Issaquah School District EE Guide 2016 8.4.16

A Summary of Employee Benefit Plans

Enrollment Guide for the 2016-2017 School Year

This guide is only a brief description of insurance coverage under the Issaquah School District benefits program. The
provisions of the actual plan documents and contracts will govern in the case of any discrepancy.

This Page Intentionally Left Blank
2

TABLE OF CONTENTS

Who Is Eligible/How to enroll/When to Enroll…………………………………..… 5-6
What’s New for 2016-2017 Plan Year………………………………………………….. 7-9
Important Deadlines to Remember……………..…….……………………………….. 9
Medical – Premera Blue Cross…………………………………………………….………. 10
Medical – Group Health ………………………………………………………..…..………. 11
Dental – Delta Dental of Washington………………………………………….……… 12
Vision –Northwest Administrators, Inc. (NBN)…………………….……………… 13
Term Life and AD&D – The Standard & Unum…………………………………..... 14
Long Term Disability – The Standard………………………………..…………………. 14
Short Term Disability (Bus Drivers Only) – The Standard…………………….. 15
Employee Assistance Program (EAP) – First Choice Health………….………. 16
Health Care & Dependent Care FSA….………………………………………………… 17
Health Savings Account (HSA) Information………..………………………….……. 18
Monthly Premium and Your Costs…………………………………………..…….…… 19-21
Voluntary Life Benefits – The Standard.......……………………………..….…….. 22
Voluntary Disability Benefits – American Fidelity…………………….………… 23
Voluntary Long Term Care Benefits & Rates – Unum.………………………… 23-25
Other Voluntary Benefits….…………………………………………………………..…… 26
Legislative Resources………..…………………………………………………………….... 27
Contact Information………………………………………………………………………….. 28
Online Benefits Site……….………………………………………………………………….. 29
Notice of Special Enrollment Rights……………………………………………………. 30
Newborns’ and Mothers’ Health Protection Act of 1996……………….……. 30
Women’s Health and Cancer Rights Act of 1998 (WHCRA)……….………... 31

3

This Page Intentionally Left Blank
4

Issaquah School District offers you and your eligible family members a comprehensive and valuable benefits program.
We encourage you to take the time to educate yourself about your options and choose the best coverage for you and
your family.

Who is Eligible?

Employees hired by the 15th of any month will have benefits effective the first of the following month. For employees
hired after the 15th, benefits will be effective the first of the month following 30 days of employment. The following
family members are eligible for medical, dental and vision coverage:

• Your lawful spouse or state–registered domestic partner.
• Your dependent children to age 26 - natural children, stepchildren, legally adopted children, children for whom

you assume a legal obligation for support in anticipation of adoption (children of a domestic partner), or children
specified in a court order or divorce decree.

How to Enroll

Newly Eligible: Review this guide to familiarize yourself with the benefit plans that we offer to enroll in:
• Premera Blue Cross plan, you will need to go on-line through UPoint (formerly known as Your Benefits Resources
(YBR)) portal http://resources.hewitt.com/wea/
• Group Health forms are available in the Payroll Department or on the Benefits Portal at:

http://www.issaquah.wednet.edu/human-resources/benefits
User Name: IssaquahSD
Password: IssaquahSD411

Currently Enrolled Participant: Review this guide to familiarize yourself with the benefit plan(s) that we offer. If you
want to make changes to your benefit plan(s), you will need to complete the respective process:

• On-line for Premera Blue Cross through UPoint (formerly known as Your Benefits Resources (YBR)) portal
http://resources.hewitt.com/wea/

• Group Health forms are available in the Payroll Department or on the Benefits Portal at:
http://www.issaquah.wednet.edu/human-resources/benefits
User Name: IssaquahSD
Password: IssaquahSD411

All benefit-eligible employees are to complete District Medical Waiver if declining District medical coverage.

5

When to Enroll

The annual open enrollment period runs from August 22, 2016 through September 30, 2016, for a November 1, 2016
effective date. Be advised, all Open Enrollment elections are a 12-month commitment and fixed for the 2016-17 plan
year unless the subscriber or dependent experiences a Qualifying Life Event.

Changes outside Open Enrollment Period – Qualifying Life Events

Unless you have a Qualified Life Event, you cannot make changes to the benefits you elect until the next open
enrollment period. Qualified changes in status include: marriage, divorce, legal separation, birth or adoption of a child,
change in child’s dependent status, death of an enrolled family member, unpaid leave of absence for an employee or
spouse, or if an employee or spouse has a significant change in employment status (part-time to full-time or vice
versa). A new enrollment form or online enrollment must be completed within 30 days of the change in status (60
days for newborns and adoptions).

The information in this Enrollment Guide is presented for illustrative purposes and is based on information provided by
your employer. The text contained in this Guide was taken from various summary plan descriptions and benefit
information. While every effort was taken to accurately report your benefits, discrepancies or errors are always possible.
In case of discrepancy between the Guide and the actual plan documents the actual plan documents will prevail. All
information is confidential, pursuant to the Health Insurance Portability and Accountability Act of 1996. If you have any
questions about your Guide, contact the Payroll Department.

6

What’s New for 2016-2017 Plan Year

Medical

Group Health
• 1.5% increase in premium. Rate change is effective 11/1/2016 through 10/31/2017. See Monthly Premium
and Your Costs on page 19 for monthly carrier premium rates.
• Benefit Change: Rehabilitation. Cardiac, pulmonary rehabilitation, and massage therapy are now included
under Rehabilitation. It is covered up to a combined total of 30 days/45 visits when clinical criteria are met.

For Group Health members: To find providers, go to ghc.org: Under “Find a Doctor or Medical Facility,” click on
“Provider & Facility Directory.” Then, under “Search for,” click “Doctors and Other Providers.” A separate box will pop
up. Under the provider network menu, choose “Group Health/Core” and then search by provider name, type, or
location.

Premera Blue Cross
• Increases in premiums range from 7.7% to 13.8% depending on the plan. Rate change is effective 11/1/2016
through 10/31/2017. See Monthly Premium and Your Costs on page 19 for monthly carrier rates.

The following is a summary of the Deductible, Copay, and Out of Pocket Changes. This is not a comprehensive list.
Please refer to the Premera plan booklets for a full description of benefits, limitations and exclusions.

