2015 Open Enrollment
Benefits
Information
Oct. 12 - 24, 2014
www.kent.edu/hr
Dear Colleagues and Family Members:
Open Enrollment for 2015
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Welcome
Healthcare Benefit Options (medical, prescription, dental and vision)
Opt-Out Option
Flexible Spending Accounts
College Advantage Ohio 529 Savings Plan
Insurance Coverage
Voluntary Indemnity Plans
Supplemental Retirement Plans
Employee Assistance Program
MEDEX Travel Assistance
Dependent Eligibility Rules
Domestic Partner Benefits
OneWellU
Locations for Computer Access
How to Enroll Online
Annual Notices Required by the Federal Government (noted below in bold)
Women’s Health and Cancer Rights Notice
Newborns’ and Mothers’ Health Protection Act
Prescription Drug Coverage and Medicare Notice
Summary of Benefits and Uniform Glossary Terms
Notice of Privacy
New Health Insurance Marketplace Coverage Options
Healthcare Provider Contact Information
Employee Contribution Table
Dental Care Benefits Charts
Vision Care Plan
The 2015 Open Enrollment period is upon us. In keeping with improved efficiencies, no paper forms will be used for Open
Enrollment, and you will be able to conduct all Open Enrollment activity through our secure Flashline Web portal. Open
Enrollment is scheduled for Oct. 12 to Oct. 24.
The Open Enrollment Period allows you the opportunity to enroll in or change:
• Your medical plan;
• Your dental plan;
• Enroll or make changes to your supplemental life insurance or other voluntary benefits;
• Add eligible dependents to your plan(s) or drop dependents from your plan(s); and
• Enroll or re-enroll in the Flexible Spending Accounts (Dependent Care Flexible Spending Account and Health Care
Flexible Spending Account)
If you are not changing plans, enrolling in new plans or adding/dropping dependents, you do not need to do anything.
Your benefits will continue as they currently are through the 2015 plan year; however, the following exceptions apply:
• You must re-enroll in your Flexible Spending Account(s) each year if you would like to continue to participate.
• If you participate in the opt-out option, you will need to complete the 2015 Opt-Out Affidavit in order to receive the
opt-out incentive.
Although there are no major plan changes to the medical, prescription, vision or dental plans for 2015, it is still important to
carefully review all the benefit plan options and costs associated with your chosen plan(s) before finalizing any enrollment
decisions. As has historically been the case, employee contributions will be spread out over a tiered structure based on salary,
with employees in the lower tiers paying a lower percentage and those in the higher tiers paying a higher percentage. Be sure to
review the contribution chart at the back of this booklet before making your 2015 election.
During this Open Enrollment period, it would be remiss not to address the university’s cost for providing healthcare benefits.
As reported in previous years, the university’s cost continues to increase, and federal healthcare reform has further impacted
employer costs. Kent State will continue to absorb a portion of insurance plan costs to ensure a competitive total compensation
package for our employees. Kent State also remains committed to mitigating costs through vigilant negotiations with insurance
carriers; building a comprehensive wellness program and promoting it to all Kent State employees.
We strongly encourage employees and their covered dependents to take advantage of the preventative care benefits afforded in
all of our medical plans. In addition, and to assist employees in maximizing their well-being, the OneWellU program sponsored
by the Division of Human Resources provides opportunities for employees to become physically active and health smart through
a variety of programs. These include opportunities to join the faculty/staff exercise program, walking clubs, movable fitness
challenges, lunch-and-learns and more. To see a complete list of wellness offerings, including free health screenings for all
benefits-eligible employees, visit the OneWellU website site at http://www.kent.edu/hr/benefits/onewellu.cfm.
We hope that you find this booklet both helpful and informative as you make your benefit choices. Open Enrollment materials
are available 24/7 by visiting the Open Enrollment home page at http://tinyurl.com/ksu-oe2015. In addition, several computer
labs are ready for use throughout the Open Enrollment period and a full listing can be found on Page 8 of this booklet.
In the event you have additional questions, you may contact the Benefits Office at 330-672-MyHR(6947) or benefits@kent.edu.
DISCLAIMER: This Open Enrollment booklet and the contents therein is provided as an informational summary only and is not intended to be a summary
plan description (SPD) or plan document. If there are differences between the booklet and the SPD or plan document, the terms of the SPD and plan
document shall be definitive. Kent State University may amend or terminate its benefits plans at any time in accordance with the law and any applicable
collective bargaining agreement. The description of the program, the plan itself or participation in the plan is not an employment contract or any type of
employment guarantee and should not be construed as such. The university makes no endorsements, warranties, promises, representations and/or
guarantees regarding the performance, use, interpretation, application, correctness or accuracy of any of the vendors’ plans and programs summarized in
this booklet. Individuals should consult with the vendor(s) as well as their personal legal, medical, insurance and/or financial, etc., advisor/professional as
it applies to their own circumstance to answer any questions and/or concerns related to their participation in the plan(s) and program(s).
Kent State University, Kent State and KSU are registered trademarks and may not be used without permission. Kent State University, an equal opportunity,
affirmative action employer, is committed to attaining excellence through the recruitment and retention of a diverse workforce. 14-1552
Sincerely,
Joseph S. Vitale, Jr. PHR
Interim Vice President for Human Resources
There are special rules if you and your spouse/domestic partner
are both Kent State employees:
Welcome
• If both employees wish to be covered under a university family
plan, neither employee will be eligible to receive the opt-out incentive.
Annual Open Enrollment for 2015 Benefit Elections
Oct. 12 to 24
• I f one of the employees has proof of other insurance, the employee with
the lowest salary would be eligible to receive the opt-out incentive.
All employees must complete an opt-out affidavit. If you do
not complete a new 2015 opt-out affidavit, you will not
receive the monthly incentive. View the opt-out form at:
http://tinyurl.com/2015OptOut.
This year’s annual open enrollment period is Oct. 12 - Oct. 24, 2014.
Open enrollment is your opportunity to:
1. Change your insurance plan(s) for the coming year;
2. Add an eligible dependent to your coverage or remove a dependent
who is no longer eligible;
3. Enroll in a Flexible Spending Account (FSA) for the coming year; and
4. Complete a new opt-out incentive affidavit, if applicable.
Flexible Spending Accounts
Prescription Drug Coverage
All of the medical plan options include prescription drug coverage, which is
provided through CVS Caremark. Under this plan, you can receive periodic
prescriptions through your local retail pharmacy for up to three refills. For
maintenance prescriptions (prescriptions taken on a regular basis for an
extended period of time), you will then need to use Caremark’s mail-order
pharmacy service. Your share of the cost for prescriptions is:
Over time, your benefit needs can change and who you cover may change. That
is why it is always a good idea to review the Open Enrollment information and
make sure that you are selecting the best, most cost-effective coverage for you
and your family.
This booklet has been designed to assist you with your open enrollment
selections. The guide gives you the details about the different plan options
available and any costs associated with them. This booklet also spells out the
process you need to follow to make your elections and have them effective
on Jan. 1, 2015. If you do not complete the online process, your
default for 2015 will be your current (2014) elected coverage.
Benefit Options for 2015
Medical Coverage
As a full-time employee of the university, you have the option of participating in
one of three Preferred Provider Organization (PPO) plans.
• 90/70 PPO
• 80/60 PPO
• 70/50 PPO NEW
You have the choice of two major carriers, both with exceptional reputations:
Anthem Blue Cross Blue Shield and Medical Mutual of Ohio. The Anthem
network includes the Cleveland Clinic Health System hospitals, the University
Hospitals Health System and Summa Health System hospitals. The Medical
Mutual network includes Cleveland Clinic hospitals as well as Summa Health
System hospitals. A comparison of the benefits available under each option can
be found on Page 25.
To assist you in maintaining your health, preventive care benefits are available
under all of the medical plans. For children (birth to age nine), well-child
care is paid at 100 percent after a $15 co-pay. For children over age nine and
adults, coverage is provided for routine physicals, routine mammograms,
Pap tests, routine PSA and routine hearing exams. Immunizations, including
annual flu shots and pneumonia vaccines, are also covered.
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The mail-order prescription drug program continues to be a great way to
save both you and the university money on your prescriptions. Mail-order
prescriptions may be picked up at any CVS pharmacy.
Dental Coverage
All three plans are available through Medical Mutual of Ohio. The 90/70 PPO
and 80/60 plans are the only plans available through Anthem Blue Cross and
Blue Shield.
An important feature to note with all the medical plan choices is simplified
access to quality healthcare. Referrals for specialist care are not required.
This gives you much more flexibility in selecting the doctors, hospitals and
other providers of your choice (benefits are higher if you stay in network).
• 10 percent - Co-insurance for generic drugs
• 20 percent - Co-insurance for brand name drugs
• 40 percent - Co-insurance for brand name drugs when a
generic is available
As another layer of protection, the maximum you will pay out of pocket for
any prescription is $60. The maximum applies to both retail and mail order
programs and caps your prescription cost regardless of whether your coinsurance is 10, 20 or 40 percent. The exception to the $60 maximum is if
you receive a brand name medication when a generic equivalent is available.
In this case, the maximum co-insurance is $100, unless your physician has
specified that the prescription be dispensed as written.
REMINDER: FSAs require an election each calendar year. If you do not make
an election, you will not have a FSA for 2015.
When you sign up for a Flexible Spending Account (FSA), also referred to
as a “reimbursement account,” you put money aside on a pre-tax basis for
out-of-pocket expenses for you and your eligible dependents – even if those
dependents are not covered under the Kent State medical or dental plan.
This account can be used for co-pays at the doctor’s office, prescriptions,
chiropractic treatment, prescribed weight-loss programs and medical, dental
and vision service expenses not covered or paid in full by your plan. Kent State
offers two FSAs, both administered by Medical Mutual.
Kent State’s dental insurance with Delta Dental includes a three-tier option.
Each PPO plan – Low, Basic and High – varies in benefits and requires
an employee contribution. The Basic and High plans also include adult
orthodontia. A detailed description of each plan is at the back of the booklet,
beginning on Page 20.
Note: AAUP tenured/tenure-track faculty members will have a different high
dental option for 2015. For details see Page 23.
Vision Insurance
Health Care Reimbursement Account
EyeMed is the employee vision care provider and is automatic when you
elect medical coverage with Medical Mutual or Anthem Blue Cross and
Blue Shield. The plan operates on a rolling 24-month calendar. With EyeMed,
you have access to more than 37,000 independent practitioner and optical
retail providers at more than 17,000 locations nationwide. Retail locations
include LensCrafters, Pearle Optical, Sears Optical, Target Optical and JC
Penney Optical.
The maximum you can contribute to a Health Care Reimbursement
Account (HCRA) is $2,500 each calendar year on a tax-free basis.
