTY users may call 711 for assistance with any phone number above.
Information provided here is a summary only. For a list of services available with your plan, refer to your Summary of Benefits and Coverage. Upon enrollment, your plan documents will contain a description of your coverage, including benefits, exclusions, and limitations. Your plan documents will prevail over this or any other plan summary. 1. Colorado state law requires that an access plan be available that describes Kaiser Foundation Health Plan of Colorado’s network provider services. To obtain a copy, please call Member Services, or visit kp.org. 2. The tax references in this document relate to federal income tax only. Consult with your financial or tax adviser for information about state income tax laws. 3. To be eligible for an HSA, you must be enrolled in an HSA-qualified deductible health plan and meet other HSA eligibility rules. For more information, see IRS Publication 969, Health Savings Accounts and Other Tax-Favored Health Plans, at irs.gov/publications. Kaiser Foundation Health Plan of Colorado does not offer financial, tax, or investment advice. Members are responsible for their own investment decisions. 4. For a full list of qualified medical expenses under Internal Revenue Code Section 213(d), see IRS Publication 502, Medical and Dental Expenses, at irs. gov/publications. 5. Choice of providers varies by plan, location, and availability at the time of selection, and is subject to change. Please see a list of providers included in your plan at kp.org/ locations. 6. These services are available when you receive care at Kaiser Permanente medical offices. Phone and video visits are available when appropriate and may not be available in select states due to licensing laws. Laws differ by state. 7. Coverage may be based on the calendar or contract year, depending on your specific plan provisions. See your Summary of Benefits and Coverage for details. 8. Depending on your specific plan provisions, maintenance medication refills must be filled at one of our Kaiser Permanente medical office pharmacies or through the Kaiser Permanente mail-order program or the maintenance medication will not be covered. Same-day and next-day prescription delivery services may be available for an additional fee. These services are not covered under your health plan benefits and may be limited to specific prescription drugs, pharmacies, and areas. Order cutoff times and delivery days may vary by pharmacy location. Kaiser Permanente is not responsible for delivery delays by mail carriers. Kaiser Permanente may discontinue same-day and next-day prescription delivery services at any time without notice and other restrictions may apply. 9. Some classes may require a fee.
Kaiser Foundation Health Plan of Colorado, 10350 E. Dakota Ave., Denver, CO 80247
Hospital Indemnity Chubb
ABOUT HOSPITAL INDEMNITY
This is an affordable supplemental plan that pays you should you be inpatient hospital confined. This plan complements your health insurance by helping you pay for costs left unpaid by your health insurance.
For full plan details, please visit your benefit website: www.mybenefitshub.com/worldcompassacademy
First Hospitalization Benefit
This benefit is payable for the first covered hospital confinement per certificate.
Hospital Admission Benefit
This benefit is for admission to a hospital or hospital sub-acute intensive care unit.
Hospital Admission ICU Benefit
This benefit is for admission to a hospital intensive care unit.
Hospital Confinement Benefit
This benefit is for confinement in hospital or hospital sub-acute intensive care unit.
Hospital Confinement ICU Benefit
The benefit for confinement in a hospital intensive care unit.
Newborn Nursery Benefit
This benefit is payable for an insured newborn baby receiving newborn nursery care and who is not confined for treatment of a physical illness, infirmity, disease or injury.
Observation Unit Benefit
This benefit is for treatment in a hospital observation unit for a period of less than 20 hours.
Wellness Benefit
Waiting Period
Maximum Benefit Per Calendar Year: 5
$100 Per Day First Day: $100 Maximum Days Per Calendar Year: 30
$200 Per Day First Day: $200 Maximum Days Per Calendar Year: 30
$500 Per Day
Maximum Days Per Confinement - Normal Delivery: 2
Maximum Days Per Confinement - Caesarean Section: 2
$500
3
$200 Per Day First Day: $200 Maximum Days Per Calendar Year: 30
$400 Per Day
First Day: $400
Maximum Days Per Calendar Year: 30
$500 Per Day
Maximum Days Per Confinement - Normal Delivery: 2
Maximum Days Per Confinement
- Caesarean Section: 2
Maximum Benefit Per Calendar Year: 2 $500 Maximum Benefit Per Calendar Year: 2
$50 Per Day
Maximum Days Per Calendar Year: 1 0 days
$50 Per Day
Maximum Days Per Calendar Year: 1 0 days
Chubb Hospital Indemnity for Covered Accidents and Sickness
Minutes
Did you know?
The average wait time for an urgent care consult is only 10 minutes.
Product Details
24/7 Access
Recuro physicians are available whenever our patients need them, day or night.
