jkv 2012 benefits enrollment guide

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“Healthy Lifestyles Begin With Opportunities”

John Knox Village 2012 Associate Benefits Enrollment Guide

Who is Eligible? A full-time associate at John Knox Village is someone who is regularly

scheduled to work 72 or more hours per pay period. Part-time associates who are eligible for benefits are those who are

regularly scheduled to work 40 to 71.9 hours per pay period. Your spouse and dependent children are also eligible for medical,

dental and voluntary supplemental life coverage. Spousal coverage may be subject to a $50 surcharge if the spouse’s

employer offers a comparable health plan, but elects to use John Knox Village’s health insurance. (See the enclosed Spousal Surcharge Waiver form.)

Benefits for eligible associates include:

Full-Time Associate Benefits Part-Time Associate Benefits

- John Knox Village Health Plan - Dental - Disability Plans - Life Insurance - Section 125 Flexible Spending Accounts

- HM Limited Medical/Accident Insurance Policies - Dental - Life Insurance - Disability Plans - Section 125 Flexible Spending Accounts

How to Enroll All eligible associates MUST RE-ENROLL IN ALL BENEFITS this year. Online benefits enrollment will take place through the MyJKV self-service intranet. Instructions will be included on the enclosed Enrollment Worksheet. (Part-time associates will use paper forms for HM insurance enrollment.)

If you do not re-enroll you will not have benefits for the 2012 plan (although you will remain covered by the company-provided Short-Term Disability and Basic Life benefits).

If you will not be enrolling for benefits in 2012, you must access MyJKV and choose the “decline” option for each benefit.

Once you have made your elections, you can go back into MyJKV at any time during the Open Enrollment period to modify your choices.

After Open Enrollment is over, your choices become final. You will not be able to change them until the next open enrollment period unless you have a qualified change in status (see below).

When to Enroll The open enrollment period runs from November 2 through November 18, 2011. The benefits you elect during open enrollment will be effective from January 1, 2012 through December 31, 2012. A schedule of on-site enrollment meetings (including dates, times and locations) is included in this Enrollment Guide packet of materials as a separate insert.

How to Make Changes Unless you have a qualified change in status, 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 spouse, child or other qualified dependent, change in residence due to an employment transfer for you or your spouse, commencement or termination of adoption proceedings, or change in spouse’s benefits or employment status.

Health and Wellness Opportunities John Knox Village’s Associate Wellness Center

Good health doesn’t just happen. It is an ongoing process – a series of actions and choices – with the goal always in mind that you want to be well. Every day. Some diseases and illnesses do “just happen” due to circumstances beyond our control. And thank goodness we have doctors and insurance companies to help us work our way through treatment when we need it. But the vast majority of health issues that any of us deal with are a direct result of the choices we make regarding the foods we

eat (or don’t eat), the amount of exercise we get (or don’t get), and the amount of stress we allow to take hold in our lives. It’s time to take charge of your health, and we’re giving you the tools to do that, through our associate wellness program: Village Wellness.

By Participating in Village Wellness’ Programs, all associates get: FREE Wellness Challenges: To help you focus on healthy lifestyle choices FREE Wellness Presentations: To help you better understand health topics that affect many of us FREE, or reduced cost, flu shots FREE wellness e-newsletters, full of helpful info to support our culture of health, wellness and safety

Associate Wellness Center Our on-site family health clinic is available for associates and family members who:

Are enrolled in the John Knox Village Health Plan,* OR Have purchased a Village Wellness Choice Membership** (AVAILABLE DURING

BENEFITS OPEN ENROLLMENT ONLY. See insert for details)

Village Wellness Members have access to:

FREE clinic visits with a nurse practitioner for themselves and/or family members who are enrolled. Much like a retail walk-in clinic, you can come to the Associate Wellness Center for services such as:

• Routine blood work • Treatment of minor injuries and

lacerations

• Vaccinations • School, sports and camp physicals

The nurse practitioner can also provide care, treatment and prescriptions for conditions such as: • Allergies • Cold and flu symptoms • Ear infections • Skin conditions • Sore throat

• Sprains and muscle strains • Upper respiratory conditions • Urinary tract infections • Viral and bacterial infections

FREE health risk assessments and lifestyle management coaching sessions, where you will learn

to manage health risk factors such as: diabetes, high blood pressure, weight, high cholesterol, high triglycerides, smoking, and more.

