5.7 Group Health Insurance - EBMC
(revised July 2003)
Kenyon College is interested in the health and well-being of both you and your family. Accordingly, a comprehensive health insurance program is available for benefit-eligible employees, their spouses, and/or same- or opposite-sex domestic partners and their children. Participation in the College's health insurance program is optional and becomes effective on the first day of eligible employment.
Premiums are based on salary levels. Please contact the Office of Human Resources for current premiums and rates of participation.
- 5.7.1 Schedule of Benefits - General Plan Information
- 5.7.2 Enrollment Information for Domestic Partners
- 5.7.3 Change in Family Status
- 5.7.4 Medical Insurance During Leaves
- 5.7.5 Health Insurance at Retirement
- 5.7.6 Health Insurance During a Medical Leave of Absence
- 5.7.7 Medical Insurance: Total Disability
- 5.7.8 Health Insurance for Eligible Dependents After Death of an Active Employee
- 5.7.9 Termination of Insurance/Consolidated Omnibus Budget Reconciliation Act (COBRA)
- 5.7.10 Flexible Reimbursement Accounts (Flex Plan)
5.7.1 Schedule of Benefits - General Plan Information
(revised July 2003)
The following benefits are provided, as further defined and limited in the literature provided by Kenyon College and EBMC:
Benefit Period 7/1 through 6/30
Dependent Age Limit end of year of 23rd birthday provided full time student status is maintained
Pre-Existing Condition Waiting Period 90 Days
Copayment As set forth in the Schedule of benefits provided at enrollment
Deductible per benefit period
High Plan:
Individual $250
Family $500
Low Plan:
Individual $500
Family $1,000
Coinsurance
High Plan:
Preferred Provider 20%
Non-Preferred Provider 40%
Low Plan:
Preferred Provider 30%
Non-Preferred Provider 50%
Coinsurance Limits
High Plan:
Preferred Provider
A. Individual $ 1,000
B. Family $2,000
Non-Preferred Provider
A. Individual $2,000
B. Family $4,000
Low Plan:
A. Individual $ 3,000
B. Family $6,000
Non-Preferred Provider
A. Individual $5,000
B. Family $10,000
Amounts incurred toward the Preferred Provider Coinsurance Limit will be applied to the Non-Preferred Provider Coinsurance Limit. In addition, amounts incurred toward the Non-Preferred Provider Coinsurance Limit will be applied to the Preferred Provider Coinsurance Limit.
Lifetime Maximum Benefit $2,000,000
HEALTH CARE COVERAGE
| High Plan: | ||
| Preferred Provider | Non-Preferred Provider | |
| Inpatient Hospital Services | 20% After Deductible | 40% After Deductible |
| Inpatient Medical Services | 20% After Deductible | 40% After Deductible |
| Surgical Services | 20% After Deductible | 40% After Deductible |
| Outpatient Services | ||
| Physician Office Visits | $15 Copayment, No Deductible and No Coinsurance* | 40% After Deductible |
| *Except as may be specified for specific Outpatient services, tests, screenings as noted in this Schedule of Benefits, Physician Office Visits rendered by a Preferred Provider will be subject to this Copayment. | ||
| Diagnostic Services | 20% After Deductible | 40% After Deductible |
| Physical Therapy | 20% After Deductible | 40% After Deductible |
| Chiropractic Care | 20% After Deductible | 40% After Deductible |
| Child Preventative Care Services* | $15 Copayment, No Deductible and No Coinsurance | 40% After Deductible |
| * Benefits for these services are limited to age 9. | ||
| Routine Mammography Screenings** | 20% After Deductible | 40% After Deductible |
** Benefits for these services are limited to $85 per screening. In addition, routine mammography screenings will be covered on an outpatient basis subject to the following schedule:
| ||
| Routine Prostate Cancer Screenings *** | 20% After Deductible 40% | After Deductible |
*** Benefits for these services are limited to one per benefit period and $65 per screening. In addition, routine prostatic screenings will be covered on an outpatient basis subject to the following schedule:
| ||
| All Other Services Listed in Outpatient Services Section | 20% After Deductible | 40% After Deductible |
| Psychiatric and Substance- Abuse Services | ||
| Inpatient Services | 20% After Deductible | 40% After Deductible |
| Outpatient Services | 50% up to $550, then 20% After Deductible | 50% up to $550, then 40% After Deductible |
| Home Health Care Services | 20% After Deductible | 40% After Deductible |
| Skilled Nursing Facility Services | 20% After Deductible | 40% After Deductible |
| Ambulance Services | 20% After Deductible | 40% After Deductible |
| Private Duty Nursing Services | 20% After Deductible | 40% After Deductible |
| Prescription Drugs | Not covered under your Medical Coverage. Refer to your Prescription Drug Coverage at the end of your Schedule of Benefits. | |
| Medical Supplies, Equipment & Appliances | 20% After Deductible | 40% After Deductible |
| Human Organ Transplant Services | ||
| Transplant Surgery | 20% After Deductible up to a $250,000 lifetime maximum | 40% After Deductible up to a $250,000 lifetime maximum |
| Acquisition | 20% After Deductible up to a $10,000 maximum per transplant | 40% After Deductible up to a $10,000 maximum per transplant |
| Dental Services for an Accidental Injury | 20% After Deductible | 40% After Deductible |
PRESCRIPTION DRUG COVERAGE
Benefit Period: 7/1 through 6/30
Dependent Age Limit: End of year of 23rd birthday
Retail Coverage
A. Deductible: $50 single/$150 family
B. Coinsurance: 20% (if you use a non-member pharmacy, the payment will be 75% of the Pharmacy's billed charges, after the Deductible and Coinsurance are applied)
Prescription Drugs are available as covered drugs when obtained from a Pharmacy. Under this portion of your Prescription Drug Coverage, covered drugs are drugs which require a prescription under federal law, are approved for general use by the Food and Drug Administration and are dispensed for your outpatient use by a licensed Pharmacy on or after your effective date. When obtaining Prescription Drugs from a Pharmacy, you should present your Prescription Drug Card.