As long as you use the account for reimbursement of eligible healthcare
expenses for you or your dependents, the reimbursement will remain tax-free.
Any eligible expenses can be paid with your Flex Save debit card. Just present
the debit card at the point of service, and the charges for the eligible expenses
will be automatically deducted.
Benefits of the EyeMed vision plan include:
• E mployees do not have to pay in advance and file a claim for
reimbursement when using an in-network provider.
• The plan offers in-network and out-of-network benefits.
• E ach covered member may select eyeglasses or contact lenses for their
benefit period. Members may select from the following options:
– Covered members receive a $240 allowance for frame, lens and lens options. You will also receive a 20 percent discount on the
purchase if your in-network balance exceeds $240.
– Covered members receive a $190 allowance for contact lenses.
You will also receive a 20 percent discount on the purchase if
your in-network balance exceeds $190.
•O
nce the in-network benefit has been exhausted, employees can receive
a 40 percent discount on a complete pair of eyeglasses or a 15 percent
discount on contact lenses.
• L aser vision correction done by an in-network provider is eligible for a
15 percent discount on the retail price or a five percent discount off the
promotional price.
• Customer service available seven days a week.
Please remember that certain over-the-counter (OTC) medicines are
eligible for reimbursement under the HCRA if they are prescribed by a doctor.
A vision summary is included on Page 24.
Opt-Out Option
You have the choice of opting out of the medical coverage, if you have other
health insurance coverage and provide proof of such coverage.
In order to be eligible for the opt-out incentive, employees cannot
be enrolled in any university health benefit plan. This applies to
medical, prescription, dental and vision coverage. The incentive
for opt-out is $100 per month.
Dependent Care Reimbursement Account
The Dependent Care Reimbursement Account (DCRA) allows you to save money on
a tax-free basis to pay for child/dependent care. This includes daycare (childcare,
summer camps, after-school programs, etc. for children under the age of 13) and
elderly care expenses for a disabled spouse or parent.
Eligible expenses are those that could otherwise be claimed for the dependent care
tax credit on your federal income tax. This account cannot be used for childcare
providers who do not report their earnings for income tax purposes.
To qualify for the DCRA, the employee (and your spouse, if married) must be at
work, looking for work, or attending school full-time during the time that your
dependent(s) receives care.
The maximum amount a married couple can contribute to a DCRA in
2015 is $5,000 if you are filing a joint return. The maximum amount each
spouse can contribute if filing separate tax returns is $2,500 per spouse.
Additional Information
For all FSAs (the HCRA and DCRA), you have until March 15 of the following year
after your contributions were made to accumulate your expenses (March 15, 2015,
for a 2014 account). If you make an FSA election for 2015, you will receive a new
debit card that will include any remaining balance from 2014 (the remaining balance
must be used by March 15, 2015).
If you currently have an HCRA or DCRA, but choose not to have one in 2015, you
may not use your debit card after Dec. 31, 2014, to spend any remaining balance.
Instead, you must pay out of pocket for eligible expenses and submit a claim form.
The expenses must be incurred by March 15, 2015, but you will have
until June 30, 2015, to submit any claim forms.
Please remember, if you do not use the funds in your HCRA or DCRA by the dates
specified, they will be forfeited as required by IRS regulations.
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Voluntary Accidental Death and Dismemberment
Insurance (AD&D)
This insurance is intended to supplement the basic AD&D insurance provided
to you by the university, and gives you the opportunity to purchase coverage
for your legally married spouse or eligible, registered domestic partner
(same or opposite gender) and the employee’s dependent children.*
This insurance helps provide financial protection by promising to pay a benefit
in the event of an insured individual’s covered death or dismemberment as the
result of an accident.
College Advantage Ohio 529 Savings Plan
Saving for college is an investment for a lifetime. College Advantage, Ohio’s
529 college savings plan is offered and administered by the Ohio Tuition Trust
Authority, a state agency. The plan provides you with a tax-free way to save
for college. Funds can be used at any college in the country for tuition, room
and board or books. College Advantage has many benefits that make saving for
college easy and affordable:
• Earnings are tax-free
• Contributions may be used as a deduction on your Ohio
income tax ($2,000 annually)
• Funds may be used at any college in the country
• Funds may be used to pay for tuition, room, board or books
• Contribute as little as $25 at a time
• Benefit from professional money management by
leading financial firms
• Save with FDIC-insured bank products
• Funds may be transferred to another child
• Funds may be withdrawn at any time
• Investment options may be changed
You can learn more about the College Advantage plan at
www.collegeadvantage.com. When enrolling online, please use the
following codes for Kent State:
Biweekly employee code: CO-6280
Semimonthly employee code: CO-6281
Payroll contact: Lisa Heilman
HR contact: Mark McLeod
Insurance Coverage
Kent State offers a variety of insurance plans for all full-time employees. An
overview of each plan, offered by Standard Insurance Co., is listed below.
Evidence of Insurability (EOI) is a medical questionnaire that must be
completed to determine approval for many of the voluntary insurance plans
offered. The EOI is required if you did not enroll within 31 days of starting
your employment at Kent State. If you previously enrolled and are increasing
your level of coverage, you must also complete an EOI. If you select a voluntary
insurance plan and are required to submit an EOI, you will receive further
instructions during the Open Enrollment process.
Basic Life/Accidental Death and Dismemberment Insurance
Life insurance is provided to all full-time employees at a level of three times
the annual base salary with a maximum coverage level of $225,000. Employees
age 65 or older will have a reduced coverage level based on their age. This
benefit continues to be provided by the university at no cost to employees, and
the level of coverage is automatically updated when your salary level changes.
You can obtain a copy of the life insurance booklet in the HR Forms Library at:
www.kent.edu/hr/forms/benefits.
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The cost for you, your spouse/domestic partner and/or your children is based
on the amount of coverage you choose (the rates will be provided when you go
through the online open enrollment process).
Coverage Amounts:
• Employee coverage is available in increments of $25,000, up to a
maximum of $250,000.
• Spouse/domestic partner coverage is 50 percent of the employee’s
coverage amount if you choose to insure only you and your spouse/
domestic partner. If you choose to insure you, your spouse/domestic
partner and your children, your spouse/domestic partner coverage is
40 percent of the employee’s coverage amount.
For eligible employees with less than five years of service or in the Alternative
Retirement Plan, Voluntary LTD Insurance provides gap coverage. For
eligible employees with five or more years of service who are
enrolled in OPERS/STRS, this insurance provides a valuable
supplement to the OPERS/STRS benefits. For example:
•O
PERS/STRS has a 365-day benefit waiting period; Voluntary LTD has
a 180-day benefit waiting period.
• I n most cases, OPERS/STRS requires you to become disabled before age
60 to qualify for benefits; Voluntary LTD has no age requirement.
• V oluntary LTD insurance benefits are not subject to federal taxes;
OPERS/STRS benefits are.
Note: It is important for employees to update beneficiary designations for
any life insurance policies. You can verify your beneficiary designations by
contacting the Benefits office. You can also complete the Beneficiary Change
Form at www.kent.edu/hr/forms/benefits and return it to the Benefits Office
in Heer Hall.
*You must purchase coverage for yourself in order to purchase coverage for your spouse/domestic partner
and dependent children.
• Coverage for children is 10 percent of the employee’s coverage amount
if you choose to insure only you and your children, not to exceed
$25,000 for each child. If you choose to insure you, your spouse/
domestic partner and your children, coverage for children is 5 percent
of your coverage amount, not to exceed $25,000 for each child.
Voluntary Indemnity Plans
• Age Reductions: Insurance coverage for you or your spouse/domestic
partner is reduced to 65 percent of the original amount at age 70, to 45
percent of the original amount at age 75, to 30 percent of the original
amount at age 80, to 20 percent of the original amount at age 85, to
15 percent of the original amount at age 90, and to 10 percent of the
original amount at age 95.
Plan Options:
Voluntary Supplemental Life Insurance
Supplemental life insurance provides extra life insurance protection for you,
a legally married spouse or eligible, registered domestic partner (same or
opposite gender) and/or dependent children. Coverage for dependent children
only costs $1 per month for $10,000 of coverage. The cost for you and your
spouse or domestic partner is based on the amount of coverage you choose,
your salary and your age (the rates will be provided when you go through the
online open enrollment process).
Coverage Amounts:
• Employee coverage is available in the amount of one, two or three times
your annual earnings, up to a maximum of $500,000. Acceptable
evidence of good health will be required to become insured for any
amount of coverage. Individuals who were previously declined coverage
will remain declined.
•Spouse/domestic partner coverage is available in increments of $10,000,
up to a maximum of $250,000, not to exceed 100 percent of the amount
of the employee’s life coverage. Acceptable evidence of good health will
be required for your legally married spouse/domestic partner to become
insured. Individuals who were previously declined coverage will
remain declined.
• Coverage for children is available in the amount of $10,000.
AFLAC offers a variety of voluntary indemnity plans. These plans provide
protection for you and your family members when an unexpected accident or
illness occurs.
• A flac Group Accident Insurance – helps with the costs that arise
when you have a covered accident such as a fracture, dislocation or
laceration. Covered at home and at work.
• A flac Group Critical Illness Insurance – provides cash benefits if
you’re diagnosed with or treated for a covered illness, such as cancer, a
heart attack or a stroke. Guaranteed issue coverage is available for all
employees up to $30,000 and up to $15,000 for the spouses.
• A flac Group Hospital Indemnity Insurance – helps pay the
out-of-pocket costs associated with a hospital stay including benefits
for inpatient and outpatient services including an emergency room/
physician office benefit and more.
• A flac Short-Term Disability Insurance – provides cash benefits in
the case of illness or injury to help you maintain your standard of living
and help you pay your bills. Guaranteed issue coverage up to $3,000.
Additional information about these plans can be found at:
www.kent.edu/hr/benefits/supplemental/voluntary-indemnity-plans.cfm.
Contact information for an Aflac representative is listed on Page 18.
Voluntary Long-term Care (LTC)
Long-term care insurance pays for home healthcare, assisted living and nursing
home care to help people with the functions of day-to-day living (bathing,
dressing, toileting, transferring and eating) as well as services related to
rehabilitation, chronic illness and cognitive impairment.
Many working age people are buying LTC insurance to avoid the risk of
becoming uninsurable. Once accepted, changes to your health do not affect
your coverage or premiums. In addition, Medicare, disability insurance and
other types of health insurance are not designed for long-term care coverage.
Medicaid won’t pay until after recipients have “spent down” their assets to
low levels.
The state of Ohio Long Term Care Partnership Program provides
dollar-for-dollar asset protection. Each dollar that your partnership policy pays
out in benefits entitles you to keep a dollar of your assets if you ever
need to apply for Medicaid.