FREE consultation with a dietitian and a fitness specialist (on the dates they are scheduled to be here.)

FREE blood draws (if ordered by your family physician or the Village Wellness nurse practitioner) FREE physical therapy (if ordered by your family physician or the Village Wellness nurse

practitioner) Associate Wellness Center services are provided by Wellness Innovations and Nursing Services (WINS).

Fulfill These Requirements, and You’ll Earn…

FREE Access to the Associate Wellness Center See previous page for details.

FREE (or discounted) JKV Health Insurance

If you enroll in the John Knox Village Health Plan in 2012 and complete ALL of the requirements for the Village Wellness program in 2012, you can earn FREE individual base plan health insurance at JKV for 2013, or a discount off of the rate for family coverage.

Deposits to Your JKV Health Plan Health Fund

Associates who enroll in the John Knox Village Health Plan in 2012 and who: complete their Health Risk Assessment; attend their follow-up appointment with the nurse practitioner and any recommended coaching sessions; and complete two of four wellness challenges and two of four wellness presentations during 2012; can earn up to $250 individual/$500 family to be deposited to their health fund in two installments – half in July 2012 and half in January 2013. (See pages 7-8 to learn more about how a health fund can help you control your health care costs.)

Village Wellness Choice Memberships** —ONLY AVAILABLE DURING BENEFITS OPEN ENROLLMENT—

Benefits-eligible associates

Full-Time (Regularly scheduled to work 72 or more hours per pay period.) Part-Time (Regularly scheduled to work 40 to 71.9 hours per pay period.)

Do you want the benefits of the Associate Wellness Center but not the health insurance benefits? For a modest deduction each pay period, you can buy a Village Wellness Choice membership for yourself, or yourself AND family** – but only during benefits open enrollment. Look for the Village Wellness Choice Membership Enrollment Form in your benefits packet.

* Family members are not required – but are encouraged – to participate in these activities. **Those who purchase Village Wellness Choice Memberships are not required – but are encouraged – to participate in these activities, but are welcome to join in on the challenges and presentations.

This sounds great! How can I get in on it?

All you have to do is: Sign up for the John Knox Village Health Plan. Complete a health risk assessment in early 2012. Attend any follow-up appointments recommended by the Associate Wellness Center’s nurse

practitioner. Complete one wellness challenge and one wellness presentation in the first half of the year, and one

of each in the second half of the year.

More Wellness Benefits & Services

John Knox Village Fitness Center – FREE for All Associates John Knox Village associates get free use of the Squire Anderson Fitness Center, located in the Villager Complex, behind Places Restaurant & Café.

Low-Cost Fitness Classes for Associates We have a Fitness Center. We have a wellness program that encourages physical fitness. It only makes sense that we should offer fitness classes for associates, too! Prices are kept low, on purpose, so everyone has the opportunity to come work off a few pounds, lower their stress level, improve their cardiovascular health and walk a little taller for knowing they’re taking action to stay healthy.

Get Your Preventive Care – It’s FREE! If you enroll in the John Knox Village Health Plan, preventive care services are covered once a year, when you go to an “In-Network” provider. The insurance pays 100 percent (if that’s the reason for your visit – so don’t go tacking on a bunch of extra “stuff” to have the doctor do while you’re there). What’s included? (See page 11 for more information.)

Routine Adult Annual Physical & Immunizations (1 exam per 12 months for members age 18 and older.)