Mail Service Coverage (30 to 90 day supply)
| Copayment: | |||
| A. Generic | $15.00 per prescription | ||
| B. Brand Formulary | $30.00 per prescription | C. Non-Preferred/Other Brand | $45.00 per prescription |
Maintenance Drugs prescribed in quantities of 30 to 90-day supplies are covered when dispensed for your Outpatient use by the Mail Service Drug Company on or after your effective date. Each prescription or refill is limited to a 90-day supply. Insulin syringes and needles are covered only when prescribed and dispensed at the same time as insulin. The Plan will pay for all charges except the Copayment amount.
| Low Plan: | ||
| Preferred Provider | Non-Preferred Provider | |
| Inpatient Hospital Services | 30% After Deductible | 50% After Deductible |
| Inpatient Medical Services | 30% After Deductible | 50% After Deductible |
| Surgical Services | 30% After Deductible | 50% After Deductible |
| Outpatient Services | ||
| Physician Office Visits | $20 Copayment, No Deductible and No Coinsurance* | 50% After Deductible |
| *Except as may be specified for specific Outpatient services, tests, screenings as noted in this Schedule of Benefits, Physician Office Visits rendered by a Preferred Provider will be subject to this Copayment. | ||
| Diagnostic Services | 30% After Deductible | 50% After Deductible |
| Physical Therapy | 30% After Deductible | 50% After Deductible |
| Chiropractic Care | 30% After Deductible | 50% After Deductible |
| Child Preventative Care Services* | $20 Copayment, No Deductible and No Coinsurance | 50% After Deductible |
| * Benefits for these services are limited to age 9. | ||
| Routine Mammography Screenings** | 30% After Deductible | 50% After Deductible |
** Benefits for these services are limited to $85 per screening. In addition, routine mammography screenings will be covered on an outpatient basis subject to the following schedule:
| ||
| Routine Prostate Cancer Screenings *** | 20% After Deductible | 40% After Deductible |
*** Benefits for these services are limited to one per benefit period and $65 per screening. In addition, routine prostatic screenings will be covered on an outpatient basis subject to the following schedule:
| ||
| All Other Services Listed in Outpatient Services Section | 30% After Deductible | 50% After Deductible |
| Psychiatric and Substance- Abuse Services | ||
| Inpatient Services | 30% After Deductible | 50% After Deductible |
| Outpatient Services | 50% up to $550, then 20% After Deductible | 50% up to $550, then 20% After Deductible |
| Limited to 40 visits per year. | ||
| Home Health Care Services | 30% After Deductible | 50% After Deductible |
| Limited to one visit per day. | ||
| Skilled Nursing Facility Services | 30% After Deductible | 50% After Deductible |
| Ambulance Services | 30% After Deductible | 50% After Deductible |
| Private Duty Nursing Services | 30% After Deductible | 50% After Deductible |
| Prescription Drugs | Not covered under your Medical Coverage. Refer to your Prescription Drug Coverage at the end of your Schedule of Benefits. | |
| Medical Supplies, Equipment & Appliances | 30% After Deductible | 50% After Deductible |
| Human Organ Transplant Services | ||
| Transplant Surgery | 30% After Deductible up to a $250,000 lifetime maximum | 50% After Deductible up to a $250,000 lifetime maximum |
| Acquisition | 30% After Deductible up to a $10,000 maximum per transplant | 50% After Deductible up to a $10,000 maximum per transplant |
| Dental Services for an Accidental Injury | 30% After Deductible | 50% After Deductible |
PRESCRIPTION DRUG COVERAGE
Benefit Period: 7/1 through 6/30
Dependent Age Limit: End of year of 23rd birthday
Retail Coverage
A. Deductible: $75 single/$225 family
B. Coinsurance: 20% ($10 minimum)
Prescription Drugs are available as covered drugs when obtained from a Pharmacy. Under this portion of your Prescription Drug Coverage, covered drugs are drugs which require a prescription under federal law, are approved for general use by the Food and Drug Administration and are dispensed for your outpatient use by a licensed Pharmacy on or after your effective date. When obtaining Prescription Drugs from a Pharmacy, you should present your Prescription Drug Card.