Legacy Services is an independent agency that offers individual policies from
the major carriers with a wide range of options that allow you to customize
coverage to fit your needs and budget. Certain health conditions may affect
eligibility.
Any coverage selected will be paid for entirely by the employee and
will not be eligible for payroll deduction.
To schedule a one-on-one consultation or for any other questions, contact
Legacy at 800-230-3398, ext. 101 or email custsvc@4groupltci.com.
Supplemental Retirement Plans
There are two supplemental retirement plans available to Kent State employees
on a tax-deferred basis: a 403(b) or a 457(b) account. These two plans allow
you to make pretax contributions by convenient payroll reduction and save that
money for your retirement. For calendar year 2014 the maximum contribution
was $17,500. The IRS will announce the contribution limits for 2015 in late
October. If you are age 50 or older in 2015, you can direct an additional
$5,500 into each plan.
The 403(b) and the 457(b) plans were created to encourage long-term savings.
Distributions are available when you reach age 59-and-a-half; distributions are
mandated at 70-and-a-half years of age. As you consider these opportunities,
you may wish to talk with your financial advisor about distribution
opportunities when you leave employment.
Voluntary Long-Term Disability Insurance (LTD)
LTD insurance provides financial protection for eligible employees by paying
a percentage of monthly earnings in the event of a covered disability. Your
cost is based on which option you choose, your salary and your age (the rate
will be provided when you go through the online open enrollment process).
Evidence of good health will be required during this enrollment period.
Voluntary LTD insurance will become effective Jan. 1, 2015, for new enrollees
and current participants who elect to increase their level of coverage
(i.e., move from Option 1 to Option 2).
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Contributing to either one of these supplemental retirement plans can
help you take control of your future. Other sources of retirement income,
including state pension plans and, if applicable, Social Security, rarely
replace a person’s final salary upon retirement.
NEW
Dependent Eligibility Rules and
Documentation Requirements
Category of Dependent
Supporting Documentation
For 2015 a new Roth option is available for the 403(b) and 457 plans.
Roth participants can make supplemental retirement contributions
on an “after-tax” basis. For some individuals, this may be a
significant advantage.
Legally married spouse***
domestic partner
Individuals of the same sex who are
lawfully married under state law IRS2013-17 in IRB 2013-38
Marriage certificate/affidavit of
domestic partnership
A list of providers for both programs, including the list of Roth providers,
is available in online at www.kent.edu/hr/forms/benefits/index.cfm.
Look for the links in the Retirement Programs section.
Biological child under the age of 28
Birth certificate listing parents
Adopted child or child under the age of
21 for which you are the legal guardian
Birth certificate listing parents and
court order recognizing guardianship/
placement with employee
Unmarried/married child under the
age of 28
Birth certificate listing parents
Unmarried disabled child over the age
of 21, if approved as incapacitated
under the health plan
Birth certificate listing parents and copy of
approval letter from medical carrier for a
disabled status under the medical plan
Employee Assistance Program
IMPACT Solutions is Kent State’s employee assistance program (EAP)
that offers confidential support for Kent State employees and their family
members, whether or not they are living with you.
IMPACT offers an array of counseling services including individual,
family and couple counseling by licensed professionals. IMPACT
can assist with problems such as stress, anxiety, depression, child
management, substance abuse, or help with issues involving consumer
affairs, child or eldercare, financial or legal matters.
Kent State has contracted with IMPACT to provide up to six confidential
counseling sessions at no cost to faculty, staff and/or their family
members, per issue. If treatment is needed beyond the six sessions,
IMPACT will make every effort to transition the client with a provider that
participates in their insurance network.
All resources are available 24/7 by calling 800-227-6007. You can also
visit the IMPACT website at www.myimpactsolution.com and use “kent”
as the login.
FrontierMEDEX Travel Assistance
Assistance is available to full-time Kent State employees and their family
members who travel more than 100 miles from home or internationally,
for a maximum of 180 days. There is no fee; it is offered as part of the
group life insurance from the Standard Co.
Services are available 24/7 and include assistance with pre-trip planning,
legal issues, emergency transportation, personal security, medical
assistance and travel.
For more information, contact FrontierMEDEX at 1-800-527-0218 or
operations@medexassist.com.
Dependent Eligibility Rules
As healthcare costs rise, proper management and financial control of
health plans have become increasingly important. As a part of this
process, the university must verify that the dependents enrolled under the
medical and drug plans meet the university’s eligibility rules.
If you previously submitted documentation to the Benefits Office and are
not adding any dependents, no further action is required on your part.
However, if you are adding a new dependent or going from
single to family coverage, you must provide the proper
documentation (see chart) to the Benefits Office by the end of
the Open Enrollment period. Questions should be directed to the
Benefits hotline at 330-672-MyHR (6947) or benefits@kent.edu.
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2015 Employee Contribution Rates For Dependents Ages 26-28
Semimonthly and biweekly additional premiums per pay deductions
Medical Mutual
Plan Option-90/70
Plan Option-80/60
Plan Option-70/50
12-Month Rate
10-Month Rate
9-Month Rate
$118.45
$142.14
$157.93
$114.00
$136.80
$152.00
$110.46
$132.55
$147.27
Anthem
12-Month Rate
10-Month Rate
9-Month Rate
***If you are divorced, your former spouse is ineligible for Kent State University’s medical plan coverage.
In this case, you will need to remove your ex-spouse from the plan as of the date of the event and provide
proof of divorce. Please provide a copy of the divorce decree that lists the parties and the date filed with
the court.
Plan Option- 90/70
$108.99
$130.79
$145.32
Plan Option- 80/60
$106.09
$127.30
$141.45
Adult Dependent Eligibility
Under the state legislation, adult dependents, ages 26 to 28, who meet the state
eligibility requirements may also be covered under the employee’s medical plan
(medical, vision and prescription drug). An additional premium will be assessed
for dependents in this age group.
Employees can enroll their eligible dependents during the Open Enrollment
period; the coverage will begin Jan. 1, 2015. Proof of the dependent relationship
is required to add an adult child to your medical coverage. The form can be
accessed at www.kent.edu/hr/forms/benefits. The Benefits Office will conduct
random audits to verify dependent eligibility.
Domestic Partner Benefits
Kent State University offers domestic partner benefits to eligible employees. The
benefits extend to both same gender and opposite gender partners of university
faculty, unclassified and classified employees.
The benefits offered to eligible domestic partners are:
• Medical, prescription, vision and dental insurance
• Dependent life insurance
• Voluntary Accidental Death and Dismemberment Insurance (AD&D)
• Tuition fee waiver
To initiate the domestic partner benefits process, the employee must complete
an Affidavit of Domestic Partnership form, which includes supporting
documentation attesting that the domestic partners meet the conditions listed
below:
• Are at least 18 years of age and have the capacity to enter into
a contract;
• Share a permanent residence (unless residing in different cities, states or
countries on a temporary basis);
• Are the sole domestic partner of each other, having been in the
relationship for at least six months and intending to remain in the
relationship indefinitely;
• Are not currently married to, or legally separated from, another person
under statutory or common law;
• Are responsible for each other’s welfare;
• Are not related by blood to a degree that would bar marriage in the state of
Ohio; and
• Are financially interdependent on each other. This includes documentation of
at least three of the following:
• Joint ownership of real estate property or joint tenancy on a
residential lease;
• Joint ownership of an automobile;
• Joint bank account or credit account;
• Will, designating the domestic partner as the primary beneficiary;
• Retirement plan or life insurance policy designating the domestic
partner as the primary beneficiary;
• Durable power of attorney, signed to the effect that powers are
granted to one another.
Information and the affidavit form can be found online at
www.kent.edu/hr/benefits/domestic-partners.cfm.
6
OneWellU – Wellness for a
Lifetime
The university is committed to helping faculty and staff
live a healthy lifestyle. OneWellU, the university’s wellness program, provides
health education resources and activities that support healthy lifestyle choices
and behaviors. During May 2014, the Division of Human Resources, along
with partners Be Well Solutions and University Health Services, introduced
a variety of options to assist all full-time, benefits-eligible employees in
achieving better health. Employees now have access to an online wellness
Web portal supported by Be Well Solutions. This secure and confidential
portal serves not only as a place for employees to track and monitor their
own health and wellness progress, but it also offers numerous resources to
educate participants on topics such as food, fitness and stress management.
All participants have a personal account that includes an online health risk
assessment, as well as personal health risk profile. The health risk profile
encompasses results from the health risk questionnaire, as well as any health
screening information, such as cholesterol, blood pressure and glucose levels.
Employees are able to participate in a free health screening. The entire health
screening, including fingerstick blood analysis, blood pressure, body mass
index and review process takes approximately 30-45 minutes to complete.
All participants in the program have the opportunity to reach out to a health
coach from Be Well Solutions to assist them with setting any health goals
they desire. The health coaches will help participants start with identifying
realistic goals and provide support and encouragement along the way. While
all participants are welcome to work with a health coach, those employees
that are identified as high risk will receive a special invitation to work with a
health coach, however this is not required. The Be Well Solutions Web portal
can be accessed at www.bewelldata.com. Employee login information can be
found on the OneWellU website http://www.kent.edu/hr/benefits/onewellu.
cfm. Additionally, all employees that complete the health screening and
online health risk questionnaire will receive a free MOVband to help monitor
personal physical activity. This will serve as a fun method for the Kent State
University community to work as a group to get “MOVing.”
Please stay tuned for new exciting wellness opportunities by visiting our
OneWellU website at http://www.kent.edu/hr/benefits/onewellu.cfm.
See below for current activities and programs that are offered.
Programs
• Weight Watchers at Work is offered weekly on the Kent Campus; and
employees at all locations can take advantage of a discount on the Weight
Watchers monthly pass to attend meetings in their community or for the online
program. Details can be found on the OneWellU website listed above. MMO
participants are eligible for partial reimbursement.
• The Chef’s Garden (through Medical Mutual) brings vegetable, herbs and
other produce straight from the garden to your home. You can also get recipes
and view instructional videos featuring the produce you receive.
• The OneWellU Walking Program is a popular program due to its flexible
nature. Employees are motivated and challenged to achieve specified step
goals each week. Pedometers or other step-tracking devices are utilized to
monitor daily steps, which are logged on the American Heart Association
website www.startwalkingnow.org. Employees who achieve the weekly step
goal are eligible for prize drawings, and the employee with the most steps
over the duration of the program is also recognized with a grand prize.