Routine Well-Child Exams & Immunizations (7 exams in first 12 months of life, 3 exams in the 13

th-24

th month of life, and 1 exam per calendar year thereafter to age 18.)

Routine Gynecological Care Exams

(Includes routine tests and related lab fees; limited to 1 routine exam per calendar year.)

Routine Mammograms

Pap Smear

Routine Eye Exam

Colonoscopy [Age 50 and over – Once every 10 years]

Sigmoidoscopy [Age 50 and over – Once every 5 years]

Double Contrast Barium Enema [Age 50 and over – Once every 5 years]

Routine Prostate Screening/Prostate-Specific Antigen (PSA) Test [Age 40 and over]

Routine Digital Rectal Exam [Age 40 and over]

Employee Assistance Program (EAP) Saint Luke’s Health System

(816) 931-3073 or 1-(800) EAP-1223 Whenever you need help balancing your personal or work life, the Saint Luke’s employee assistance program (EAP) provides free CONFIDENTIAL counseling services and a wealth of free online resources, as well as referral services for legal, financial, and child care needs. Available for all associates, as well as associate family members.

Legal issues Financial issues Face-to-face or telephonic counseling

Parenting Caregiving stress Life balance

John Knox Village Health Fund

An extra $250/$500 to help pay for your

health care costs

The John Knox Village health fund account is an additional benefit of up to $250 for individuals, or $500 for those also enrolling family in the health plan. The health fund is provided to associates who: Enroll in the John Knox Village Health Plan Fulfill the Village Wellness program requirements, including: An annual

health risk assessment, attending lifestyle management/coaching sessions, participating in wellness challenges, and attending wellness presentations.

More details on page 5.

If you fulfilled these requirements in 2011, you will automatically have a deposit of 50% of your health fund dollars ($125/$250) to your health fund account on January 1, 2012. (Deposits to the HRA / health fund will be provided by John Knox Village. Contributions from associates are not permitted, per IRS regulations.)

If you are new to John Knox Village’s health plan, you can work in the first 6 months of 2012 to fulfill the plan requirements and earn a deposit of $125/$250 (50% of available funds) to your health fund in July 2012.

How do I use the health fund? You can use the health fund to pay for your health care costs, including your deductible, coinsurance, co-pays and prescription drug costs. What if I don’t use it all? In the event you still have money in your health plan health fund at the end of the calendar year, those dollars will roll over into your health fund for the following year.

Health Plan Health Fund Highlights:

Services covered at 100% with no deductible will be paid by the insurance plan and not the health plan health fund.

There is no maximum limit on the amount that can be rolled over to future years. Expenses eligible to be covered by the fund include those medical and prescription drug

expenses covered by the John Knox Village Health Plan. Any amounts over the reasonable and customary limit, plan limits, or expenses for non-covered benefits are not eligible for reimbursement by the fund.

Did you know…?

Health Fund Dollars

Reduce your out-of-pocket costs. You can use the money in your health plan health fund to pay for eligible medical expenses and prescriptions. The fund dollars you use can help you satisfy your medical plan’s annual deductible.

The benefits of preventive care, without the cost. Your health plan provides 100% coverage for nationally-recommended preventive care, with no deduction from your health fund or out-of-pocket costs for you when you see an in-network provider.

Favorable tax treatment. Coverage under the health fund and expenses reimbursed through the health fund are excludable from your gross income.