Premera PPO Plan 2 –
• Medical annual deductible increasing from $200 for an individual and $600 for a family to $300 for an individual
and $900 for a family
• Medical in-network out-of-pocket maximum increasing from $1,700 for an individual and $5,100 for a family to
$2,000 for an individual and $6,000 for a family
• Added an in-network Specialist Office Visit copay of $35; out-of-network of $40
• Prescription drug mail order copays increasing to $20 for Generic, $40 for Preferred brand name, and $65 for
Non-Preferred brand name drugs

Premera PPO Plan 3 –
• Medical annual deductible increasing from $300 for an individual and $900 for a family to $500 for an individual
and $1,500 for a family
• Medical in-network out-of-pocket maximum increasing from $2,950 for an individual and $8,850 for a family to
$3,000 for an individual and $9,000 for a family
• Added an in-network Specialist Office Visit copay of $40; out-of-network of $50
• Prescription drug mail order copays increasing to $30 for Generic, $50 for Preferred brand name, and $70 for
Non-Preferred brand name drugs

Premera PPO EasyChoice A –
• Medical in-network annual deductible increasing from $1,000 for an individual and $3,000 for a family to $1,250
for an individual and $3,750 for a family
• In-network Office Visit copay increasing from $15 to $25 for Non-Specialist Visits and added a Specialist Visit
Copay of $35
• Diagnostic x-ray and lab will change from $0 for the first $1,000 then deductible and coinsurance to 1st $250
subject to coinsurance, then deductible and coinsurance
• Prescription drug retail Generic copay increasing from $5 to $10
• Prescription drug mail order copays increasing to $20 for Generic, 30% for Preferred brand name, and 30% for
Non-Preferred brand name drugs

7

What’s New for 2016-2017 Plan Year - Continued

Premera PPO EasyChoice B –
• Change in provider network from Premera ‘Heritage’ to ‘Heritage Prime’. Premera’s Heritage PRIME was
designed to be a smaller (narrow) network with better provider discounts. Part of this change involves removing
the Providence/Swedish and Franciscan Health Systems effective January 1, 2017. Pease refer to the Easy
Choice B Summary Benefits and Coverage 2017 for more information regarding these changes and the Premera
provider directory for provider availability.
• Added a Specialist Office visit copay of $40

Premera PPO Basic Plan –
• Medical in-network annual deductible increasing from $1,250 for an individual and $2,500 for a family to $2,100
for an individual and $4,200 for a family
• Office Visit copay increasing from $30 to $35 for Non-Specialist Visits and added a Specialist Visit Copay of $50
• Combined Medical and Pharmacy in-network out-of-pocket maximum to $6,600 for an individual and $13,200
for a family
• Pharmacy annual deductible increasing from $500 for an individual and $1,000 for a family to $750 for an
individual and $1,500 for a family
• Retail pharmacy non-preferred drug copay increasing from $45 to $50
• Mail order pharmacy Generic drug copay increasing from $15 to $30 and Non-Preferred drug copay increasing
from $90 to $100

Premera QHDHP –
• Medical in-network annual deductible increasing from $1,500 for an individual or $3,000 for a family to $1,750
for an individual or $3,500 for a family
• Medical in-network out-of-pocket maximum increasing from $4,000 for an individual and $8,000 for a family to
$5,000 for an individual and $10,000 for a family; individual out-of-pocket maximum now applies to each
individual on the plan

Your plan provides a higher level of benefits (and lower out-of-pocket costs) when you use network providers. The plan
also features an out-of-network option. When you use a licensed health care provider who is not part of the network
(also called an out-of-network provider) benefits for covered services are provided at a lower level of benefits (and
higher out-of-pocket costs).

To find providers, go to www.premera.com and select “Find a Doctor”. Your WEA Select Plan is called a “Heritage”,
“Heritage Prime” or “Foundation” plan. It uses a network of contracted providers (known as “Heritage Network”,
“Heritage Prime Network” or “Foundation Network”) to provide health care services to you. These providers are also
called “network providers.”

NOTE: Network Providers are subject to change at any time. Please contact Premera to confirm your provider is in-
network at the time of service.

Dental

• Premium decrease from $121.90 to $120.10 per month. Rate change is effective 11/1/2016 through
10/31/2017.

• Delta Dental Plan A will now cover composite (tooth colored) fillings on any tooth.

Vision

• No plan changes at this time.

8

Flexible Spending Account (FSA)

• No changes to allowed contribution amounts. See page 17 for maximum contributions.

Life and Disability - Unum

• No plan changes at this time.

Important Deadlines to remember:

• Premera Blue Cross changes are accepted online at the UPoint (formerly known as Your Benefits Resources
(YBR)) website http://resources.hewitt.com/wea through 9:59 p.m. PDT on 9/30/16. The Premera Blue Cross
open enrollment information is now available for review and action on this website.

• Group Health Cooperative medical plan changes are made using the Group Health Enrollment and Change
Form. This form and Group Health plan information are available in the Payroll Department or online at
http://www.issaquah.wednet.edu/human-resources/benefits. Enrollment/change forms need to be received by
4:30 p.m. PDT on 9/30/16.

• All benefit-eligible employees are to complete District Medical Waiver if declining District medical coverage.
Who do I contact with questions?

• Contact the Benefits Coordinator in the Payroll Department at:
o If your last name begins A-K contact Rhonda Kurtenbach: 425.837.7065
o If your last name begins L-Z contact Jenny Shim: 425.837.7152

9

Medical – Premera Blue Cross

Issaquah School District offers a Preferred Provider medical plan through Premera Blue Cross. This plan allows you to
use any provider and hospital of your choosing. The level of benefits you receive through the plan is dependent upon
your choice of an in-network or an out-of-network provider. You will receive a significantly higher level of benefit when
you obtain services from an in-network provider. To find a provider near you visit www.premera.com.

Premera / WEA

Plan 2 Plan 3 Easy Choice A Easy Choice B Basic Plan QHDHP

Network Heritage Heritage Heritage Heritage Prime Heritage Prime Foundation

Deductible PCY Applies Unless Noted as DW
Individual
Family $300 $500 $1,250 $750 $2,100 $1,750
$900 $1,500 $4,200 $3,500
$3,750 $2,250

Coinsurance 80% 80% 80% 75% 70% 80%

Out of Pocket Excludes Prescription Copays
Individual
Family $2,000 $3,000 $4,000 $3,500 $6,600 $5,000
$6,000 $9,000 $13,200 $10,000
$8,000 $7,000

Preventive Care 100% (DW) 100% (DW) 100% (DW) 100% (DW) 100% (DW) 100% (DW)
Exam

Office Visit Exam DW DW DW DW DW 80%
Primary Care $25 copay $30 copay $25 copay $30 copay $35 copay
Specialist $35 copay $40 copay $35 copay $40 copay $50 copay

Lab & X-ray 100% (DW) 100% (DW) 100% (DW) 100% (DW) 100% (DW) 100% (DW)
Preventive

Other 80% 80% 80%* 75% 70% 80%

Hospital Copays $150/day, $300/day, 80% 75% 70% 80%
Inpatient $450 max, $900 max, 80% 75% 70% 80%
Outpatient
80% 80%
$100, 80% $150, 80%