7
• MOVchallenges are on the horizon for all KSU employees using a
MOVband, which can be obtained by participating in the health screening
and risk assessment questionnaire offered by Be Well Solutions. The
MOVband wristband displays time, moves and miles. The MOVband can be
synced online to the individual’s personal activity dashboard, where the
user can set goals, check progress and join challenge groups.
Locations for Computer Access (see http://helpdesk.kent.edu/Labs)
In addition to the computer labs listed below, HR staff will be available at several computer lab sessions to assist employees in
completing the online Open Enrollment process. Click here to view http://tinyurl.com/2014oelab.
Lab
Other Resources
• University Health Services (UHS) is a full-service, primary care medical
facility on the Kent Campus. UHS treats chronic and short-term medical
conditions and offers a range of wellness services. The services are available to
faculty and staff, as well as students, and most major medical insurance plans
are accepted. Visit www.kent.edu/uhs for more information.
• The Student Recreation and Wellness Center offers a wide variety of
cardio and strength equipment, access to the natatorium, racquetball and
basketball courts, climbing wall and many other recreational and fitness
opportunities. Employees receive a membership discount. More information is
available at www.kent.edu/recservices/memberships/index.cfm.
• The Nutrition Outreach Program offers its services to all Kent State
employees. The Nutrition Outreach Program provides nutrition education on
weight control, cardiovascular/hypertension, digestive disorders, diabetes,
eating disorders, general nutrition/wellness, pediatric nutrition, childhood
obesity, sports nutrition, vegetarian, food allergies and food safety.
For more information on how to schedule an appointment, please visit
http://www.kent.edu/ehhs/nutr/nutrition-outreach-program.cfm.
• Lunch and Learn seminars are held monthly and topic information can
be found on the OneWellU website. Each session lasts one hour and is free
and open to faculty and staff. Lunches can be pre-ordered during the
registration process.
• The Division of Human Resources has partnered with the School of Health
Sciences to launch a Faculty/Staff Exercise Program. This program is
specifically designed to assist those individuals who may benefit from a more
structured and personal exercise program due to a sedentary lifestyle or for
individuals who may have some risk factors that require more supervision,
such as hypertension, diabetes, family history of heart or coronary disease,
metabolic disease, etc. The program is located in the MACC Annex off of
Midway Drive on the Kent Campus and is overseen by Ellen Glickman, Ph.D.
Glickman is professor and coordinator of exercise physiology in the School of
Health Sciences. For more details on the program, visit the OneWellU website
http://www.kent.edu/hr/benefits/onewellu.cfm.
• The Division of Human Resources publishes a quarterly wellness newsletter
that is distributed to all faculty and staff via email. Be sure to check out the
quarterly publications for updated information on wellness activities and
programs along with the OneWellU website frequently.
• Wellness Webinars will be offered at least four times over the next calendar
year to enable all Kent State employees an opportunity to learn more about
wellness-related topics of interest. Participants can listen live from their
workspace, or they may choose to listen to a recorded session at a later time.
• Kent State University, along with IMPACT Solutions, our employee assistance
provider, is partnering with Right Direction, an initiative addressing
depression in the workplace. The goal is to spread awareness that depression
is treatable, and help to reduce the stigma surrounding depression. Resources
can be found at www.RightDirectionForMe.com.
Campus
Location
Client Services
Kent
Library, Room 150
Client Services
– Bowman 1
Kent
Bowman, Room 122
Client Services
– Bowman 2
Kent
Bowman, Room 218
Architecture
Kent
Taylor, Room 307
Business
Kent
Business, Rooms A224, A226 and A230
Nursing
Kent
Henderson, Room 215
Education
Kent
White, Rooms 203, 205, 211 and 221
Math and Computer Science
Kent
Main Classroom Lab
Math and Computer Science
Kent
Math and Computer Science, Room 160
Pan-African Studies
Kent
Oscar Ritchie, Room 120
MACC Annex
Kent
MACC Annex, Room 274
Computer Room
Kent
Van Campen
Technology
Kent
Van Deusen, Rooms 206 and 207
Liquid Crystal Institute
Kent
LCM, Room 328
Physics
Kent
Smith, Room 311
(Restricted to Physics faculty and staff)
University Facilities Management
Kent
University Facilities Management computer lab
(advance permission required for use)
Kent
Kent Student Center – Room 222
Kent
Student Recreation and Wellness Center
(members only)
Ashtabula
Main Hall: C210, Library: L217
Draime Estate
Gardens
Guest House, Staff Office
East Liverpool
Geauga
Main Hall: Room 104, Library, Study Area,
Slak Shak
Mary Patterson: Rooms 320, 402-E
Rooms 126, 128, 144, and 167
Regional Academic Center:
Rooms 117, 119, 120 and 124
Salem
Main Building: Rooms 113, 125, and 165
Stark
Main Hall/East Wing Computer Lab:
Room E101
Trumbull
Theatre/Library: Internet Cafe
Tuscarawas
Founders Hall: A110, A200, A207, A220 and A224
Science Tech: ST 119 and 208
8
How to Enroll Online
Open Enrollment will be done through a secure portal. The annual Open
Enrollment period will begin Sunday, Oct. 12, (12 a.m. Eastern
Standard Time) and end at 5 p.m. on Friday, Oct. 24, 2014.
You may enroll or subsequently change your enrollment at any time
during the open enrollment period. There are no manual enrollment
forms. If there is some reason that you cannot enroll using the online
enrollment system, please contact the Benefits hotline at 330-672-MyHR
(6947) or benefits@kent.edu.
1. Access Open Enrollment
Log in to FlashLine using your existing username
and password.
Women’s Health and Cancer Rights Notice
This Congressional Act of 1998 requires benefit plans to provide coverage for reconstructive surgery and related services
following a mastectomy. All terms and conditions (including deductibles and coinsurance) of your medical plan apply to this
coverage. Specifically, the benefits include:
• Coverage for reconstructive surgery of the breast on which a mastectomy has been performed.
• Coverage for surgery and reconstruction of the other breast to produce a symmetrical appearance.
• Coverage for prostheses and physical complications through all stages of a mastectomy, including swelling associated
with the removal of lymph nodes.
Click on the “My HR” tab.
On the left side of the screen, look for the “Employment
Details” box and click on the “Open Enrollment through Oct. 24” link.
If you need help with your username or password, please visit:
http://support.kent.edu or call the Helpdesk at
330-672-4357(help). For HR assistance, please contact
the Kent State Benefits Office at 330-672-MyHR (6947) or
email: Benefits@kent.edu.
Treatment will be in a manner that is determined in consultation with the attending physician and patient.
In addition, the plan may not:
• Interfere with a woman’s rights under the plan to avoid these requirements.
• Offer inducements to the health provider, or assess penalties against the health provider, in an attempt to interfere with the
requirements of the law.
This law requires written notice of the availability of the coverage be delivered to all plan participants upon enrollment and
annually thereafter. This notice serves to fulfill this requirement.
Newborns’ and Mothers’ Health Protection Act
For the 2015 Open Enrollment navigation guide, go to http://tinyurl.com/OEnavguide.
The Newborns’ and Mothers’ Health Protection Act of 1996 provides protections for mothers and their newborn children with
regard to hospital lengths of stay following childbirth. All terms and conditions (including deductibles and coinsurance) of your
medical plan apply to this coverage. Specifically, the benefits include:
• Coverage must provide benefits for hospital lengths of stay in connection with childbirth to cover the minimum length of stay for
all deliveries.
• Group Health Plans may not restrict mothers’ and newborns’ benefits for a hospital length of stay in connection with childbirth
to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section.
• Determination of whether an admission is in connection with childbirth is a medical decision to be made by the attending
provider. An example clarifies that delivery does not have to occur inside a hospital in order for an admission to be “in
connection with childbirth.”
Exception to the interim rules permits an exception to the 48-hour (or 96-hour) general rule if the attending provider decides, in
consultation with the mother, to discharge the mother or her newborn earlier.
9
10
Important Notice from Kent State University About
Your Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription
drug coverage with Kent State University and about your options under Medicare’s prescription drug coverage. This information
can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare
your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare
prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription
drug coverage is at the end of this notice.
There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:
1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you
join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription
drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also
offer more coverage for a higher monthly premium.
2. K ent State University has determined that the prescription drug coverage offered by the Kent State University Health Plan is,
on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and
is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage
and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.
When Can You Join A Medicare Drug Plan?
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15 to
December 7.
However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for
a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.
What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?
If you decide to join a Medicare drug plan, your current Kent State University coverage will not be affected. You can keep this
coverage if you elect Medicare Part D and this plan will coordinate with Part D coverage. A description of the prescription drug
benefits available to Kent State employees is available at http://www.kent.edu/hr/benefits/Caremark-Prescription.cfm.
See pages 7- 9 of the CMS Disclosure of Creditable Coverage To Medicare Part D Eligible Individuals Guidance (available at
http://www.cms.hhs.gov/CreditableCoverage/), which outlines the prescription drug plan provisions/options that Medicare
eligible individuals may have available to them when they become eligible for Medicare Part D.
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?
You should also know that if you drop or lose your current coverage with Kent State University and don’t join a Medicare drug plan
within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug
plan later.
For More Information About Your Options Under Medicare Prescription Drug Coverage:
More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook.
You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare
drug plans.
For more information about Medicare prescription drug coverage:
• Visit www.medicare.gov
• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You”
handbook for their telephone number) for personalized help
• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available.
For information about this extra help, visit Social Security on the Web at www.socialsecurity.gov, or call them at
1-800-772-1213 (TTY 1-800-325-0778).
Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy
of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required
to pay a higher premium (a penalty).
Date:
Oct. 12, 2014
Name of Entity/Sender:
Kent State University
Contact--Position/Office:
Loretta B. Shields, PHR
Executive Director, Benefits and Compliance
Address: Kent State University
Heer Hall - Human Resources
P.O. Box 5190
Kent OH 44242-0001
Phone Number: 330-672-3107
Summary of Benefits and Uniform Glossary of Terms
Federal legislation requires employers to provide employees with a Summary of Benefits (SBC) and a Uniform Glossary
of Terms for each health plan. You can view the SBC for each Kent State health plan online at
www.kent.edu/hr/benefits/sbc.cfm.
If you have questions about any of the plans, contact the Benefits Office at 330-672-MyHR (6947) or benefits@kent.edu.
These documents are designed to provide health plan information in a uniform format to allow consumers to compare the
terms of plans offered and to assist consumers in understanding the benefits provided.
If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at
least 1 percent of the Medicare base beneficiary premium per month for every month that you did not have that coverage.
For example, if you go 19 months without creditable coverage, your premium may consistently be at least 19 percent higher
than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare
prescription drug coverage. In addition, you may have to wait until the following October to join.