John Knox Village Health Fund

Here’s how the health fund works:

Health Care Health Fund Case Study

Ana is a healthy 40-year old single associate who is physically active and financially stable. She is enrolled in the John Knox Village Health Plan. She earned $250 for her health fund by participating in the plan’s health and wellness opportunities. She is enrolled the Base Plan option which has an annual deductible of $3,000 for individual coverage. If Ana uses her HRA to pay for covered services, this will reduce the out-of-pocket amount needed to meet her deductible before traditional health coverage begins. Here is a look at a year of Ana’s insurance usage, assuming she uses in-network providers:

Ana – Individual Coverage Amount

Charged

Fund

Balance

Ana

Pays

Health fund - $250 contribution by John Knox Village (in two $125

installments) $250

Office Visit/Lab tests for urinary tract infections - $150 Prescription drugs - $50

$200 $50* $0

Annual physical, Pap test, mammogram, flu shot

Preventive care services are covered 100% by Cigna health plan. $0 $50 $0

Health Fund Rollover to 2013 $ 50 $ 50

Since Ana did not spend all of her HRA dollars, she did not need to pay any amounts out-of-pocket this year. The

remaining $50 rolls over into 2013.

*If Ana had used the Associate Wellness Center for her office visit and lab work, she could have saved $150 and

would still have $200 in her health fund.

Juan and Anita – Family Coverage

Juan is a 35-year-old associate whose wife, Anita, works for a company that offers only a major

medical plan, so he is covering Anita on his insurance. Together, they have a $6,000 deductible.

Amount

Charged

Fund

Balance

Juan &

Anita Pay

Health fund - $500 contribution by John Knox Village (in two $250

installments) $500

2 Annual physicals 2 Flu shots 2 Vision exams Preventive care services are covered 100% by Cigna health plan.

$0 $500 $0

3 Office visits * $150 $350 $0

ER visit for laceration $600 $0

$50 co-pay $200 out of pocket

Health Fund Rollover to 2013 $0

Since Juan & Anita used all of their health fund to help pay for their health care expenses, there is no money to roll over

into 2013. *They could have saved $150 if their office visits had been at the Associate Wellness Center.

Health Plan and Prescription Drug Plan Benefits are big news these days, especially health care benefits. As health care costs continue to rise, your health care coverage becomes ever more critical.

Plan Highlights for 2012

What’s staying the same? THE PRICE. For those associates who successfully completed their Village Wellness

requirements in 2011, the monthly premiums for the Health Plan will stay the same for 2012. The Plans. We will continue to offer our Base and Buy-Up Plans. Both are Preferred Provider

Organizations (PPOs) and have been designed to provide you and your family with comprehensive and affordable coverage. - There will not be any changes to our current level of benefits for the health plan in 2012. - All deductibles, out-of-pocket limits, copayments, etc., will remain the same.

The Health Fund Contributions. In addition, we will continue to contribute to our health plan’s health fund at the same levels that we did for 2011.

We are also continuing to provide a list of Chronic and Preventive Medications for certain health conditions such as hypertension, diabetes, heart disease, high cholesterol, asthma, depression, and more, that will be available with a co-pay amount year-round, regardless of whether you have met your deductible.

Any changes? – We are changing the companies which provide the medical, pharmacy and claims processing services for our plan in 2012. Because the names have changed, here’s what you can expect:

Plan Administration / Claims / Customer Service FMH/CoreSource will now be the Plan’s administration firm. This means FMH will pay claims, answer your calls through its customer service center, and provide a variety of other services to John Knox Village participants. You will receive your new 2012 member ID card from FMH in December 2011. It will include the same types of information that your current card displays, including the FMH customer service phone number.

PLEASE NOTE that your insurance card will list “Premier Life” in addition to John Knox Village. This is not a mistake. Premier Life is our parent corporation, so both names are listed on our insurance paperwork.

Provider Network Cigna – We have contracted to use Cigna’s managed care network of medical providers and Cigna’s discounted rates, beginning January 1, 2012. Although you have the freedom to choose to receive care from any physician, hospital, or other medical care provider, generally, the Plan will pay a higher percentage of a covered expense if the care is provided “in-network” by a Cigna network provider. To see if your physician is in the Cigna network or to find a new physician, go to www.mycignaforhealth.com Click on “Find a Health Care Professional” on the right side of the page. (This list very similar to the one we’ll be using, but not exactly. Because provider lists change frequently, this is just a guideline.)