Emergency Room $75, 80% $100, 80% $100, 80% $150, 75% $200, 70% 80%

Prescription up to 34 day up to 34 day up to 30 day up to 30 day Up to 30 day up to a 30
Drugs supply supply supply day supply
supply supply Subject to
$750 indiv / deductible
Deductible None None $500 per person $250 per $1,500 family
PCY person PCY 20%
PCY 20%
Generic $10 $15 $10 (DW) $5 (DW) $15 20%
$30 20%
Brand $20 $25 30% $30 $50 up to 90 day
30% supply
Non Formulary $35 $40 30% $45 Up to 90 day 20%
supply
Specialty $50 $60 30% 30% $30/$60/$100 Not covered

up to 100 day up to 100 up to 90 day up to 90 day Not Covered $12,500
supply supply
Mail Order supply day supply $12,500 10
$20/30%/30% $10/$75/$112
$20/$40/$65 $30/$50/$70

Vision Not covered Not covered
Exam/ Hardware Not covered Not covered

Employee Only

Life Insurance $12,500 $12,500 $12,500 $12,500

(Unum)

DW = Deductible Waived, DC = Deductible and Coinsurance, PCY = Per Calendar Year
*1st $250 subject to coinsurance, DW, then DC

Medical – Group Health

The HMO/Managed Care type plans provide you with managed benefits and usually at a lower cost at the time of
service. However, these plans require that you select a primary care provider (PCP) from their list of providers. Your PCP
will then either provide or coordinate all of your care (except in the case of medical emergency). To find a provider near
you visit www.ghc.org.

Network Group Health
Deductible PCY Group #0034100

Individual HMO
Family
Coinsurance $0
Out of Pocket Maximum $0
Individual None
Family
Preventive Care $2,000
Exam $4,000
Office Visit Copay
Exam 100%
Lab & X-ray
Preventive 100% after $25 copay
Other
Hospital 100%
100%
Inpatient
100% after $200 copay per admit
Outpatient 100% after $25 copay
100% after $100 copay
Emergency Room up to 30 day supply
None
Prescription Drugs $15
Deductible $30
Generic Not covered
Brand up to 90 day supply
Non Formulary $30/$60

Mail Order $25
Not covered
Vision
Exam
Hardware

11

Dental – Delta Dental of Washington

Issaquah School District offers a dental plan through Delta Dental of Washington. To receive the highest level of
benefits, you will need to receive services from a Delta Dental PPO provider.

To find a provider near you visit www.DeltaDentalWA.com.

Services Delta Dental PPO
Plan A with Orthodontia D
Deductible (Individual / Family)
Class I - Diagnostic & Preventive Group #0186
Exams, X-rays, Sealants, Cleanings, etc. None
Class 2 - Restorative
Fillings, Extractions, and Crowns Incentive Plan* – 70% - 100%
Class 3 - Major Services
Dentures, Partials, Bridges, and Implants Incentive Plan* – 70% - 100%
*Preauthorization Required
Class 4 – Orthodontia 50%
Adults and Dependent Children to Age 19
50% to $1,250
Annual Maximum Per Plan Year Lifetime Maximum
$1,750 if you use a Premier, non PPO Provider
$2,000 if you use a Delta Dental PPO Provider

If you choose a nonparticipating dentist, you will be responsible for having the dentist complete and sign claim forms. It
will also be up to you to ensure that the claims are sent to Delta Dental of Washington. Claim payments will be based
on actual charges or Delta Dental of Washington’s maximum allowable fees for nonparticipating dentists, whichever is
less. You will be responsible for any balance remaining. Please be aware that Delta Dental of Washington has no control
over nonparticipating dentists’ charges or billing procedures.

*How the Incentive Plan Works:
Delta Dental of Washington encourages regular dental care. Delta Dental pays 70% of covered services for Preventive
and Restorative care during the first plan year of coverage. This advances by 10% annually (effective November 1) –
providing the plan is used at least once per benefit year for applicable services to a maximum of 100%. Failure to use
the plan once each benefit year causes the level to drop by 10% below the last level of payment, but never below the
original 70%. Each eligible employee and dependent creates his or her own percentage point level. The incentive plan
does not apply to the 50% allowance for the cost of Major care, Implants, or Orthodontia.

12

Vision – Northwest Administrators, Inc. (NBN)

Vision coverage is provided through NBN. Please take advantage of these great services available to you and your
family. The benefit period begins on the date the glasses or contact lenses are ordered and continues for consecutive 12
months.

Services NBN

Copays (Exam / Hardware) $0 / $0+

Frequency Once Per 365 Days*
Exam Once Per 365 Days*
Lenses (Pair) Once Per 730 Days*
Frames Once Per 365 Days*
Contact Lenses (Elective and Medically Necessary)

Exam 100%+

Lenses Covered in full**+
Single Vision
Lined Bifocal
Lined Trifocal

Frames Covered in full***+

Contacts (instead of glasses)

Elective (in lieu of all other benefits) $300 allowance towards the cost of the exam,

fitting fee, and lenses+

Medically Necessary Covered in full+

*These time frames are strictly enforced (i.e. to the day)

** Covered in full applies to the cost of basic lenses

***Selection offered by the plan covered in full

+When services are rendered by a Northwest Benefit Network Provider.

Contacts: Patient must be eligible for both the examination and lenses (glasses) at the time services for contact lenses
begin. The elective contacts benefit allowance can be used only once per benefit period.

The Northwest Administrators, Inc. self-funded vision plan contracts with a panel of eye care professionals through
Northwest Benefit Network (NBN). They provide vision care for employees and their dependents covered under this
plan. Going to a panel provider assures the highest level of reimbursement for claims.

Please contact NW Administrators, Inc. at 800.732.1123 or visit their website at www.nwadmin.com for questions
regarding benefits and/or eligibility. Click on the NBN Vision Provider Locator section to access provider directory.

13

Term Life and AD&D Benefits –The Standard & Unum

Issaquah School District provides you with Basic Life and AD&D benefits. In the event that there is a payout of life
benefits, monies will be dispersed to your appointed beneficiary.

Group Life The Standard
Group #399979-D
Class 1 Class 2 Class 3 Class 4
Class Description Principals, Food Service,
Administrators, and Bus Drivers and Custodians and Secretaries, and
Benefit Amount Un-Represented Educational Assistants Maintenance
Guarantee Issue Teachers
AD&D
Age Reduction $50,000 $25,000 $15,000 $10,000

Up to $30,000

Matches Life Benefit

65% of Benefit Amount at Age 70 / 50% of Benefit Amount at Age 75

Group Life Unum
Group #W-138
Eligibility Employees enrolled in Premera Blue Cross Plans 2, 3, Easy Choice A & B, Basic, and QHDHP
$12,500
Benefit Amount
$8,125 at Age 65 / $6,250 at Age 70
Age Reduction

Long Term Disability Income Benefits –The Standard

Issaquah School District provides you with long-term disability income replacement benefits. In the event you become
disabled from a non work-related injury or sickness, LTD benefits provide you with a source of income.