Mail Service Coverage
No Coverage
5.7.2 Enrollment Information for Domestic Partners
(revised July 1998)
As a Kenyon College benefits eligible employee, you may enroll an unmarried same- or opposite-sex domestic partner and/or your domestic partner's child(ren) in the Kenyon College health insurance plan through EBMC.
To enroll yourself and your domestic partner and/or your domestic partner's child(ren), you must:
1. Complete the regular Medical Plan enrollment form.
2. Complete, sign and have your partner sign the Certification of Domestic Partnership form.
Definition of a Domestic Partner
Kenyon College defines domestic partner as the partner of an eligible employee or retiree who is of the same or opposite sex, sharing a long-term committed relationship of indefinite duration with the following characteristics:
- Living together for at least six months.
- Having an exclusive mutual commitment similar to that of marriage.
- Financially responsible for each other's well-being and debts to third parties. This means that you have entered into a contractual commitment for that financial responsibility or have joint ownership of significant assets (such as home, car, bank accounts) and joint liability for debts (such as mortgages or credit cards.)
- Neither partner is married to anyone else nor has another domestic partner.
- Partners are not related by blood closer than would bar marriage in the state of their residence.
Eligibility Requirements for Your Domestic Partner's Children
In order for your partner's child to be claimed as a dependent under Kenyon College's plan, the child must meet all of the following requirements:
A. The child(ren) of the employees domestic partner must be the legal tax dependents of the employee under IRS Sec. 152.
Legal tax dependent is defined as follows:
- is a citizen of the United States, Mexico, Canada, the Canal Zone, or the Republic of Panama;
- is a member of your household for the year, had his or her principal place of abode in your home for the year;
3) by engaging in the relationship, does not violate local law;
- receives over half of his or her support for the year from you. Support includes food, shelter, clothing, medical and dental care, and education; and
- the dependent's gross income must be less than the federal personal exemption amount unless the dependent is under age19 OR a full-time student (enrolled as a full-time student for at least five months during the year), under age 24.
5.7.3 Change in Family Status
(revised July 1997)
If an employee needs to change his or her coverage due to a change in his or her family status (i.e., marriage or the birth or adoption of a child, addition of a domestic partner, etc.) the employee should contact the Office of Human Resources within thirty-one days of the event.
5.7.4 Medical Insurance During Leaves
(revised July 1997)
Medical insurance during a Sabbatical. A faculty member on sabbatical leave may continue participation in the health insurance program on a regular active-member basis for a period not to exceed twelve (12) months providing he or she was enrolled in the health plan prior to the beginning of the sabbatical.
Insurance Premium Payment During Leaves of Absence. Kenyon College will continue to pay its share of health insurance premiums for employee coverage and dependent coverage for a maximum of twelve (12) weeks during a family/medical Leave. While you are on any other type of unpaid leave of absence from Kenyon, you will be responsible for paying the total premiums for your coverage and that of your dependents while on leave. Failure to do so may result in loss of coverage and possible refusal by the insurance carrier to allow your coverage to be reinstated. Premiums in full for other benefits (life, disability, etc.) are the responsibility of the employee.
5.7.5 Health Insurance at Retirement
(revised July 1997)
When employees retire, they and their eligible dependents may continue enrollment in the College's group health plan providing they pay the cost of the applicable premiums. The earliest age an employee may retire and keep the health insurance benefits is age 59 ½.
If an employee retires before age 65, he or she may pay the same premiums as active employees if at least ten years of continuous service while enrolled in the health plan prior to the date of retirement were completed; OR if the employee completed less than ten years of service, he or she must have been enrolled in the health insurance plan during the total term of employment. If an employee retires at age 65 or over and meets the service requirements, Kenyon will contribute 30 percent of the Medicare carve-out premium as detailed below.