Pharmacy Benefit Manager National Pharmaceutical Services (NPS), Inc. will replace Aetna as our pharmacy benefits management team. Their network of pharmacies is nationwide and will include all of the major chains stores that you currently use, as well as many other local and regional pharmacies. They will also process your mail order prescriptions.

YOU MAY RECEIVE MAIL FROM ANY OF THE ABOVE John Knox Village health plan service providers (FMH/CoreSource, Cigna or NPS, Inc.)

PLEASE DO NOT throw these envelopes away, as they will contain important program information including your/your family’s Member ID Card(s).

You may reach the FMH/CoreSource Customer Service Center

Effective January 2, 2012 Monday - Friday

8 a.m. - 7 p.m. Central Time

Toll-Free: 1-(866) 585-1534

Health Plan Comparison

John Knox Village Health Care Plan

Please read the following pages carefully. Familiarize yourself with the benefits available, then use the Plan to meet your needs; but use it wisely.

BASE PLAN BUY-UP PLAN

Annual Health Fund Amount

Individual $250 $125 January 1, 2011, for those who completed the Village Wellness requirements in 2012.

(An additional $125 is available mid-year by completing stated wellness criteria)*

Family $500 $250 January 1, 2011, for those who completed the Village Wellness requirements in 2012.

(An additional $250 is available mid-year by completing stated wellness criteria)*

John Knox Village credits your health plan’s health fund account with a set amount of money that you may use to pay eligible health care services (In-Network and Out-of-Network), including reducing your Individual or Family Deductible. Once you have used up your health fund dollars, you will be responsible for Covered Expenses until the remaining Deductible is met or an additional deposit is made to your fund. At the end of the calendar year, health fund money you have not spent automatically stays in your account to be used at a later date. *(See pages 7-8 to learn how you can earn health fund deposits.)

In Network Out-of-Network In Network Out-of-Network

Annual Deductibles

Individual $3,000 $2,000

Family $6,000 $4,000

Deductible shares between In-Network & Out-of-Network for each option.

Out-of-Pocket Maximum

Individual $4,500 $3,500

Family $9,000 $7,000

The Out-of-Pocket Maximums do include the deductibles. The In-Network and Out-of-Network is a combined maximum. The Plan will pay the designated percentage of Covered Expenses until the Out-of-Pocket Maximum Amounts are reached, at which time the Plan will pay 100% of the remainder of Covered Expenses for the rest of the Benefit Period unless stated otherwise. The following charges do not apply to the Out-of-Pocket Maximum and are never paid at 100%:

Penalty amounts for failure to pre-certify a Hospital admission Expenses not covered by the Plan Expenses in excess of amounts covered by the Plan Expenses in excess of Usual, Customary and Reasonable amounts Co-payments Non-emergent services

Standard Benefit Percentages that the Plan Pays

For most services…

80% 60% 90% 70%

For services within the Network where no In-Network Provider is available…

Not Applicable 80% Not Applicable 90%

For services at an In-Network facility rendered by an Out-of-Network Provider when the member has no choice of provider; for Ancillary Services such as Radiology, Pathology, Laboratory, Anesthesia and Emergency Room Physician


Services received Out-of-Network while traveling or Dependents living outside the Network area…




Preventive/Routine Care

Preventive Services

100% Deductible Waived

60% after Deductible



Including but not limited to exams, diagnostics and other services as required by the Patient Protection and Affordable Care Act.