For More Information About This Notice Or Your Current Prescription Drug Coverage:
Contact the person listed below. NOTE: You’ll get this notice each year. You will also get it before the next period you can join
a Medicare drug plan, and if this coverage through Kent State University changes. You also may request a copy of this notice at
any time.
11
12
NOTICE OF PRIVACY PRACTICES FOR KENT STATE UNIVERSITY EMPLOYEE GROUP HEALTH PLAN
Effective April 14, 2003
Revised on Sept. 17, 2013
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS
TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires health plans to notify plan participants and beneficiaries about its
policies and practices to protect the confidentiality of their health information. This document is intended to satisfy HIPAA’s notice requirement with
respect to all health information created, received, or maintained by the Kent State University group health plan (the plan), as sponsored by Kent State
University (the university).
Your Personal Health Information
The plan needs to collect, create, receive and maintain records that contain health information about you to administer the plan and provide you with
health care benefits. This notice describes the plan’s health information privacy policy with respect to your medical, prescription drug, dental, vision,
health care flexible spending account (FSA), and wellness benefits. The notice tells you the ways the plan may use and disclose health information about
you, describes your rights, and the obligations the plan has regarding the use and disclosure of your health information. However, it does not address the
health information policies or practices of your healthcare providers.
Kent State University’s Pledge Regarding Health Information Privacy
The privacy policy and practices of the plan protects confidential health information that identifies you or could be used to identify you and relates to a
physical or mental health condition or the payment of your health care expenses. This individually identifiable health information is known as protected
health information (PHI). Your PHI will not be used or disclosed without a written authorization from you, except as described in this notice or as
otherwise permitted by federal and state health information privacy laws.
Privacy Obligations of the Plan
The plan is required by law to:
• Make sure that health information that identifies you is kept private;
• Give you this notice of the plan’s legal duties and privacy practices with respect to health information about you;
• Follow the terms of the notice that is currently in effect; and
• Notify affected individuals following a breach of unsecured PHI.
How the Plan May Use and Disclose Health Information About You
• Your Authorization. Except as outlined below, the plan will not use or disclose your PHI for any purpose, unless you have signed a form authorizing the
use or disclosure of such PHI. Most uses and disclosures of psychotherapy notes, as applicable, require your authorization. Subject to certain limited
exceptions, the plan may not use or disclose PHI for marketing without your authorization. The plan will not sell your PHI without your authorization.
You have the right to revoke that authorization in writing unless the plan has taken any action in reliance on the authorization.
• For Treatment. The plan may disclose your PHI to a healthcare provider who renders treatment on your behalf. For example, if you are unable to
provide your medical history as the result of an accident, the plan may advise an emergency room physician about the types of prescription drugs you
currently take.
• For Payment. The plan may use and disclose your PHI so claims for health care treatment, services, and supplies you receive from healthcare providers
may be paid according to the plan’s terms. For example, the plan may receive and maintain information about surgery you received to enable the Plan to
process a hospital’s claim for reimbursement of surgical expenses incurred on your behalf.
• For Health Care Operations. The plan may use and disclose your PHI to enable it to operate or operate more efficiently or make certain all of the plan’s
participants receive their health benefits. For example, the plan may use your PHI for case management or to perform population-based studies designed
to reduce healthcare costs. In addition, the plan may use or disclose your PHI to conduct compliance reviews, audits, actuarial studies, and/or for fraud
and abuse detection. The plan may also combine health information about many plan participants and disclose it to the University in summary fashion
so it can decide what coverages the plan should provide. The plan may remove information that identifies you from health information disclosed to
the university so it may be used without the university learning the identity of the individual. The plan is prohibited from using or disclosing PHI that is
genetic information for underwriting purposes.
13
• To the university. The plan may disclose your PHI to designated university personnel so they can carry out their plan-related administrative functions,
including the uses and disclosures described in this notice. Such disclosures will be made only to the university’s manager of university benefits (the
plan Administrator) and/or the members of the university’s benefits department. These individuals will protect the privacy of your health information and
ensure it is used only as described in this notice or as permitted by law. Unless authorized by you in writing, your health information: (1) may not be
disclosed by the plan to any other university employee or department, and (2) will not be used by the University for any employment-related actions and
decisions or in connection with any other employee benefit plan sponsored by the university.
• To a business associate. Certain services are provided to the plan by third party administrators know as “business associates.” For example, the plan may
input information about your healthcare treatment into an electronic claims processing system maintained by the plan’s business associate so your claim
may be paid. In so doing, the plan will disclose your PHI to its business associate so it can perform its claims payment function. However, the plan will
require its business associates, through contract, to appropriately safeguard your health information.
• Treatment Alternatives. The plan may use and disclose your PHI to tell you about possible treatment options or alternatives that may be of interest to you.
• Health and wellness-related benefits and services. The plan may use and disclose your PHI to tell you about health-related benefits or services that may be
of interest to you. For example, we may send health care information to you on topics such as women’s health, diabetes, asthma, heart disease, etc.
We may also work with other agencies, health care providers, and pharmaceutical companies to provide good health and disease management and
prevention programs.
• Individual involved in your care or payment of your care. The plan may disclose PHI to a close friend or family member involved in or who helps pay for
your healthcare. The plan may also advise a family member or close friend about your condition, your location (for example, that you are in the hospital)
or death.
• As required by law. The plan will disclose your PHI when required to do so by federal, state or local law, including those that require the reporting of
certain types of wounds or physical injuries.
Special Use and Disclosure Situations
The plan may also use or disclose your PHI under the following circumstances:
• Lawsuits and disputes. If you become involved in a lawsuit or other legal action, the plan may disclose your PHI in response to a court or administrative
order, a subpoena, warrant, discovery request, or other lawful due process.
• Law enforcement. The plan may release your PHI if asked to do so by a law enforcement official, for example, to identify or locate a suspect, material
witness, or missing person or to report a crime, the crime’s location or victims, or the identity, description, or location of the person who committed the
crime.
• Workers’ compensation. The plan may disclose your PHI to the extent authorized by and to the extent necessary to comply with workers’ compensation
laws or other similar programs.
• Military and veterans. If you are or become a member of the U.S. armed forces, the plan may release medical information about you as deemed necessary
by military command authorities.
• To avert serious threat to health or safety. The plan may use and disclose your PHI when necessary to prevent a serious threat to your health and safety, or
the health and safety of the public or another person.
• Public health risks. The plan may disclose health information about you for public health activities. These activities include preventing or controlling
disease, injury or disability; reporting births and deaths; reporting child abuse or neglect; or reporting reactions to medication or problems with medical
products or to notify people of recalls of products they have been using.
• Health oversight activities. The plan may disclose your PHI to a health oversight agency for audits, investigations, inspections, and licensure necessary for
the government to monitor the health care system and government programs.
• Research. Under certain circumstances, the plan may use and disclose your PHI for medical research purposes.
• National security, intelligence activities and protective services. The plan may release your PHI to authorized federal officials: (1) for intelligence,
counterintelligence, and other national security activities authorized by law, and (2) to enable them to provide protection to the members of the U.S.
government or foreign heads of state, or to conduct special investigations.
• Organ and tissue donation. If you are an organ donor, the plan may release medical information to organizations that handle organ procurement or organ,
eye, or tissue transplantation or to an organ donation bank to facilitate organ or tissue donation and transplantation.
• Coroners, medical examiners and funeral directors. The plan may release your PHI to a coroner or medical examiner. This may be necessary, for
example, to identify a deceased person or to determine the cause of death. The plan may also release your PHI to a funeral director, as necessary, to carry
out his/her duty.
Your Rights Regarding Health Information About You
Your rights regarding the health information the plan maintains about you are as follows:
• Right to inspect and copy. You have the right to inspect and copy your PHI. This includes information about your plan eligibility, claim and appeal records,
and billing records, but does not include psychotherapy notes. The plan must make PHI available in electronic format upon request and where available.
You may request that copies of your PHI be sent to a third party.
• To inspect and copy health information maintained by the plan, submit your request in writing to the plan Administrator. The plan may charge a fee for the
cost of copying and/or mailing your request. In limited circumstances, the plan may deny your request to inspect and copy your PHI. Generally, if you are
denied access to health information, you may request a review of the denial.
14
• Right to amend. If you feel that health information the plan has about you is incorrect or incomplete, you may ask the plan to amend it. You have the right
to request an amendment as long as the information is kept by or for the plan. If a requested amendment or correction is made by the Plan, notification
may be made to others who work with us and have copies of the uncorrected record if such notification is necessary.
To request an amendment, send a detailed request in writing to the plan administrator. You must provide the reason(s) to support your request. The plan
may deny your request if you ask the plan to amend health information that was: accurate and complete; not created by the plan; not part of the health
information kept by or for the plan; or not information that you would be permitted to inspect and copy.
• Right to an accounting of disclosures. You have the right to request an “accounting of disclosures.” This is a list of disclosures of your PHI that the plan
has made to others, except for those necessary to carry out health care treatment, payment, or operations; disclosures made to you; or in certain other
situations. The first list you request within a 12-month period is free of charge, but the plan may charge you for additional lists within the same 12-month
period. The Plan will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.
To request an accounting of disclosures, submit your request in writing to the planadministrator. Your request must state a time period, which may not
be longer than six years prior to the date the accounting was requested.
• Right to request restrictions. You have the right to request a restriction on the health information the Plan uses or discloses about you for treatment,
payment, or health care operations. You also have the right to request a limit on the health information the Plan discloses about you to someone who
is involved in your care or the payment of your care, like a family member or friend. For example, you could ask that the Plan not use or disclose
information about a surgery you had.
To request restrictions, make your request in writing to the plan administrator. You must advise us: 1) what information you want to limit; (2) whether
you want to limit the plan’s use, disclosure, or both; and (3) to whom you want the limit(s) to apply.
Note: The plan is not required to agree to your request.
• Right to request confidential communications. You have the right to request that the plan communicate with you about health matters in a certain way
or at a certain location. For example, you can ask that the Plan send you explanation of benefits (EOB) forms about your benefit claims to a specified
address.
To request confidential communications, make your request in writing to the plan administrator. The plan will make every attempt to accommodate
all reasonable requests. Your request must specify how or where you wish to be contacted.
• Right to a paper copy of this notice. You have the right to a paper copy of this notice. You may write to the plan administrator to request a written copy of
this notice at any time.
Changes to this Notice
The Plan reserves the right to change this notice at any time and to make the revised or changed notice effective for health information the Plan already
has about you, as well as any information the plan receives in the future. The plan will post a copy of the current notice in the university’s benefits office
at all times.
Complaints
If you believe your privacy rights under this policy have been violated, you may file a written complaint with the plan administrator at the address listed
below. Alternatively, you may complain to the Secretary of the U.S. Department of Health and Human Services, generally, within 180 days of when the act or
omission complained of occurred.