Integrated Prescriptions
Prescriptions are immediately sent to the patient’s preferred pharmacy for easy pickup.
Primary Care Coordination
Primary care and behavioral health can be integrated with urgent care.
Multi-Channel
Options
Live video, phone, and messaging options let each patient receive care the way they like.
Consult Transcription
Consults can be recorded and transcribed, allowing patients continuous access to information.
Conditions Treated
Acne / Rashes
Allergies
Cold / Flu / Cough
GI Issues
Ear Problems
Fever / Headache
Insect Bites
Nausea / Vomiting
Pink Eye
Respiratory Issues
UTI’s / Vaginitis
And More
Virtual Behavioral Health
Co laborative Mental We lness
Comprehensive behavioral health care from therapy and counseling to psychiatry and medication management.
Product Highlights
Holistic Targeted Accessible
Primary care and behavioral health doctors collaborate closely to ensure coordinated treatment plans that care for the whole patient.
Pharmacogenetic (PGx) testing ensures the right behavioral health medication is prescribed, the first time.
While today behavioral healthcare is difficult to access for so many, at Recuro it is available and affordable.
Dental Insurance
Vision Insurance
ABOUT VISION
Vision insurance provides coverage for routine eye examinations and can help with covering some of the costs for eyeglass frames, lenses or contact lenses.
For full plan details, please visit your benefit website: www.mybenefitshub.com/worldcompassacademy
Insight network
EXAM SERVICES
Exam at PLUS Providers
Exam
Retinal Imaging
CONTACT LENS FIT AND FOLLOW-UP
Fit and Follow-up - Standard
Fit and Follow-up - Premium
FRAME
Frame at PLUS Provider
Frame
STANDARD PLASTIC LENSES
Single Vision
Bifocal
Trifocal/Lenticular
Progressive - Standard
Progressive - Premium Tier 1 - 4
LENS OPTIONS
Anti Reflective Coating - Standard
Anti Reflective Coating - Premium Tier 1 - 2
Anti Reflective Coating - Premium Tier 3
Photochromic - Non-Glass
Polycarbonate - Standard
Polycarbonate - Std < 19 years of age
Scratch Coating
Tint
UV Treatment
All Other Lens Options
CONTACT LENSES
Contacts - Conventional at Plus Providers
Contacts - Conventional
Contacts - Disposable at Plus Providers
Contacts - Disposable
Contacts - Medically Necessary
OTHER
Hearing Care from Amplifon Network
Lasik or PRK from U.S. Laser Network
SCHEDULE OF BENEFITS
$0 copay $10 copay Up to $39
Up to $40 Up to $40 Not covered
Up to $40; contact lens fit and two follow-up visits 10% off retail price Not covered Not covered
40% OFF additional complete pair of prescription eyeglasses
20 % OFF non-covered items, including nonprescription sunglasses
Frequency
to $75
$0 copay; 20% off balance over $200 allowance $0 copay; 20% off balance over $150 allowance Up to $75
$25 copay
$25 copay
$25 copay
$80 copay
$110 - 240 Up to $30 Up to $50 Up to $70 Up to $50 Up to $50
$45 copay
$57 - 68
$100 copay $75 $40 $0 copay $15 $15
20% off retail price
$0 copay; 15% off balance over $200 allowance
$0 copay; 15% off balance over $150 allowance
$0 copay; 100% of balance over $200 allowance
$0 copay; 100% of balance over $150 allowance
$0 copay; paid-in-full
Discounts on hearing aids; call 1.877.203.0675 15% off retail or 5% off promo price; call 1.800.988.4221
Up to $23
Up to $23 Up to $23 Not covered Not covered
Up to $20 Not covered Not covered Not covered Not covered
Up to $75
Up to $75
Up to $75
Up to $75
Up to $300
Not covered Not covered
• Exam once every plan year
• Frame once every plan year
• Lens once every plan year
• Contact Lens once every plan year
Plan allows member to receive frame and lens services or contacts
Disability Insurance
ABOUT DISABILITY
Disability insurance protects one of your most valuable assets, your paycheck. This insurance will replace a portion of your income in the event that you become physically unable to work due to sickness or injury for an extended period of time.
For full plan details, please visit your benefit website: www.mybenefitshub.com/worldcompassacademy
GROUP SHORT-TERM DISABILITY INSURANCE BENEFIT HIGHLIGHTS
Just over 1 in 4 of today’s 20 year-olds will become disabled before they retire (age 67).1
World Compass Academy
A disability can happen to anyone. A back injury, pregnancy, or serious illness can lead to months without a regular paycheck. If you’re unable to work for a short period of time due to a non-
PREMIUMS
Your employer pays 100% of the premium for your coverage.2
ASKED & ANSWERED WHO IS ELIGIBLE?
workrelated condition, illness or injury, short-term disability insurance offers financial protection by paying you a portion of your earnings.