Mammograms One per Benefit Period

Pap Smear One per Benefit Period

Prostate Specific Antigen Test (PSA)

Age 40 and over - one per Benefit Period

Digital Rectal Exam (DRE)

Age 40 and over - one per Benefit Period

Sigmoidoscopy Age 50 and over - one every five (5) years

Double contrast Barium Enema (DCBE)

Age 50 and over - one every five (5) years

Colonoscopy Age 50 and over - one every ten (10) years

Routine Eye Exam (Includes refraction)





Physician Services

Office Visit



90% after Deductible 70% after Deductible

All Other Services in Physician’s Office




Allergy Testing, Treatment and Injections




Outpatient Diagnostic Lab and X-Ray




Urgent Care Services




Inpatient Services




Outpatient Services




Emergency Room (Co-pay waived if admitted) Non-Emergent Services

$50 Co-pay per visit, then 80% after Deductible


$50 Co-pay per visit, then 90% after Deductible


Ambulance 80% after Deductible 90% after Deductible

Working Spouse Surcharge If your spouse works for a company that offers a comparable health plan, but you elect to cover him or her under John Knox Village’s health plan, you may incur a $50 monthly surcharge. See the Working Spouse Surcharge Waiver form in your Benefits Enrollment Packet for more information.


In Network Out-of-Network In Network



Private Duty Nursing (Outpatient)

Maximum: 70 Visits per Benefit Period

Hospice Care 80% after Deductible 60% after Deductible




Home Health Care

Maximum: 120 Visits per Benefit Period



Skilled Nursing Facility

Maximum: 60 Days per Benefit Period

Outpatient Physical, Speech & Occupational Therapy



Chiropractic Care 80% after Deductible 60% after Deductible


Mental and Nervous Disorder & Substance Abuse

Inpatient 80% after Deductible 60% after Deductible


Outpatient 80% after Deductible 60% after Deductible


Office / Clinic (Includes Hospital or other Clinic)




Durable Medical Equipment



Prosthetics 80% after Deductible 60% after Deductible


100% - Deductible Waived Wig after Cancer Treatment

Lifetime Maximum: $300

Did you know…? You and your family have access to a registered nurse anytime, day or night. By simply calling the Saint Luke’s NurseLine you can get health advice or register for a class.

Kansas City Metro (816)-932-6220

Outside of Kansas City 1-(800)-932-6220



PRESCRIPTION DRUG BENEFITS

Subject to the Base Plan Deductible. Once met, you then pay only the applicable copay shown below for the remainder of the year.

Subject to the Buy-Up Plan Deductible. Once met, you then pay only the applicable copay shown below for the remainder of the year.

Deductible: For most

medications

For chronic conditions and to prevent certain illnesses1

The Deductible is waived for certain preventive and chronic medications. A full list of these drugs is included as a separate insert within this packet of information or from the John Knox Village Human Resources Department. Please note that co-payments paid from your HRA / health fund for these drugs will not reduce the deductible.

Co-payments

Retail Pharmacy (Up to a 30-day supply)

Generic $15

Brand Name Preferred

$25

Brand Name Non-Preferred

$40

Mail Order (Up to a 90-day supply)

Generic $30 Not Applicable $30 Not Applicable

Brand Name Preferred

$50 Not Applicable $50 Not Applicable

Brand Name Non-Preferred

$80 Not Applicable $80 Not Applicable

Self-Injectables (Up to a 30-day supply)

All Drugs 100% of negotiated charge

60% of the recognized charge

100% of negotiated charge

70% of the recognized charge

1 See the separate listing of these drugs included in this enrollment packet.

Please see the 2012 Enrollment Worksheet contained in this packet for payroll deduction information.

Pre-existing Condition Limitation For members age 19 or over this Plan imposes a pre-existing condition exclusion, which may be waived in some circumstances and may not be applicable to you or your covered dependents. A pre-existing condition exclusion means that if you have a medical condition before enrolling in this plan, you may have to wait a certain period of time before the plan will provide coverage for that condition. This exclusion applies only to conditions for which medical advice, diagnosis, care, or treatment was recommended or received or for which the individual took prescribed drugs within 90 days. Generally, this period ends the day before your coverage becomes effective. However, if you were in a waiting period for coverage, 90 days ends on the day before the waiting period begins. The exclusion period, if applicable, may last up to 365 days from your first day of coverage, or, if you were in a waiting period, from the first day of your waiting period. If you had prior creditable coverage within 90 days immediately before the date you enrolled under this plan, then the pre-existing conditions exclusion in your plan, if any, will be waived. For additional information regarding the pre-existing condition exclusions period, please contact the John Knox Village Human Resources department at (816) 347-2848.