Note: You will not be penalized or retaliated against for filing a complaint.
Other Uses and Disclosures of Health Information
• Other uses and disclosures of health information not covered by this notice or by the laws that apply to the plan will be made only with your written
authorization. If you authorize the plan to use or disclose your PHI, you may revoke the authorization, in writing, at any time. If you revoke your
authorization, the plan will no longer use or disclose your PHI for the reasons covered by your written authorization; however, the plan will not reverse
any uses or disclosures already made in reliance on your prior authorization.
Contact Information
If you have any questions about this notice, please contact:
Plan Administrator
Kent State University
University Benefits, Heer Hall
635 Loop Road
Kent OH 44242-0001
330-672-3107
benefits@kent.edu
P:\Kent State University (2278)\HIPAA\Notice of Privacy Practices\ HIPAA Employee Group Health Plan Privacy Notice - Revised 2013
15
16
Healthcare Provider Contact Information
Medical Plans Anthem Blue Cross/
Blue Shield
Medical Mutual of Ohio (MMO)
Employee Assistance Program
Phone Website
1-866-811-9727
Customer Service
www.anthem.com
1-800-586-4509
Customer Service
www.medmutual.com
Impact – EAP/Work Life Online Account Login: Kent
www.impactemployeeassistance.com
1-800-227-6007
(Available 24/7)
Prescription Drug Plan
CVS/Caremark
www.caremark.com
1-888-202-1654
Customer Service
Dental Plans
EyeMed Flexible Spending Accounts
Medical Mutual Ohio-(MMO) Voluntary Insurance Plans 17
www.deltadentaloh.com
Delta Dental
1-800-524-0149
Customer Service
Vision Plan www.eyemedvisioncare.com
1-866-939-3633
Customer Service
1-800-525-9252
Customer Service
www.mytakecareplan.com
AFLAC (Voluntary Indemnity Plans)
1-216-382-9500 www.aflac.com
Legacy Services, Inc.
(Longterm Care Insurance)
1-800-230-3398/ext. 101
www.servilink.net/legacyltc
18
KENT STATE UNIVERSITY
Employee Contribution Rates
Calendar Year 2015
Semi-Monthly & Bi-Weekly
12 - Month
(24 Pays Annually)
Salary Range
0.00
- 22,000.00
22,000.01
26,500.00
26,500.01 31,000.00
31,000.01 37,000.00
37,000.01 44,000.00
44,000.01 52,000.00
52,000.01 63,500.00
63 ,500.01 78,500.00
78,500.01 - 100,000.00
100,000.01 - 150,000.00
150,000.01 - 200,000.00
200,000.01 +
90 / 70 PPO
Single
Family
$25.94
$68.77
$30.82
$81.71
$35.70
$94.65
$40.58
$107.59
$45.46
$120.53
$50.34
$133.46
$54.78
$145.24
$59.23
$157.02
$63.67
$168.79
$68.11
$180.57
$72.55
$192.35
$76.99
$204.12
MEDICAL MUTUAL
80 / 60 PPO
Single
Family
$19.27
$51.07
$23.96
$63.52
$28.66
$75.97
$33.36
$88.42
$38.05
$100.87
$42.75
$113.32
$47.03
$124.66
$51.30
$135.99
$55.58
$147.32
$59.85
$158.65
$64.13
$169.99
$68.40
$181.32
Delta Dental of Ohio
70 / 50 PPO
Single
Family
$13.14
$34.84
$17.70
$46.90
$22.25
$58.97
$26.80
$71.03
$31.35
$83.09
$35.90
$95.15
$40.04
$106.13
$44.18
$117.11
$48.32
$128.09
$52.47
$139.07
$56.61
$150.05
$60.75
$161.03
ANTHEM
90 / 70 PPO
80 / 60 PPO
Single
Family
Single
Family
$23.87
$62.58
$17.93
$47.00
$28.36
$74.35
$22.30
$58.46
$32.85
$86.13
$26.67
$69.92
$37.34
$97.90
$31.04
$81.38
$41.83
$109.67
$35.41
$92.84
$46.32
$121.45
$39.78
$104.30
$50.41
$132.16
$43.76
$114.73
$54.50
$142.88
$47.74
$125.16
$58.58
$153.59
$51.72
$135.59
$62.67
$164.31
$55.70
$146.02
$66.76
$175.03
$59.67
$156.45
$70.84
$185.74
$63.65
$166.88
10 - Month
(20 Pays Annually)
Salary Range
0.00 22,000.00
22,000.01 26,500.00
26,500.01 31,000.00
31,000.01 37,000.00
37,000.01 44,000.00
44,000.01 52,000.00
52,000.01
63,500.00
63 ,500.01
78,500.00
78,500.01 - 100,000.00
100,000.01 - 150,000.00
150,000.01 - 200,000.00
200,000.01 +
90 / 70 PPO
Single
Family
$31.13
$82.53
$36.98
$98.05
$42.84
$113.58
$48.70
$129.11
$54.55
$144.63
$60.41
$160.16
$65.74
$174.29
$71.07
$188.42
$76.40
$202.55
$81.73
$216.68
$87.06
$230.81
$92.39
$244.95
MEDICAL MUTUAL
80 / 60 PPO
Single
Family
$23.12
$61.29
$28.76
$76.23
$34.39
$91.17
$40.03
$106.11
$45.66
$121.05
$51.30
$135.99
$56.43
$149.59
$61.56
$163.19
$66.69
$176.79
$71.82
$190.38
$76.95
$203.98
$82.08
$217.58
70 / 50 PPO
Single
Family
$15.77
$41.81
$21.23
$56.28
$26.70
$70.76
$32.16
$85.23
$37.62
$99.71
$43.08
$114.18
$48.05
$127.36
$53.02
$140.53
$57.99
$153.71
$62.96
$166.88
$67.93
$180.06
$72.90
$193.23
ANTHEM
90 / 70 PPO
80 / 60 PPO
Single
Family
Single
Family
$28.64
$75.10
$21.51
$56.41
$34.03
$89.22
$26.76
$70.16
$39.42
$103.35
$32.00
$83.91
$44.81
$117.48
$37.25
$97.66
$50.20
$131.61
$42.49
$111.41
$55.58
$145.74
$47.74
$125.16
$60.49
$158.59
$52.51
$137.68
$65.39
$171.45
$57.29
$150.19
$70.30
$184.31
$62.06
$162.71
$75.20
$197.17
$66.83
$175.22
$80.11
$210.03
$71.61
$187.74
$85.01
$222.89
$76.38
$200.26
9 - Month
(18 Pays Annually)
Salary Range
0.00 22,000.00
22,000.01
26,500.00
26,500.01
31,000.00
31,000.01 37,000.00
37,000.01 44,000.00
44,000.01 52,000.00
52,000.01 63,500.00
63 ,500.01 78,500.00
78,500.01 - 100,000.00
100,000.01 - 150,000.00
150,000.01 - 200,000.00
200,000.01 +
90 / 70 PPO
Single
Family
$34.59
$91.70
$41.09
$108.95
$47.60
$126.20
$54.11
$143.45
$60.61
$160.70
$67.12
$177.95
$73.04
$193.65
$78.97
$209.36
$84.89
$225.06
$90.81
$240.76
$96.73
$256.46
$102.66
$272.16
MEDICAL MUTUAL
80 / 60 PPO
Single
Family
$25.69
$68.10
$31.95
$84.70
$38.21
$101.30
$44.48
$117.90
$50.74
$134.50
$57.00
$151.10
$62.70
$166.21
$68.40
$181.32
$74.10
$196.43
$79.80
$211.54
$85.50
$226.65
$91.20
$241.76
70 / 50 PPO
Single
Family
$17.53
$46.45
$23.59
$62.54
$29.66
$78.62
$35.73
$94.70
$41.80
$110.79
$47.86
$126.87
$53.39
$141.51
$58.91
$156.15
$64.43
$170.79
$69.96
$185.43
$75.48
$200.07
$81.00
$214.71
ANTHEM
90 / 70 PPO
80 / 60 PPO
Single
Family
Single
Family
$31.83
$83.44
$23.90
$62.67
$37.81
$99.14
$29.73
$77.95
$43.80
$114.84
$35.56
$93.23
$49.79
$130.53
$41.39
$108.51
$55.77
$146.23
$47.22
$123.79
$61.76
$161.93
$53.04
$139.07
$67.21
$176.22
$58.35
$152.97
$72.66
$190.50
$63.65
$166.88
$78.11
$204.79
$68.96
$180.79
$83.56
$219.08
$74.26
$194.69
$89.01
$233.37
$79.56
$208.60
$94.46
$247.66
$84.87
$222.51
DENTAL PLAN OPTION
Delta Dental PPO High Option
AAUP Tenured/Tenure Track High Option*
Delta Dental PPO Basic Option
Delta Dental PPO Low Option
12-Month & Bi-weekly
Single
$4.24
$4.40
$2.66
$2.30
EE +1
$7.91
$8.23
$5.00
$4.29
Family
$13.32
$14.07
$8.92
$7.53
10-Month
Single
$5.08
$5.14
$3.19
$2.76
EE +1
$9.50
$9.63
$6.00
$5.14
9-Month
Family
$15.99
$16.46
$10.71
$9.03
Single
$5.65
$5.72
$3.54
$3.06
EE +1
$10.55
$10.70
$6.66
$5.72
Family
$17.77
$18.29
$11.90
$10.04
Dental Benefit Highlights for
Kent State University
Low Plan
Delta Dental PPOSM (Point-of-Service)
Coverage Effective January 1, 2013
Delta Dental
PPO Dentist
Delta Dental
Premier®
Dentist
Plan Pays
Nonparticipating
Dentist
Plan Pays*
Plan Pays
Diagnostic & Preventive
Diagnostic and Preventive Services –
includes exams, cleanings, fluoride, and
100%
100%
100%
space maintainers
Brush Biopsy – to detect oral cancer
100%
100%
100%
Bitewing Radiographs – bitewing X-rays
100%
100%
100%
Emergency Palliative Treatment – to
60%
50%
50%
temporarily relieve pain
Basic Services
All Other Radiographs – other X-rays
60%
50%
40%
Restorative Services – fillings and crowns
60%
50%
40%
Endodontic Services – root canals
60%
50%
40%
Non-Surgical Periodontic Services – non60%
50%
40%
surgical services to treat gum disease
Simple Extractions – non-surgical removal of
60%
50%
40%
teeth
Other Basic Services – misc. services
60%
50%
40%
Relines and Repairs – to bridges and dentures
60%
50%
40%
Orthodontic Services
Orthodontic Services – includes braces
0%
0%
0%
* When you receive services from a Nonparticipating Dentist, the percentages in this column indicate
the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This
Nonparticipating Dentist Fee may be less than what your dentist charges, which means that you will be
responsible for the difference.