To learn more about Short-Term Disability insurance, visit www.thehartford.com/employee-benefits/employees
You are eligible if you are an active full time employee who works at least 30 hours per week on a regularly scheduled basis.
AM I GUARANTEED COVERAGE?
This insurance is guaranteed issue coverage - it is available without having to provide information about your health.
WHEN CAN I ENROLL?
Your employer will automatically enroll you for this coverage.
WHEN DOES THIS INSURANCE BEGIN?
This insurance will become effective on the date you become eligible. You must be actively at work with your employer on the day your coverage takes effect.
WHEN DOES THIS INSURANCE END?
This insurance will end when you no longer satisfy the applicable eligibility conditions, premium is unpaid, you leave your employer, or the coverage is no longer offered.
WHAT DOES IT MEAN TO BE DISABLED?
Disability is defined in The Hartford’s certificate with your employer.
Due to accidental bodily injury, sickness, mental illness, substance abuse or pregnancy you are unable to perform the essential duties of your occupation, and as a result, you are earning 20% or less of your pre-disability weekly earnings or you are able to perform some, but not all, of the essential duties of your occupation and as a result, you are earning more than 20% but less than 80% of your predisability weekly earnings.
Pre-disability earnings are defined in your policy.
Disability Insurance
The Hartford
GROUP VOLUNTARY LONG-TERM DISABILITY INSURANCE BENEFIT HIGHLIGHTS
More than 1 in 4 adults in the U.S. has some type of disability.1
World Compass Academy
A disability can happen to anyone. Long-term disability insurance helps protect your paycheck if you’re unable to work for a long period of time after a serious condition, injury or sickness.
To learn more about Long-Term Disability insurance, visit www.thehartford.com/employee-benefits/employees COVERAGE
INFORMATION
(PERCENT OF YOUR EARNINGS)
(BASED ON MONTHLY INCOME LOSS BEFORE THE DEDUCTION OF OTHER INCOME BENEFITS)
• Disabled before: Age 63
• Benefit duration: As long as you are disabled
• Benefit duration maximum: The greater of your Social Security
• Normal Retirement Age or 4 years
ASKED & ANSWERED
WHO IS ELIGIBLE?
You are eligible if you are an active full time employee who works at least 30 hours per week on a regularly scheduled basis.
AM I GUARANTEED COVERAGE?
If you elect coverage during your scheduled enrollment period or if this is the first time you are eligible to elect coverage, evidence of insurability is not required.
Outside your scheduled enrollment period and during a family status change period, evidence of insurability is required to elect coverage for the first time.
This coverage is subject to a pre-existing condition exclusion, which is detailed on the Limitations & Exclusions sheet. Please refer to the Limitations & Exclusions sheet provided with this benefit highlights sheet for more information on limitations and exclusions, such as preexisting conditions.
HOW MUCH DOES IT COST AND HOW DO I PAY FOR THIS INSURANCE?
Premium is provided on the Premium Worksheet.
Premiums will be automatically paid through payroll deduction, as authorized by you during the enrollment process. This ensures you don’t have to worry about writing a check or missing a payment.
WHEN CAN I ENROLL?
You may enroll during any scheduled enrollment period, or within 31 days of the date you have a change in family status.
WHEN
DOES THIS INSURANCE BEGIN?
Insurance will become effective in accordance with the terms of the certificate (usually the first day of the month following the date you elect coverage).
You must be actively at work with your employer on the day your coverage takes effect.
Disability Insurance
The Hartford
Traditional LTD and STD Disability - Definitions
What is disability insurance? Disability insurance protects one of your most valuable assets, your paycheck. This insurance will replace a portion of your income in the event that you become physically unable to work due to sickness or injury for an extended period of time.
Pre-Existing Condition Limitations - Please note that all plans will include pre-existing condition limitations that could impact you if you are a first-time enrollee in your employer’s disability plan. This includes during your initial new hire enrollment. Please review your plan details to find more information about pre-existing condition limitations.
How do I choose which plan to enroll in during my open enrollment?
You will enroll in Long Term and Short Term Disability on two separate pages during your open enrollment walkthrough. Generally your short term coverage and long term coverage work together so that once your short term coverage ends, at that time your long term coverage would begin if you are still disabled and approved to remain on your claim. In other words, your short term coverage may continue for up to 12 weeks and your long term coverage begins the 13th week.