Long-Term Disability The Standard
Group #399979-C
Class 1 Class 2

Class Description Bus Drivers and Mechanics Administrators, Teachers, Principals,
Secretaries, and Un-Represented
Employees

Elimination Period You must be disabled for 90 days before You must be disabled for 60 days
benefits are payable before benefits are payable

Monthly Benefit 60% of first $4,167 of Base pay up to 60% of first $16,667 of Base Pay up to
$2,500 $10,000

Pre-Existing Condition Exclusion 3 3 / 12 3 / 12

3 You have a pre-existing condition if you received medical treatment, consultation, or services including diagnostic measures, or took prescribed
drugs or medicines in the 3 months prior to your effective date of coverage; and the disability begins in the first 12 months after your effective date
of coverage; unless you have been treatment-free from the pre-existing condition for 12 consecutive months after your effective date.

14

Short Term Disability Income Benefits – The Standard - Bus Drivers Only

Issaquah School District provides you with short-term disability income replacement benefits. In the event you become
disabled from a non work-related injury or sickness, STD benefits provide you with a source of income.

Short-Term Disability The Standard

Class Description Class 1 and 2 Class 3 and 4 Class 5 and 6
Elimination Period Package hours 7.0+ per day
Weekly Benefit Package hours 4.0 - 4.99 Package hours 5.0 – 6.99
Benefit Duration per day per day

Benefits begin 15 days after accident or illness

60% of your weekly income 60% of your weekly income to 60% of your weekly income to

to a maximum of $100 a maximum of $150 a maximum of $200

13 Weeks

Disabilities Covered Physical disease, injury, pregnancy, or mental disorder

See Certificate of coverage for specific limitations and exclusions. Benefits cease once you return to work or any
occupation. No Short Term Disability benefits will be paid for any period of disability when you are able to work in your
own occupation and able to earn at least 20% of your pre-disability earnings.

15

Employee Assistance Program (EAP) – First Choice Health

Issaquah School District provides an Employee Assistance Program (EAP) through First Choice Health EAP. They have
many services available to employees and their family members. Personal issues, planning for life events or simply
managing daily life can affect your work, health and family. First Choice provides support, resources and information for
personal and work-life issues. Your EAP is company-sponsored, confidential and provided at no charge to you and your
dependents. Use your EAP to help you and your family deal with everyday challenges, including:
Counseling Services – First Choice Health EAP offers counseling services for emotional stress, family stress, and many
other issues. Call the EAP telephone number listed below and an appointment will be arranged between a local
counselor and the employee / family members. Up to 6 visits are allowed per issue.
Elder Care Consultation - Many families experience concerns regarding the care of an elderly parent. Services are
available to offer advice or to assist with arranging care.
Childcare Consultation - This service offers families and parents information whenever a childcare need arises. Qualified
childcare professionals help identify resources such as: daycares, summer activities, special needs resources, how to
become a parent, and school-age preparations.
Legal Consultation - With the exception of employment-related issues, employees will receive a 30-minute legal
consultation with an attorney (in person or over the phone) through EAP services. If the attorney is retained, the
employee will receive a 25% discount on standard rates.
Training and Education - Employees are encouraged to take advantage of the Training and Education offered through
the First Choice EAP on-line services. Log on to the website and click the Training Button on the left, enter the username
issaquahsd and password 411 to access the training tools available.
Identity Theft Resolution - Many Americans have been victimized by identity theft and consumer fraud. Qualified legal
professionals are available to provide step-by-step guidance and consultation about Identity Theft or Fraud.

They are many ways EAP services may be helpful. Employees and their families are encouraged to call.

Confidential Help
Available 24 hours a day, 7 days a week

(800) 777-4114
www.firstchoiceeap.com

16

Health Care & Dependent Care FSA

Plan Year is September 1 through August 31. Open Enrollment is conducted in June.

Health Care Flexible Spending Arrangement (FSA) is a voluntary program that enables employees to set aside pre-tax
dollars out of their paycheck to pay for eligible health care expenses. Monies put into the plan avoid both Federal
Income Tax and FICA. The average savings is about 25-30%. Maximum FSA contribution amount for 2016-17 plan year
(9/1/2016-8/31/2017) is $2,550. Please note: Participating in these benefits reduces your Social Security earnings,
which could impact your Social Security benefit at retirement.

Common eligible expenses are prescription and office visit copays; vision expense, dental work, orthodontia and
expenses that are applied to medical plan deductibles. Expenses that are for one’s general well-being, cosmetic in
nature or not medically necessary are not eligible.

Carryover Feature - The Carryover option allows participants to rollover up to $500 into the following plan year. The plan
will continue to rollover up to $500 from year to year until the account is depleted or the employee terminates
employment. Any amount in excess of the allowed carryover amount will be forfeited.

**Plan Perk: The Health Care FSA is pre-funded, meaning that participants will have access to their full annual election
amount at the very beginning of the plan year, regardless of the amount contributed to date. Think of the Health Care
FSA as a tax-free interest-free loan that helps you pay for those larger medical expenses

Tax Savings Example - Jill earns $36,000 annually and has out of pocket costs for deductibles and co-pays on her Medical
& Dental plans. Jill wears contacts and also needs a dental crown this year.

WITHOUT Health Care FSA: WITH Health Care FSA:

Gross Taxable Pay: $36,000 Gross Taxable Pay: $36,000

Taxes at 24.5% -$8,820 Pre-Tax Health Care Costs -$2,400

Net Take Home $27,180 Taxable Pay $33,600

Out of Pocket Health Care Costs -$2,400 Taxes at 23.8% -$7,997

Spendable Income After Health Care Costs $24,780 Spendable Income After Health Care Costs $25,603 5

5 Jill has increased her take home pay by $823 per year (approximately $69 per month) by participating in the Health

Care Flexible Spending Arrangement. Jill will save even more if her premiums are also deducted on a pre-tax basis
through the Premium Conversion Plan.

Dependent Care (FSA) – A Dependent Care FSA can be used to pay for your qualified day care expenses with pre-tax
dollars. The care provider can be a licensed day care facility or a private individual. Keep in mind that day care expenses
must be for children 12 or younger, unless the child is incapable of self-care.

Important Note: A Dependent Care FSA works like a bank account. You cannot be reimbursed more than you have
contributed to the account year to date.

To decide on an election amount, estimate your day care expense for the entire plan year and take into consideration
any school holidays, breaks and summer vacation. Your election will be taken out evenly from each paycheck. The Day
Care FSA limit is set by the IRS and is a calendar year limit of $5000 per family. Since your plan year is not on a calendar
year, take extra care in calculating your annual election.

For more information and a list of eligible expenses please visit www.naviabenefits.com or www.irs.gov.
IRS Regulations do not allow Domestic Partner claims to be submitted for reimbursement through the Flexible Spending
Account (FSA) unless they qualify as a tax dependent under Code Section 152.