Maximum Payment – $750 per person total per benefit year on all services.
Deductible – $50 deductible per person total per benefit year. The deductible does not apply to oral
exams, preventive services, bitewing X-rays, and brush biopsy.
Note - This document is intended as a supplement to your Certificate and Summary of Benefits.
Please refer to your certificate and summary for policy exclusions and limitations.
Welcome to Ohio’s largest dental
benefits family!
As a member of Delta Dental of Ohio, you
have access to the nation's largest dental
networks: Delta Dental PPO and Delta Dental
Premier.
 Nationwide, 3 out of 4 dentists participate
 Great access to care as well as reduced
fees through our agreements with dentists
 You cannot be balance billed - giving you
added savings
 Network dentists will complete and file
your claim - no paperwork for you
 You only have to pay your copayments
and/or deductibles when you receive
dental services from a PPO or Premier
Dentist
 You don't have to wait for your claim to be
paid to be reimbursed!
While you can visit nonparticipating dentists,
you can be billed the full amount immediately
and then wait to be reimbursed.
Quality Dental Program
Delta Dental provides quick and accurate
claims processing. We pay more than 90
percent of claims in 10 days or less. Delta
Dental also offers world-class customer
service from our award winning call center.
Online Access
Our online Consumer Toolkit lets you access
your dental plan securely over the Internet.
You can find a dentist, check benefits, select
paperless EOBs, review claims and amounts
used toward maximums, print ID cards, and
more at your convenience.
A Healthy Smile
Keep your smile healthy with dental benefits
from Delta Dental. Your smile is a good
indicator of your health. Did you know that
your dentist can detect up to 120 different
diseases, including diabetes and heart
disease? Early detection is one of the best
ways to prevent further complications.
Questions?
If you have questions, call our Customer
Service team at (800) 524-0149 or look
online at www.deltadentaloh.com.
Effective 1/1/2015
Effective 1/1/2015
19
20
Delta Dental of Ohio
Delta Dental of Ohio
Dental Benefit Highlights for
Dental Benefit Highlights for
Basic Plan
High Plan
Kent State University
PPOSM
Delta Dental
(Point-of-Service)
Coverage Effective January 1, 2013
Delta Dental
PPO Dentist
Delta Dental
Premier®
Dentist
Plan Pays
Kent State University
Nonparticipating
Dentist
Plan Pays*
Plan Pays
Diagnostic & Preventive
Diagnostic and Preventive Services –
includes exams, cleanings, fluoride, and
100%
100%
100%
space maintainers
Brush Biopsy – to detect oral cancer
100%
100%
100%
Bitewing Radiographs – bitewing X-rays
100%
100%
100%
Sealants – to prevent decay of permanent teeth
75%
65%
60%
Basic Services
Emergency Palliative Treatment – to
75%
65%
60%
temporarily relieve pain
All Other Radiographs – other X-rays
75%
70%
50%
Restorative Services – fillings and crowns
75%
70%
50%
Endodontic Services – root canals
75%
70%
50%
Periodontic Services – to treat gum disease
75%
70%
50%
Oral Surgery Services – extractions and
75%
70%
50%
dental surgery
Other Basic Services – misc. services
75%
70%
50%
Major Services
Major Restorative Services – includes inlays
50%
50%
40%
and onlays
Occlusal Guards/Adjustments – bite guards
50%
50%
40%
and occlusal adjustments
Relines and Repairs – to bridges and dentures
50%
50%
40%
Prosthodontic Services – includes bridges,
50%
50%
40%
implants, and dentures
Orthodontic Services
Orthodontic Services – includes braces
50%
50%
0%
Orthodontic Age Limit –
No age limit
Up to age 19
N/A
* When you receive services from a Nonparticipating Dentist, the percentages in this column indicate
the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This
Nonparticipating Dentist Fee may be less than what your dentist charges, which means that you will be
responsible for the difference.
Maximum Payment –
PPO Dentist or Premier Dentist – $1,000 per person total per benefit year on all services except
orthodontics. $1,000 per person total per lifetime on orthodontic services.
Nonparticipating Dentist – $1,000 per person total per benefit year on all services.
These are not separate maximums by type of dentist.
Deductible –
PPO Dentist or Premier Dentist – $50 deductible per person total per benefit year. The deductible
does not apply to oral exams, preventive services, X-rays, brush biopsy, sealants, and orthodontic
services.
Nonparticipating Dentist – $50 deductible per person total per benefit year. The deductible does
not apply to oral exams, preventive services, X-rays, brush biopsy, and sealants.
Welcome to Ohio’s largest dental
benefits family!
As a member of Delta Dental of Ohio, you
have access to the nation's largest dental
networks: Delta Dental PPO and Delta Dental
Premier.
 Nationwide, 3 out of 4 dentists participate
 Great access to care as well as reduced
fees through our agreements with dentists
 You cannot be balance billed - giving you
added savings
 Network dentists will complete and file
your claim - no paperwork for you
 You only have to pay your copayments
and/or deductibles when you receive
dental services from a PPO or Premier
Dentist
 You don't have to wait for your claim to be
paid to be reimbursed!
While you can visit nonparticipating dentists,
you can be billed the full amount immediately
and then wait to be reimbursed.
Quality Dental Program
Delta Dental provides quick and accurate
claims processing. We pay more than 90
percent of claims in 10 days or less. Delta
Dental also offers world-class customer
service from our award winning call center.
Online Access
Our online Consumer Toolkit lets you access
your dental plan securely over the Internet.
You can find a dentist, check benefits, select
paperless EOBs, review claims and amounts
used toward maximums, print ID cards, and
more at your convenience.
A Healthy Smile
Keep your smile healthy with dental benefits
from Delta Dental. Your smile is a good
indicator of your health. Did you know that
your dentist can detect up to 120 different
diseases, including diabetes and heart
disease? Early detection is one of the best
ways to prevent further complications.
Questions?
If you have questions, call our Customer
Service team at (800) 524-0149 or look
online at www.deltadentaloh.com.
Note - This document is intended as a supplement to your Certificate and Summary of Benefits.
Please refer to your certificate and summary for policy exclusions and limitations.
9/11/2012
21
Delta Dental PPOSM (Point-of-Service)
Coverage Effective January 1, 2013
Delta Dental
PPO Dentist
Delta Dental
Premier®
Dentist
Plan Pays
Nonparticipating
Dentist
Plan Pays*
Plan Pays
Diagnostic & Preventive
Diagnostic and Preventive Services –
includes exams, cleanings, fluoride, and
100%
100%
100%
space maintainers
Sealants – to prevent decay of permanent teeth
100%
100%
100%
Brush Biopsy – to detect oral cancer
100%
100%
100%
Radiographs – X-rays
100%
100%
100%
Basic Services
Emergency Palliative Treatment – to
90%
80%
65%
temporarily relieve pain
Restorative Services – fillings and crowns
90%
80%
65%
Endodontic Services – root canals
90%
80%
65%
Periodontic Services – to treat gum disease
90%
80%
65%
Oral Surgery Services – extractions and
90%
80%
65%
dental surgery
Other Basic Services – misc. services
90%
80%
65%
Major Services
Major Restorative Services – includes inlays
60%
50%
50%
and onlays
Occlusal Guards/Adjustments – bite guards
60%
50%
50%
and occlusal adjustments
Relines and Repairs – to bridges and dentures
60%
50%
50%
Prosthodontic Services – includes bridges,
60%
50%
50%
implants, and dentures
Orthodontic Services
Orthodontic Services – includes braces
60%
50%
0%
Orthodontic Age Limit –
No age limit
Up to age 19
N/A
* When you receive services from a Nonparticipating Dentist, the percentages in this column indicate
the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This
Nonparticipating Dentist Fee may be less than what your dentist charges, which means that you will be
responsible for the difference.
Maximum Payment –
PPO Dentist or Premier Dentist – $1,250 per person total per benefit year on all services except
orthodontics. $1,000 per person total per lifetime on orthodontic services.
Nonparticipating Dentist – $1,250 per person total per benefit year on all services.
These are not separate maximums by type of dentist.
Deductible –
PPO Dentist or Premier Dentist – $25 deductible per person total per benefit year. The deductible
does not apply to oral exams, preventive services, X-rays, brush biopsy, sealants, and orthodontic
services.
Nonparticipating Dentist – $25 deductible per person total per benefit year. The deductible does
not apply to oral exams, preventive services, X-rays, brush biopsy, and sealants.
Welcome to Ohio’s largest dental
benefits family!
As a member of Delta Dental of Ohio, you
have access to the nation's largest dental
networks: Delta Dental PPO and Delta Dental
Premier.
 Nationwide, 3 out of 4 dentists participate
 Great access to care as well as reduced
fees through our agreements with dentists
 You cannot be balance billed - giving you
added savings
 Network dentists will complete and file
your claim - no paperwork for you
 You only have to pay your copayments
and/or deductibles when you receive
dental services from a PPO or Premier
Dentist
 You don't have to wait for your claim to be
paid to be reimbursed!
While you can visit nonparticipating dentists,
you can be billed the full amount immediately
and then wait to be reimbursed.
Quality Dental Program
Delta Dental provides quick and accurate
claims processing. We pay more than 90
percent of claims in 10 days or less. Delta
Dental also offers world-class customer
service from our award winning call center.
Online Access
Our online Consumer Toolkit lets you access
your dental plan securely over the Internet.
You can find a dentist, check benefits, select
paperless EOBs, review claims and amounts
used toward maximums, print ID cards, and
more at your convenience.
A Healthy Smile
Keep your smile healthy with dental benefits
from Delta Dental. Your smile is a good
indicator of your health. Did you know that
your dentist can detect up to 120 different
diseases, including diabetes and heart
disease? Early detection is one of the best
ways to prevent further complications.
Questions?
If you have questions, call our Customer
Service team at (800) 524-0149 or look
online at www.deltadentaloh.com.
Note - This document is intended as a supplement to your Certificate and Summary of Benefits.
Please refer to your certificate and summary for policy exclusions and limitations.