Your short term coverage will generally be a weekly benefit. This is the maximum amount of money you will receive from the carrier on a weekly basis once your disability claim is approved by the carrier. This is generally a flat percentage of your salary.
Your long term coverage will generally be a monthly benefit. This is the maximum amount of money you will receive from the carrier on a monthly basis once your disability claim is approved by the carrier. This is generally a flat percentage of your salary.
Life and AD&D
New York Life
ABOUT LIFE AND AD&D
Group term life is the most inexpensive way to purchase life insurance. You have the freedom to select an amount of life insurance coverage you need to help protect the well-being of your family.
Accidental Death & Dismemberment is life insurance coverage that pays a death benefit to the beneficiary, should death occur due to a covered accident. Dismemberment benefits are paid to you, according to the benefit level you select, if accidentally dismembered.
For full plan details, please visit your benefit website: www.mybenefitshub.com/worldcompassacademy
Compass Academy Voluntary Life Schedule of Benefits Summary
Units of $10,000 to the lesser of 7 times salary or $500,000
lesser of 7 times annual compensation or $150,000
Eligibility Employees must participate in voluntary plan for dependents to participate
Spouse Life Benefit Units of $5,000 to the lesser of $250,000 or 50% of Employee’s
World
New York Life
Benefits:
Employee Benefit
Coverage
Loss of Life
Voluntary AD&D
Units of $10,000 to the lesser of 7 times salary or $500,000
Voluntary, Employee paid, 24 Hour Accidental Death & Dismemberment Benefits. Other enhancements will be defined in the policy.
100% of the Principal Sum Dismemberment
Loss of Two or More Hands or Feet
Loss of Sight of Both Eyes
Loss of Speech and Hearing (in both ears)
Quadriplegia (Total paralysis of upper and lower limbs)
Paraplegia (Total paralysis of both lower or both upper limbs)
Hemiplegia (Total paralysis of upper and lower limbs on one side of the body)
Uniplegia (Total paralysis of one upper or one lower limb)
Loss of One Hand or Foot
Loss of Sight in One Eye
Severance and Reattachment of One Hand or Foot
Loss of Speech
Loss of Hearing (in both ears)
Loss of Thumb and Index Finger of the Same Hand
Loss of all Four Fingers of the Same Hand
Loss of all the Toes of the Same Foot
Spouse Benefit
Spouse Maximum Principal Sum
Child Benefit
Benefit Reductions
100% of the Principal Sum
100% of the Principal Sum
100% of the Principal Sum
100% of the Principal Sum
75% of the Principal Sum
50% of the Principal Sum
25% of the Principal Sum
50% of the Principal Sum
50% of the Principal Sum
50% of the Principal Sum
50% of the Principal Sum
50% of the Principal Sum
25% of the Principal Sum
25% of the Principal Sum
20% of the Principal Su
Units of $5,000 to $250,000
Spouse coverage terminates at age 70
$250,000
Flat $10,000
We can help you meet your Age Discrimination in Employment Act (ADEA) responsibilities by extending coverage to all active employees, regardless of age.
Benefits reduced for employees based on ages at time of accident according to the following schedule:
50% at age 70
Critical Illness Insurance Chubb
ABOUT CRITICAL ILLNESS
Critical illness insurance can be used towards medical or other expenses. It provides a lump sum benefit payable directly to the insured upon diagnosis of a covered condition or event, like a heart attack or stroke. The money can also be used for non-medical costs related to the illness, including transportation, child care, etc.
For full plan details, please visit your benefit website: www.mybenefitshub.com/worldcompassacademy
Chubb’s innovative approach to Critical Illness combines ongoing benefit solutions to lessen the financial impact of serious illnesses along with advocacy packages to help employees manage diabetes, change their behavior, promote recovery and wellness.
Benefit Amount (X Face Amount)
– Pays a percentage of face amount
once
Pays 100% of the face amount; Benefits payable for HIV or Hepatitis B, C, or D, MRSA, Rabies, Tetanus, or Tuberculosis contracted on the job.
Childhood Conditions
Pays 100% of the dependent child face amount; Provides benefits for childhood conditions (Autism Spectrum Disorder; Cerebral Palsy; Congenital Birth Defects; Heart, Lung, Cleft Lip, Palate, etc; Cystic Fibrosis; Down Syndrome; Gaucher Disease; Muscular Dystrophy; Type 1 Diabetes).
Miscellaneous Disease Rider + COVID-19
The Miscellaneous Disease Rider is payable once per covered condition.