17

Health Savings Account (HSA)

An HSA, or Health Savings Account, available to medical qualified high-deductible health plan (QHDHP) participants, is a
unique tax-advantaged account that can be used to pay for current or future healthcare expenses. With an HSA, you will
have:

• A tax-advantaged saving account that you can use to pay for eligible medical expenses as well as deductible, co-
insurance, prescriptions, vision, and dental care5.

• Unused funds that will roll over year to year. There's no "use it or lose it" penalty.
• Potential to build more savings through investing. You can choose from a variety of HSA self-directed investment

options ($2,500 minimum balance required).
• Additional retirement savings. After age 65, funds can be withdrawn for any purpose without penalty but may

be subject to income tax if not used for qualified medical expenses.

How an HSA Saves You Money
• Lower Monthly Premiums - Choosing a high deductible health plan helps you reduce your monthly dependent
insurance premiums. You can use these savings to help fund your HSA account.
• HSA Tax Benefits - There are three key tax benefits to a Health Savings Account (HSA).
1. Contributions to an HSA are tax-free, which means your net pay increases.
2. Earnings to an HSA from interest and investments are tax-free.
3. Distributions from an HSA to pay for qualified medical expenses are tax-free, including many that aren't
typically covered by health insurance plans5.

IRS regulations for owning and contributing to an HSA:
• Maximum Contribution Limit for 2016 - $3,350 for an individual, $6,750 for a family.
• Maximum Contribution Limit for 2017 - $3,400 for an individual, $6,750 for a family.
• HSA holders age 55+ may make Catch Up contributions up to an additional $1,000 per year, per family.
• Unavailable to employees age 65 or older.
• You may not be covered under Medicare A or B.
• You may not be covered under a Flexible Spending Account or Health Reimbursement Account.
• You may not be covered by other health insurance programs that are not HSA compatible (including military
coverage).
• You may not be claimed as a dependent on another person’s tax return.

5 For a complete list of IRS-qualified medical expenses, please visit www.irs.gov.

NOTE: Issaquah School District and Propel Insurance do not provide tax advice. Please consult your tax advisor.

18

Monthly Premium and Your Costs

At Issaquah School District we are proud to offer a comprehensive benefit plan for you and your family. The state
allocation for 2016-2017 is $780.00 per month. NOTE: The specific amount available to each employee varies by
bargaining group and FTE status.

The allocation is first used to pay for negotiated required benefits such as group life, long term disability, dental, and
vision coverage. The balance of the allocation dollars are then available for employees to spend toward the purchase of
medical benefits. Any allocation dollars remaining are “pooled” within bargaining units and divided among employees
with payroll deductions to help defray the cost of medical premiums.

No portion of the state allocation or pooling dollars can be applied to the purchase of other voluntary insurance
programs.

Refer to the tables below for monthly Premiums as of November 1, 2016.

Monthly Medical Rates:

Medical Option Employee (EE) EE & Spouse EE & Spouse & EE & Children
Children

Premera WEA Plan 2 $979.90 $1,793.75 $2,150.55 $1,308.40

Premera WEA Plan 3 $895.85 $1,640.10 $1,966.50 $1,196.30
$659.70 $1,198.70 $1,436.35 $875.30
Premera WEA $532.55 $966.80 $1,158.20 $706.25
Easy Choice
Plans A & B

Premera Basic Plan

Premera WEA QHDHP $516.80 $938.05 $1,108.40 $685.30

Group Health HMO $667.73 $1,243.20 $1,449.56 $931.24
Plan

Important: If you wish to elect domestic partner coverage please contact the District’s Benefits Coordinator for additional
information.

19

Monthly Premium and Your Costs – Continued…

Administrators, Principals, and Plan Monthly Premium
Un-Represented Employees
Delta Dental of Washington (WEA) $120.10
Dental – Full Family Plan A with Orthodontia D $22.00
Vision – Full Family $10.44
Employee Term Life & AD&D Northwest Administrators, Inc. (NBN) $11.53
Employee Long Term Disability The Standard
$50,000
The Standard

Bus Drivers Plan Monthly Premium
Dental – Full Family
Vision – Full Family Delta Dental of Washington (WEA) $120.10
Employee Term life & AD&D Plan A with Orthodontia D
Employee Long Term Disability $22.00
Northwest Administrators, Inc. (NBN)
Employee Short Term Disability $5.22
(Employee Paid) The Standard
$25,000 $11.53

The Standard $5.06
$7.59
The Standard $10.12
Class 1 and 2: (4.0 – 4.99 hours)
Class 3 and 4: (5.0 – 6.99 hours)

Class 5 and 6: (7.0+ hours)

Educational Assistants Plan Monthly Premium
Dental – Full Family $120.10
Vision – Full Family Delta Dental of Washington (WEA) $22.00
Employee Term Life & AD&D Plan A with Orthodontia D $5.22

Northwest Administrators, Inc. (NBN)

The Standard
$25,000

20

Monthly Premium and Your Costs – Continued…

Food Service Plan Monthly Premium
Dental – Full Family $120.10
Vision – Full Family Delta Dental of Washington (WEA) $22.00
Employee Term Life & AD&D Plan A with Orthodontia D $2.09

Northwest Administrators, Inc. (NBN)

The Standard
$10,000

Custodians and Maintenance Plan Monthly Premium
Dental – Full Family $120.10
Vision – Full Family Delta Dental of Washington (WEA) $22.00
Employee Term Life & AD&D Plan A with Orthodontia D $3.13

Northwest Administrators, Inc. (NBN)

The Standard
$15,000

Secretaries and Teachers Plan Monthly Premium
Dental – Full Family $120.10
Vision – Full Family Delta Dental of Washington (WEA) $22.00
Employee Term Life & AD&D Plan A with Orthodontia D $2.09
Employee Long Term Disability $11.53
Northwest Administrators, Inc. (NBN)

The Standard
$10,000

The Standard

Mechanics Plan Monthly Premium
Dental – Full Family Delta Dental of Washington (WEA) $120.10
Vision – Full Family $22.00
Employee Long Term Disability Plan A with Orthodontia D $11.53
Northwest Administrators, Inc. (NBN)

The Standard

21

Voluntary Life Benefits – The Standard

Voluntary Life & The Standard
AD&D
Employee Spouse Dependent Child(ren)
Group # 399979 A spouse of an employee Dependent children (ages 15
All Bargaining Units covered covered under the Basic Life
Eligibility under the Basic Life Benefits Benefits. Employee must be days to 26 years of age) of
employees who are enrolled
Benefit Amount $10,000 enrolled in the plan
In Increments of: in the plan
$5,000
Guarantee Issue $2,000

$30,000 during the first 31 days $10,000 during the first 31 $10,000. During open
of eligibility. During open days of eligibility. During open enrollment a Medical History
enrollment a Medical History
enrollment a Medical History Statement is required.
Statement is required. Statement is required.