22
9/11/2012
NEW
Delta Dental of Ohio
Dental Benefit Highlights for
AAUP Tenured/Tenure-Track Faculty #1010 High Plan
Effective 1/1/2015
Delta
Dental
PPO
Delta Dental PPOSM (Point-of-Service)
Dentist
Plan Pays
Diagnostic & Preventive
Diagnostic and Preventive Services exams, cleanings, fluoride, and space
100%
maintainers
Sealants - to prevent decay of
100%
permanent teeth
Brush Biopsy - to detect oral cancer
100%
Radiographs - X-rays
100%
Basic Services
Emergency Palliative Treatment - to
90%
temporarily relieve pain
Minor Restorative Services - fillings
90%
Endodontic Services - root canals
90%
Periodontic Services - to treat gum
90%
disease
Oral Surgery Services - extractions and
90%
dental surgery
Major Restorative Services - crowns
90%
Other Basic Services - misc. services
90%
Major Services
Crown Repair - to individual crowns
60%
Occlusal Guards/Adjustments - bite
60%
guards and occlusal adjustments
Relines and Repairs - to bridges and
60%
dentures
Prosthodontic Services - bridges,
60%
dentures, and implants
Orthodontic Services
Orthodontic Services - braces
60%
Orthodontic Age Limit -
Delta
Dental
Premier®
Dentist
Plan Pays
100%
Nonparticipating
Dentist
Plan Pays*
100%
100%
100%
100%
100%
100%
100%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
50%
50%
50%
50%
50%
50%
50%
50%
60%
Up to age 19
60%
* When you receive services from a Nonparticipating Dentist, the percentages in this
column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be
paid for those services. The Nonparticipating Dentist Fee may be less than what your
dentist charges and you are responsible for that difference.
Maximum Payment – $1,250 per person total per benefit year on Diagnostic &
Preventive, Basic Services, and Major Services. $1,000 per person total per lifetime on
Orthodontics.
Deductible – $25 deductible per person total per benefit year The deductible does not
apply to oral exams, preventive services, X-rays, brush biopsy, sealants, and
orthodontic services.
Note – This document is only intended to provide a brief description of your benefits.
Please refer to your Certificate and summary for a complete description of benefits,
exclusions, and limitations.
23
Welcome to Ohio's largest dental
benefits family!
As a member of Delta Dental of Ohio,
you have access to the nation's largest
dental networks: Delta Dental PPO and
Delta Dental Premier.
 It's easy to find a dentist! Four out of
five dentists nationwide participate in
our network.
 You have superior access to care
and fee savings because of our
agreements with participating
dentists.
 Our dentists cannot balance bill you,
which means more money in your
pocket!
 No troublesome paperwork!
Network dentists will fill out and file
your claims.
 Pay only your copayments and/or
deductibles when you receive care
from network dentists – there are no
hidden fees.
 You can still visit nonparticipating
dentists, but you may be billed the
full amount at the time of service and
then have to wait to be reimbursed.
Quality Dental Program
With our quick and accurate claims
processing, we pay more than 90% of
claims in 10 days or less. Delta Dental
also offers world-class customer
service from our award winning call
center.
Online Access
Our online Consumer Toolkit lets you
access your dental plan securely over
the Internet. You can find a dentist,
check benefits, select paperless
notices, review claims and amounts
used toward maximums, print ID cards,
and more – all at your own
convenience.
A Healthy Smile
Keep your smile healthy with dental
benefits from Delta Dental. Your smile
is a good indicator of your health. Did
you know that your dentist can detect
up to 120 different diseases, including
diabetes and heart disease? Early
detection is one of the best ways to
prevent further complications.
Questions?
If you have questions, please call our
Customer Service team at (800) 5240149 or look online at
www.DeltaDentalOH.com.
Vision Care Plan
Administered through EyeMed Vision
Type of Service
2015 - EyeMed
*In Network *
Eye Examination
Covered in full
$90
Single Vision
$240 + discount
$240
Bi-focal Vision
$240 + discount
$240
Tri-focal Vision
$240 + discount
$190
Contacts
Laser Vision Correction
Additional Pair Benefit
Out of
Network
up to
$190 + discount $190
up$190
to $200
15% off retail
price or 5% off
promotional price
N/A
15% to 40%
discount
N/A
*Maximum benefit per person during a rolling 24-month period.
The Employee group Vision Care Plan is administered through EyeMed and is automatic when you elect medical coverage with
Medical Mutual SuperMed Plus PPO or Anthem Blue Cross Blue Shield PPO. Covered members may elect to use their benefit
allowance for eyeglasses or contact lenses. The full benefit allowance must be used at time of service (i.e., when you purchase a pair
of glasses or contact lenses); any remaining balance will not roll over to a future purchase.
How to receive benefits: You may receive service from any vision care provider. If you use an in-network provider, you
do not need to submit a claim form. If you are using an out-of-network provider you must submit a claim form to EyeMed for
reimbursement of covered expenses in accordance with the above schedule. The EyeMed vision claim form is available in the
Human Resources forms library at: http://www.kent.edu/hr/forms/benefits. The booklet describing the vision program is also
available on the same website.
24
**PLAN**
BENEFIT PERIOD
Primary Care Physician (PCP) Required
Dependent age limit
MEDICAL PLANS FOR CALENDAR YEAR 2015
PPO Option 90/70 (Anthem & Med Mutual)
Calendar Year (January 1 to December 31)
No
age 25, age 26-28 Adult Child
BENEFIT
Network
Non-Network
$250/$500
$750/$1,500
$1,500/$3,000
10%
30%
Annual Deductible
Annual out-of-pocket max (excl deductible)
Coinsurance (employee pays)
IN-PATIENT CARE
Semi-private room and board
90%
$100 copay, then 70%
Surgery
90%
70%
Anesthesia
90%
70%
Consultations
90%
70%
Maternity care
90%
$100 copay, then 70%
Lab and X-ray services
90%
70%
Therapy services
90%
70%
Drugs and Medications
90%
70%
OUT-PATIENT CARE
Outpatient surgery
90%
70%
Second Surgical Opinion
100%
100%
Diagnostic services, lab and x-ray
90%
70%
MRI (require prior authorization)
90%
70%
Cardiac Rehabilitation
90%
70%
Physical, occupational and speech therapy
90%
70%
4
$15 copay then 100%
70%
Office visits - PCP
4
$30 copay then 100%
70%
Office visits - Specialist
$15 copay then 100%
70%
Urgent Care4
4
$15 copay then 100%
not covered
Routine Physical exam
1
100%
not
covered
Routine Testing (5 standard)
$15 copay then 100%
70%
Well child care (birth to age18) 4
Immunizations
100%
70%
100%
70% no deductible
Routine Mammogram2
2
$15 copay then 100%
70% no deductible
Routine Pap test
2
100%
70% no deductible
Routine PSA
Routine Hearing Exam
$15 copay then 100%
70% no deductible
Prenatal and postnatal maternity care
90%
70%
Sterilization
90%
70%
Allergy test and treatment
90%
70%
90%
Durable medical equipment
90%
Emergency room services (emergency)
$50 copay then 90%
$50 copay then 70%
- non-emergency use of emergency room3
90%
Ambulance
Biologically Based Mental Illness Services $15 copay then 100%
Substance/Chemical Abuse
90%
70%
Inpatient
90%
70%
Outpatient benefit
90%
70%
90%, 120 days per calendar year
Skilled nursing facilities
90%, 120 days per calendar year
Home healthcare
90%
Private Duty Nursing
90%
Hospice
Organ transplants
90%
70%
Prescription Drug (CVS Caremark)
1)
2)
3)
4)
5)
PPO Option 80/60 (Anthem & Med Mutual)
Calendar Year (January 1 to December 31)
No
age 25, age 26-28 Adult Child
BENEFIT
Network
Non-Network
$350/$700
$900/$1,800
$2,000/$4,000
20%
40%
PPO Option 70/50 (Offered by Med Mutual ONLY)
Calendar Year (January 1 to December 31)
No
age 25, age 26-28 Adult Child
BENEFIT
Network
Non-Network
$500/$1,000
$1,000/$2,000
$2,500/$5,000
30%
50%
80%
80%
80%
80%
80%
80%
80%
80%
$100 copay, then 60%
60%
60%
60%
$100 copay, then 60%
60%
60%
60%
70%
70%
70%
70%
70%
70%
70%
70%
$100 copay, then 50%
50%
50%
50%
$100 copay, then 50%
50%
50%
50%
80%
100%
80%
80%
80%
80%
$15 copay then 100%
$30 copay then 100%
$15 copay then 100%
$15 copay then 100%
100%
$15 copay then 100%
100%
100%
$15 copay then 100%
100%
$15 copay then 100%
80%
80%
80%
60%
100%
60%
60%
60%
60%
60%
60%
60%
not covered
not covered
60%
60%
60% no deductible
60% no deductible
60% no deductible
60% no deductible
60%
60%
60%
70%
100%
70%
70%
70%
70%
$15 copay then 100%
$30 copay then 100%
$15 copay then 100%
$15 copay then 100%
100%
$15 copay then 100%
100%
100%
$15 copay then 100%
100%
$15 copay then 100%
70%
70%
70%
50%
100%
50%
50%
50%
50%
50%
50%
50%
not covered
not covered
50%
50%
50% no deductible
50% no deductible
50% no deductible
50% no deductible
50%
50%
50%
80%
80%
$50 copay then 80%
$50 copay then 60%
80%
$15 copay then 100%
80%
60%
80%
60%
80%
60%
80%, 120 days per calendar year
80%, 120 days per calendar year
80%
80%
80%
60%
70%
70%
$50 copay then 70%
$50 copay then 50%
70%
$15 copay then 100%
70%
50%
70%
50%
70%
50%
70%, 120 days per calendar year
70%, 120 days per calendar year
70%
70%
70%
50%
10% coinsurance generic, 20% coinsurance brand, 40% coinsurance for
10% coinsurance generic, 20% coinsurance brand, 40% coinsurance for brand if 10% coinsurance generic, 20% coinsurance brand, 40% coinsurance for brand if
brand if generic is available; $60 max per prescription Retail or Mail Service. generic is available; $60 max per prescription Retail or Mail Service. If a brand
generic is available; $60 max per prescription Retail or Mail Service. If a brand
If a brand name drug is prescribed and a generic is available, the maximum name drug is prescribed and a generic is available, the maximum coinsurance is name drug is prescribed and a generic is available, the maximum coinsurance is
coinsurance is $100 unless the physician has indicated "dispense as
$100 unless the physician has indicated "dispense as written".Mail Service
$100 unless the physician has indicated "dispense as written".Mail Service required
written".Mail Service required after 90 days for maintenance medications.
required after 90 days for maintenance medications.
after 90 days for maintenance medications.
EKG, chest x-ray, complete blood count, SMA 12, urinalysis.
Once per calendar year for covered persons within eligible groups
No coverage for facility charges during non-emergency use of emergency room; benefits cover professional component only.
Office visit co-pays apply to cost of the office visit only.
All plans are grandfathered.
This is a summary. If there is a difference between this summary
and the plan documents, benefits will be paid in accordance with
the plan documents.
25