Covered Conditions include: Addison’s Disease, Cerebrospinal Meningitis, COVID-19, Diphtheria, Huntington’s Chorea, Legionnaire’s Disease, Malaria, Myasthenia Gravis, Meningitis, Necrotizing Fasciitis, Osteomyelitis, Polio, Rabies, Scleroderma, Systemic Lupus, Tetanus, Tuberculosis. COVID-19 means a disease resulting in a positive COVID-19 diagnostic screening and 5 consecutive days of hospital confinement.
Critical Illness Insurance
Benefits are payable for a subsequent diagnosis of Aneurysm - Cerebral or Aortic, Benign Brain Tumor, Cancer, Coronary Artery Obstruction, Heart Attack, Major Organ Failure, Stroke, or Sudden Cardiac Arrest.
* No benefits will be paid for a date of diagnosis that occurs prior to the coverage effective date
- Covered individuals must be treatment free from cancer for 12 months prior to diagnosis date and in complete remission
- There is no pre-existing conditions limitation
- All amounts are Guaranteed Issue - no medical questions required for coverage to be issued
Accident Insurance The Hartford
ABOUT ACCIDENT
Do you have kids playing sports, are you a weekend warrior, or maybe you’re accident prone? Accident plans are designed to help pay for medical costs associated with accidents and benefits are paid directly to you.
For full plan details, please visit your benefit website: www.mybenefitshub.com/worldcompassacademy
GROUP VOLUNTARY ACCIDENT INSURANCE BENEFIT HIGHLIGHTS
Nearly 3 million emergency department visits every year are caused by youth sports 1
World Compass Academy
With Accident insurance, you’ll receive payment(s) associated with a covered injury and related services. You can use the payment in any way you choose – from expenses not covered by your major medical plan to day-to-day costs of living such as the mortgage or your utility bills.
To learn more about Accident insurance, visit www.thehartford.com/employee-benefits/employees
COVERAGE INFORMATION
This insurance provides benefits when injuries, medical treatment and/or services occur as the result of a covered accident. Unless otherwise noted, the benefit amounts payable under each plan are the same for you and your dependent(s).
Accident Insurance
The Hartford
PREMIUMS
The amounts shown are monthly amounts (12 payments/ deductions per year):4
ASKED & ANSWERED WHO IS ELIGIBLE?
You are eligible for this insurance if you are an active full-time employee who works at least 30 hours per week on a regularly scheduled basis.
Your spouse and child(ren) are also eligible for coverage. Any child(ren) must be under age 26.
CAN I INSURE MY DOMESTIC OR CIVIL UNION PARTNER?
Yes. Any reference to “spouse” in this document includes your domestic partner, civil union partner or equivalent, as recognized and allowed by applicable law.
AM I GUARANTEED COVERAGE?
This insurance is guaranteed issue coverage – it is available
without having to provide information about your or your family’s health. All you have to do is elect the coverage to become insured.
HOW MUCH DOES IT COST AND HOW DO I PAY FOR THIS INSURANCE?
Premiums are provided above. You may elect insurance for you only, or for you and your dependent(s), by choosing the applicable coverage tier.
Premiums will be automatically paid through payroll deduction, as authorized by you during the enrollment process. This ensures you don’t have to worry about writing a check or missing a payment.
WHEN CAN I ENROLL?
You may enroll during any scheduled enrollment period.
WHEN DOES THIS INSURANCE BEGIN?
Insurance will become effective in accordance with the terms of the certificate (usually the first day of the month following the date you elect coverage).
You must be actively at work with your employer on the day your coverage takes effect. Your spouse and child(ren) must be performing normal activities and not be confined (at home or in a hospital/care facility), unless already insured with the prior carrier.
2025 Plan Year
Enrollment Guide General Disclaimer: This summary of benefits for employees is meant only as a brief description of some of the programs for which employees may be eligible. This summary does not include specific plan details. You must refer to the specific plan documentation for specific plan details such as coverage expenses, limitations, exclusions, and other plan terms, which can be found at the World Compass Academy Benefits Website. This summary does not replace or amend the underlying plan documentation. In the event of a discrepancy between this summary and the plan documentation the plan documentation governs. All plans and benefits described in this summary may be discontinued, increased, decreased, or altered at any time with or without notice.
Rate Sheet General Disclaimer: The rate information provided in this guide is subject to change at any time by your employer and/or the plan provider. The rate information included herein, does not guarantee coverage or change or otherwise interpret the terms of the specific plan documentation, available at the World Compass Academy Benefits Website, which may include additional exclusions and limitations and may require an application for coverage to determine eligibility for the health benefit plan. To the extent the information provided in this summary is inconsistent with the specific plan documentation, the provisions of the specific plan documentation will govern in all cases.