Maximum Benefit $500,000 not to exceed 5x $150,000, not to exceed 50% $10,000
annual earnings of employee amount

Monthly Rate For Rate Per $10,000 The Standard Rate Per $1,000
Employee and Spouse $0.70 Voluntary Life & AD&D $9.20
$0.80 $14.00
Age $1.40 Group # 399979 $22.00
Under 30 $2.30 Age $34.00
30 – 39 $3.90 $65.70
40 – 44 $6.20 60 – 64
45 – 49
50 – 54 65 – 69
55 – 59
70 – 74
75 – 79
80 – 89

Monthly Rate For Dependent Child(ren) The Standard
*Rate is per family unit, regardless of number of children Voluntary Life & AD&D

Increments Group # 399979
$2,000 Rate
$4,000
$6,000 $0.40
$8,000
$10,000 $0.80

$1.20
$1.60
$2.00

22

Voluntary Disability Benefits – American Fidelity

Long – Term Disability American Fidelity
WEA Select Class

Class Description Educational Assistants, Custodians, Food Service, and Maintenance

Monthly Benefit Up to 66 2/3% of your monthly income to a maximum of $7,500 per month
To Social Security Normal Retirement Age
Benefit Duration Varies
Waiting Period

Accident
Sickness

Short – Term Disability American Fidelity
WEA Select
Class Class
Class Description
Administrators, Principals, Secretaries, Mechanics
Monthly Benefit Teachers, and Un–Represented

Benefit Duration Up to 66 2/3% of your monthly income to Up to 66 2/3% of your monthly income to
Waiting Period
a maximum of $7,500 per month a maximum of $7,500 per month
Accident
Sickness 60 days 90 days

0 days or 14 days 0 days or 14 days
7 days or 14 days 7 days or 14 days

Voluntary Long Term Care Benefits – UNUM

Issaquah School District offers four Long Term Care options through UNUM. The plans are offered to employees and
their extended families.

What is Long Term Care? Long Term Care is defined as the type of care received either at home or in a facility when
someone needs assistance with activities of daily living or suffers severe cognitive impairment, due to an accident, an
illness, or advancing age. Please visit the site below for a Benefit overview, Calculator and Enrollment information:

http://unuminfo.com/issaquah/index.aspx

More information about Long Term Care plan designs and rates can be found on the next page.

Facility Monthly Benefit Amount: Minimum of $2,000 per month up to an overall maximum of $9,000 per month in
$1,000 increments.

Facility Benefit Duration: 3 years, 6 years, or Lifetime.

If your coverage terminates because you are no longer eligible for coverage, you must apply and pay premiums
directly to Unum.

23

UNUM Long – Term Care
Rates shown are for $1,000 Facility Monthly Benefit
(You may choose from $2,000 - $9,000 in Facility Monthly Benefit)

Plan Plan 1 Plan 2 Plan 3 Plan 4
Professional Home – Total Home Care 50% Professional Home – Total Home Care 50%
Benefit Community Care 50% Compound Inflation
Duration Community Care
50% Compound Inflation
Age
18-30 3 Year 6 Year Lifetime 3 Year 6 Year Lifetime 3 Year 6 Year Lifetime 3 Year 6 Year Lifetime

31 $2.80 $3.60 $5.40 $4.50 $5.80 $8.50 $18.90 $25.60 $33.10 $26.20 $35.40 $45.90
32
33 $2.90 $3.80 $5.50 $4.70 $6.10 $8.70 $19.50 $26.40 $34.20 $27.00 $36.50 $47.30
34 $3.10 $4.00 $5.60 $4.90 $6.30 $9.00 $20.10 $27.20 $35.20 $27.90 $37.70 $48.80
35 $3.20 $4.20 $5.80 $5.20 $6.60 $9.20 $20.80 $28.10 $36.30 $28.80 $38.80 $50.30
36 $3.40 $4.40 $6.00 $5.40 $7.00 $9.50 $21.40 $29.00 $37.50 $29.70 $40.10 $51.90
37 $3.60 $4.60 $6.10 $5.70 $7.30 $9.80 $22.20 $29.90 $38.70 $30.70 $41.40 $53.50
38 $3.70 $4.80 $6.40 $6.00 $7.70 $10.10 $22.90 $30.80 $39.90 $31.70 $42.70 $55.20
39 $3.90 $5.10 $6.60 $6.30 $8.00 $10.50 $23.60 $31.80 $41.20 $32.70 $44.10 $57.00
40 $4.20 $5.30 $6.80 $6.60 $8.50 $10.90 $24.40 $32.90 $42.50 $33.80 $45.50 $58.80
41 $4.40 $5.60 $7.10 $7.00 $8.90 $11.30 $25.20 $34.00 $43.90 $34.90 $47.00 $60.80
42 $4.60 $5.90 $7.40 $7.30 $9.40 $11.70 $26.00 $35.10 $45.30 $36.10 $48.60 $62.70
43 $4.80 $6.10 $7.60 $7.60 $9.70 $12.10 $26.70 $35.80 $46.30 $36.90 $49.60 $64.10
44 $5.00 $6.30 $7.80 $7.90 $10.10 $12.50 $27.30 $36.60 $47.30 $37.70 $50.60 $65.50
45 $5.20 $6.60 $8.10 $8.20 $10.40 $12.90 $28.00 $37.40 $48.40 $38.70 $51.80 $67.10
46 $5.40 $6.80 $8.40 $8.60 $10.90 $13.40 $28.70 $38.40 $49.70 $39.80 $53.10 $68.80
47 $5.70 $7.10 $8.70 $9.00 $11.30 $13.90 $29.50 $39.30 $51.00 $40.90 $54.50 $70.60
48 $5.90 $7.40 $9.00 $9.40 $11.80 $14.40 $30.30 $40.30 $52.20 $41.90 $55.80 $72.30
49 $6.20 $7.70 $9.40 $9.80 $12.30 $14.90 $30.80 $40.90 $53.10 $42.70 $56.80 $73.60
50 $6.60 $8.20 $9.90 $10.50 $13.10 $15.80 $32.30 $42.90 $55.60 $44.80 $59.40 $77.00
51 $7.10 $8.80 $10.60 $11.20 $14.00 $16.80 $34.10 $45.10 $58.40 $47.20 $62.40 $80.90
52 $7.60 $9.40 $11.30 $12.00 $14.90 $17.90 $35.90 $47.30 $61.40 $49.70 $65.60 $85.00
53 $8.20 $10.20 $12.20 $13.00 $16.20 $19.40 $38.00 $50.10 $64.90 $52.60 $69.40 $89.80
54 $8.80 $11.00 $13.20 $14.00 $17.50 $21.00 $40.30 $53.00 $68.50 $55.80 $73.40 $94.80
55 $9.30 $11.70 $14.00 $14.90 $18.60 $22.30 $41.70 $54.80 $70.70 $57.80 $75.90 $97.90
$9.90 $12.40 $14.90 $15.80 $19.70 $23.70 $43.30 $56.70 $73.10 $59.90 $78.60 $101.20
$10.60 $13.30 $16.00 $16.90 $21.10 $25.50 $44.90 $58.80 $75.80 $62.20 $81.50 $104.90