When a retired employee is eligible for Medicare at age 65, Medicare becomes the primary carrier (i.e., the plan that pays on all covered medical expenses before any other plans pay). This also applies to spouses of retirees who are eligible for Medicare. Retirees, and employees who plan to retire at age 65 or later, should contact the Social Security Administration several months prior to their eligibility date and enroll in Parts A and B of Medicare. If the retiree and eligible dependents continue their coverage under the College health insurance plan, it will act as the secondary carrier (i.e., the plan paying the balance of covered bills, if any are payable, only after all benefits have been paid by Medicare). Using this carve-out approach where Medicare is primary and Kenyon's plan is secondary, and providing the employee meets the above-referenced service requirements, the College will pay 30 percent of the premium for the secondary coverage through Kenyon's health plan. In most instances, the combination of these two plans will provide retirees and their dependents with the same full coverage they enjoyed as active employees.
Health Insurance for Eligible Dependents After the Death of A Retired Member. In the event of the death of a retired employee, the surviving spouse and eligible dependents may continue to be enrolled. Coverage will terminate on the date the surviving spouse remarries or eligible dependents lose their dependent status.
5.7.6 Health Insurance During a Medical Leave of Absence
(revised July 1998)
During an authorized leave of absence for medical reasons, the College will continue to pay its portion of the health insurance premiums if the member continues to receive his/her compensation providing that compensation does not continue beyond six (6) months after the member's medical leave began. The member must have been enrolled in the health plan prior to the commencement of the medical leave of absence and the member must continue to pay his/her portion of the premium. Continuation of coverage beyond six (6) months is addressed under the section titled COBRA.
5.7.7 Medical Insurance: Total Disability
(revised July 1998)
Disabled employees and their eligible dependents may continue enrollment in the plan at the same contribution levels as active employees up to age 65. At age 65 (the College's normal retirement age) the employee and eligible dependents may continue enrollment by paying the total cost of the program. In the event a disabled employee dies before attaining age 65, his or her dependents are treated like those of employees who were actively employed at the time of death.
To be treated as "disabled," the employee must be certified as totally disabled under the TIAA Total Disability Plan and the Social Security Administration or The State of Ohio Worker's Compensation Bureau.
5.7.8 Health Insurance for Eligible Dependents After Death of an Active Employee
(revised July 1997)
In the event of the death of an active employee who was enrolled on Kenyon's health insurance plan, the spouse and eligible dependents may continue to be enrolled for a period of one year at the same contribution levels as active employees. After the one year, the surviving spouse may continue the coverage by paying the full cost of the applicable premium. If the surviving spouse remarries or if dependents should lose their dependent status (as defined in the health insurance certificates), they will be eligible for continued coverage under COBRA.
5.7.9 Termination of Insurance/Consolidated Omnibus Budget Reconciliation Act (COBRA)
(revised July 1997)
This federal regulation states that if employees lose health insurance coverage due to a reduction in hours or termination of employment (for reasons other than gross misconduct), they and their eligible dependents can continue that coverage for up to eighteen months from the date of loss of coverage. (In certain situations, such as the covered person's total disability during the first sixty days of the COBRA period, the continuation of coverage would extend up to twenty-nine months.)
Your insurance will terminate when the insurance policy terminates, when you fail to make an agreed contribution to premium when due, when you cease to be eligible for coverage under the terms of our group insurance program, when you cease to be eligible for benefits with Kenyon, or when you are no longer employed by Kenyon. Kenyon College may, by continuing to pay the premium, keep your insurance in effect for a brief period if you cease to be an eligible employee for any reason other than resignation, dismissal, or failure to meet the terms of eligibility of our group insurance program.
5.7.10 Flexible Reimbursement Accounts (Flex Plan)
(revised July 1998)
Flexible Reimbursement Accounts are managed by EBMC.
Participation begins on the date of eligible employment and is optional. Employees can choose to reduce their gross salaries by a specified amount. The dollars are placed in one or both of the accounts mentioned below. Allocating dollars to the spending accounts results in a lower tax base.
Example: An employee earning $25,000 allocates $2,000 to the Dependent Care Account and $1,000 to the Medical Expense Account. The employee pays federal, state and Social Security taxes on $22,000. Dollars withdrawn from the accounts are distributed on a tax-free basis.
Some expenses payable from these accounts are the following:
Dependent Care Account: Expenses incurred in obtaining care for children under thirteen or a spouse or other dependent who is mentally or physically incapable of self-care and who lives with you.
Medical Expense Account: Dental expenses, eye exams, glasses, or any expense not covered by a health insurance plan.
Employees must use caution in allocating dollars to these accounts, since all monies must be used by the end of the plan year. The plan year begins July 1 and ends June 30. If there are funds left in the accounts, the employee forfeits the monies. Employee contributions for health insurance, dental insurance, and TIAA Collective Life Insurance Premiums are automatically deducted on a pre-tax basis. A new election form must be completed each year during the annual enrollment period in May.