24

UNUM Long – Term Care
Rates shown are for $1,000 Facility Monthly Benefit
(You may choose from $2,000 - $9,000 in Facility Monthly Benefit)

Plan Plan 1 Plan 2 Plan 3 Plan 4
Professional Home – Total Home Care 50% Professional Home – Total Home Care 50%
Community Care 50% Community Care 50% Compound Inflation
Compound Inflation

Benefit 3 Year 6 Year Lifetime 3 Year 6 Year Lifetime 3 Year 6 Year Lifetime 3 Year 6 Year Lifetime
Duration

Age $11.30 $14.10 $17.10 $18.00 $22.50 $27.20 $46.70 $61.00 $78.50 $64.60 $84.50 $108.70
56

57 $12.00 $15.10 $18.20 $19.10 $24.00 $29.00 $48.30 $63.00 $81.10 $66.90 $87.30 $112.20

58 $12.90 $16.30 $19.70 $20.60 $25.90 $31.30 $50.80 $66.10 $84.80 $70.30 $91.60 $117.50

59 $14.00 $17.60 $21.40 $22.30 $28.00 $34.00 $53.70 $69.80 $89.40 $74.30 $96.70 $123.70

60 $15.20 $19.10 $23.20 $24.20 $30.40 $36.90 $56.90 $73.90 $94.50 $78.80 $102.30 $130.80

61 $16.60 $20.90 $25.40 $26.40 $33.20 $40.40 $61.10 $79.60 $101.50 $84.60 $110.20 $140.50

62 $18.10 $22.70 $27.80 $28.70 $36.10 $44.20 $65.50 $85.60 $108.80 $90.70 $118.50 $150.70

63 $19.50 $24.50 $30.10 $31.00 $39.00 $47.90 $69.00 $90.50 $114.80 $95.60 $125.30 $159.00

64 $21.00 $26.30 $32.50 $33.30 $41.90 $51.70 $72.70 $95.70 $121.10 $100.70 $132.50 $167.60

65 $23.20 $29.10 $36.20 $36.90 $46.20 $57.60 $75.50 $99.60 $127.00 $104.60 $137.90 $175.80

66 $24.80 $31.10 $38.90 $39.50 $49.50 $61.80 $79.70 $105.50 $134.10 $110.40 $146.10 $185.70

67 $27.60 $34.50 $43.30 $43.90 $54.90 $68.80 $87.30 $115.90 $146.90 $120.90 $160.50 $203.40

68 $29.90 $37.40 $47.00 $47.60 $59.40 $74.80 $93.40 $124.40 $157.20 $129.40 $172.30 $217.60

69 $32.30 $40.40 $50.90 $51.40 $64.20 $81.00 $99.70 $133.20 $167.60 $138.00 $184.40 $232.00

70 $35.10 $43.80 $55.50 $55.90 $69.70 $88.20 $107.10 $143.60 $179.90 $148.20 $198.80 $249.00

71 $38.60 $48.10 $60.80 $61.40 $76.50 $96.60 $114.00 $152.70 $191.10 $157.90 $211.50 $264.60

72 $42.80 $53.30 $67.20 $68.10 $84.80 $106.90 $122.70 $164.30 $205.20 $169.90 $227.50 $284.10

73 $47.30 $58.90 $74.10 $75.20 $93.60 $117.90 $131.60 $176.00 $219.40 $182.20 $243.70 $303.80

74 $52.40 $65.10 $81.80 $83.30 $103.50 $130.10 $141.40 $188.90 $235.00 $195.70 $261.50 $325.30

75 $59.20 $73.50 $92.80 $94.20 $116.80 $147.60 $148.20 $197.60 $248.10 $205.20 $273.60 $343.60

76 $66.20 $82.10 $103.60 $105.30 $130.60 $164.80 $161.20 $214.80 $269.30 $223.20 $297.40 $372.80

77 $74.60 $92.40 $116.30 $118.60 $147.00 $185.00 $176.60 $235.10 $294.10 $244.50 $325.60 $407.10

78 $82.40 $102.10 $128.20 $131.10 $162.30 $203.90 $190.00 $252.70 $315.30 $263.10 $350.00 $436.50

79 $91.20 $112.90 $141.60 $145.10 $179.60 $225.20 $204.50 $271.80 $338.30 $283.10 $376.30 $468.40

80 $100.40 $124.20 $155.30 $159.70 $197.50 $246.90 $219.00 $290.80 $360.80 $303.20 $402.70 $499.50

25

Other Voluntary Benefits

The Issaquah School District offers a variety of voluntary plans that may be a benefit to employees. Please contact the
references listed below for information or forms on any of the following benefits:

Group Legal - Benefits Coordinator - (425) 742-0300

Pet Insurance - Benefits Coordinator - (425) 837-7065

Inspirus Credit Union (formerly School Employees Credit Union) - (888) 628-4010

www.inspiruscu.org

Leave Share Program - WAC.392-126-004

Human Resources (425) 837-7060

Deferred Compensation Program - (888) 327-5596

www.drs.wa.gov/dcp

TSA Consulting Group, Inc. - 403(b) Information - (888) 796-3786

www.tsacg.com

Workers’ Compensation Program - Building/Location Secretary or Payroll Department - (425) 837-7082

Washington State Department of Retirement Systems

For questions regarding TRS / SERS / PERS benefit information please contact the Department of Retirement Systems at
(800) 547-6657 or (360) 664-7337
www.drs.wa.gov

Insure Kids Now / Children’s Health Insurance Program (CHIP)

Low-cost or free health insurance is available for kids and teens in Washington State!
www.Insurekidsnow.gov

AFLAC Cancer Insurance

Issaquah School District offers cancer insurance through AFLAC Insurance Company. Premiums are paid through payroll
deductions. If an enrolled employee should leave the district, continuation of coverage is available directly through
AFLAC at the same rate. All benefits received from this policy are paid in addition to your medical insurance benefits. For
more information on Voluntary Cancer Insurance and/or Hospital/Sickness Insurance, please contact the Benefits
Coordinator, at 425.837.7065.

26

Legislative Resources

Health Insurance Portability and Accountability Act (HIPAA)

In December 2000, the U.S. Department of Health Services released final regulations that place restrictions on how
personal identifiable health information may be used and disclosed by certain organizations. These regulations
implement the privacy requirements contained within the Administrative Simplification subtitle of the Health Insurance
Portability and Accountability Act of 1996 (HIPAA). While some states have laws that protect health information, this
federal regulation establishes a uniform, minimum level of privacy protections for all health information.
www.hhs.gov

Family Medical Leave Act (FMLA)

On February 5, 1993, President Clinton signed into law the Federal Family and Medical Leave Act of 1993 (FMLA). This
law became effective on August 5, 1993. Generally, the Family and Medical Leave Act of 1993 provides that covered
employers must comply with certain criteria when an eligible employee requests a leave under the terms of this law. For
more information regarding FMLA, please contact Personnel Services at (425) 837-7060.
www.DOL.gov/whd/fmla/index.htm

Medicare Part D Program

Beginning in 2006, Medicare beneficiaries can receive subsidized prescription drug coverage through the new Medicare
Part D program. For more information about Medicare Part D visit the websites listed below.
www.medicare.gov
www.socialsecurity.gov

The Consolidated Omnibus Budget Reconciliation Act (COBRA)

COBRA requires that employers provide employees and dependents that lose group health benefits with an opportunity
to continue group health insurance coverage under certain circumstances. For more information about individual COBRA
rights and requirements, please contact the Payroll Department or reference the websites listed below.
www.DOL.gov
www.IRS.gov

27

Contact Information

Benefit Advisory Committee Members: Nancy Francis, Secretary
Rhonda Kurtenbach, Benefits Coordinator (A-K) Dan Smith, Maintenance
Jenny Shim, Benefits Coordinator (L-Z) Dave Holbrook, Custodians
Shanna Drake, Educational Assistant Becky Newgard, Food Service
Kimberly Allie, District Office Karl Mosbrucker, Mechanics
Sharon Klein, Transportation Ann Rolf, Unrepresented
Doug Jones, IEA
Open, Principal

Committee Support: 425.837.7065
Rhonda Kurtenbach, Benefits Coordinator (A-K), [email protected] 425.837.7152
Jenny Shim, Benefits Coordinator (L-Z), [email protected] 425.837.7009
Kimberly Allie (Director of Payroll / Budget Services), [email protected]

Carrier – Coverage Phone / Email Website

Premera / WEA – Medical 800-932-9221 www.premera.com/wea
888-901-4636 www.ghc.org
Group Health – Medical 800-554-1907
Delta Dental of Washington / WEA – Dental 800-732-1123 www.deltadentalwa.com
NW Administrators, Inc. (NBN) – Vision 800-628-8600 www.nwadmin.com
The Standard – Life and AD&D 800-368-2859 www.standard.com
The Standard – Short Term Disability 800-368-1135 www.standard.com
The Standard – Long Term Disability 800-421-0344 www.standard.com
UNUM – Term Life and AD&D 800-227-4165 www.unum.com
UNUM – Long Term Care 800-777-4114 www.unum.com
First Choice Health – EAP 800-669-3539
Navia Benefit Solutions (formerly Flex – Plan www.firstchoiceeap.com
Services, Inc.) – FSA and HSA www.naviabenefits.com

Need help or have questions? We recommend you contact the carrier first with your benefits question. If their answer is
unsatisfactory or you need additional clarification, Propel Insurance is available to help.

Propel Insurance Contacts: Linda Swannack (Individual & Medicare Plan Assistance)
Debra Harry (Account Manager) 253.310.4021
253.761.3210 [email protected]
[email protected]

28

Instantly Access Your Employee Benefits
Information from Work or Home!

Access To Your Online Benefits Site is Available
24 Hours a Day ~ 7 Days a Week!

Log onto Propel Insurance’s Website: Log onto Issaquah’s Benefits Portal:
www.propelinsurance.com www.issaquah.wednet.edu
Go to: Client Resources Go to: Human Resources
Click on: HRconnection Go to: Benefits
User Name: IssaquahSD Go to: Health Benefits Portal
Password: IssaquahSD411 Enter Password: 411

Log In For Links to:

Benefit Plan Summaries
Provider Locators
Open Enrollment Materials
Plan Forms
Employee Resources

29

Notice of Special Enrollment Rights

If you are declining enrollment for yourself or your dependents (including your spouse) because of other health
insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or
your dependents lose eligibility for that other coverage (or if the employer stops contributing towards you or your
dependents' other coverage). However, you must request enrollment within 31 days after you or your dependents'
other coverage ends (or after the employer stops contributing toward the other coverage).

If you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to
enroll yourself and your dependents. However, you must request enrollment within 60 days after the marriage, birth,
adoption, or placement for adoption.

If you decline enrollment for yourself or for an eligible dependent (including your spouse) while Medicaid coverage or
coverage under a state children's health insurance program is in effect, you may be able to enroll yourself and your
dependents in this plan if you or your dependents lose eligibility for that other coverage. However, you must request
enrollment within 60 days after your or your dependents' coverage ends under Medicaid or a state children's health
insurance program.

If you or your dependents (including your spouse) become eligible for a state premium assistance subsidy from Medicaid
or through a state children's health insurance program with respect to coverage under this plan, you may be able to
enroll yourself and your dependents in this plan. However, you must request enrollment within 60 days after your or
your dependents' determination of eligibility for such assistance.

To request special enrollment or obtain more information, contact:

Date: July 1, 2016
Name of Entity/Sender: Issaquah School District
Jenny Shim
Address: 565 NW Holly Street
Issaquah, WA 98027
Phone: 425.837.7065

Newborns' and Mothers' Health Protection Act of 1996

Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital
length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal
delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the
mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her
newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law,
require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of
48 hours (or 96 hours).

30

Women’s Health and Cancer Rights Act of 1998 (WHCRA)

In October 1998, Congress enacted the Women’s Health and Cancer Rights Act of 1998. This notice explains some
important provisions of the Act. Please review this information carefully.
As specified in the Women’s Health and Cancer Rights Act, a plan participant or beneficiary who elects breast
reconstruction in connection with a covered mastectomy is also entitled to the following benefits:

• All stages of reconstruction of the breast on which the mastectomy was performed
• Surgery and reconstruction of the other breast to produce a symmetrical appearance
• Prostheses and treatment of physical complications of the mastectomy, including lymphedemas
Health plans must provide coverage of mastectomy-related benefits in a manner determined in consultation with the
attending physician and the patient. Coverage for breast reconstruction and related services may be subject to
deductibles and coinsurance amounts that are consistent with those that apply to other benefits under this plan. Please
call your Plan Administrator for more information.

31

Important Notice

Issaquah School District offers you and your eligible family members a comprehensive and valuable benefits program.
The information in this Benefit Guide is presented for illustrative purposes to assist you in making a coverage decision.
The content contained in this Guide was compiled from various carrier documents. While every effort was taken to
accurately report your benefits, discrepancies or errors are always possible. In case of discrepancy between the Guide
and the actual plan documents the actual plan documents will prevail and the employer will bear no liability. It is
your responsibility to check actual plan documents before making a coverage or treatment decision.

Booklet Prepared 7.25.16

32