Dental Benefits Delta Dental will continue to be our dental insurance provider in 2012.

All full-time associates who are regularly scheduled to work 72 or more hours per pay period are eligible to enroll.

Part-time associates scheduled for at least 40 hours per pay period are eligible to enroll. In addition, legal spouses and dependent children up to age 26 are also eligible to participate.

Plan Highlights:

NEW: Four tiers of coverage, instead of two, will be available in 2012. (Associate, Associate + Spouse, Associate + Child(ren), or Family)

The annual deductible is $50 if you elect single coverage, and up to $150 for a family of three or more.

Diagnostic and Preventive services are not subject to the deductible and are paid at 100% when

using Delta Dental’s PPO or Premier Network providers.

The maximum annual benefit is $1,500 per year for each person you elect to enroll in the dental plan.

Orthodontia benefits are available for dependent children up to age 19 who begin their treatment

while covered by this plan. The maximum benefit per child is $2,000 (while covered by this plan).

The Delta Dental networks have thousands of dentists to choose from.

Please see the Summary of Dental Benefits on the next page.

Find a Dentist To determine if your dentist is in the Delta Dental network, or to select a participating dentist in your area:

Ask your dentist if he or she participates in the Delta Dental PPO or Delta Dental Premier program, or

Search online at www.deltadentalmo.com and click on “Looking for a Dentist?” or,

Call Delta Dental’s Customer Service Center at 1-800-335-8266

Dental Benefits

Delta PPO Network

Delta Premier Network

Non-network

Summary of Dental Benefits Based on a reduced fee

schedule wi th the dent is t – no

balance bi l l ing

Based on a contractual

agreement wi th the dent is t – no balance bi l l ing

Based on Del ta ’s maximum plan

a l lowance - balance bi l l ing is

possible Deductible $50 per person / Up to $150 per fami ly

Annual Benefit Maximum $1,500 per covered person

Diagnostic and Preventive Services

Oral exams / 2 times per calendar year Bitewing x-rays, as needed Periapical x-rays once in 36 consecutive

months Oral Prophylaxis (cleaning) twice per

calendar year Fluoride, once per calendar year for

dependent children up to age 19 Emergency palliative treatment Space maintainers, for dependent children

under age 12, limited to initial appliance only

Sealants for dependent children under age 14, once per tooth every 3 years, limited to non-decayed 1

st and 2

nd permanent molars

100% 100% 100%

Basic Services Restorative services using synthetic

porcelain and plastic material (white) on front teeth and amalgam (silver) on molar teeth

Periodontics – treatment for diseases of gums and bone supporting the teeth

Periodontal maintenance – following active periodontal therapy, limited to 2 times per calendar year

Endodontics – root canal filling and pulpal therapy

Simple and surgical extractions Oral surgery

80% 80% 80%

Major Services1 Prosthetics – bridges and dentures; a

replacement will be covered only once in 5 years

Crowns, jackets, labial veneers, inlays and onlays when required for restorative purposes, once in 5 years

50% 50% 50%

Orthodontic Services1 , 2 For eligible dependents to age 19 who

begin treatment while covered by this plan

50% 50% 50%

Separate Orthodontic Lifetime Maximum Benefit

$2,000 per e l ig ib le dependent ch i ld up to age 19

1 Waiting period will be waived for those enrolled in the current John Knox Village dental plan that have satisfied the waiting

period. 2

Orthodontic treatment in progress on the original effective date of the group contract will be covered. Benefits provided by the prior carrier will be subtracted from the lifetime maximum available from Delta Dental.

Disability Income Benefits John Knox Village provides associates with access to both Short-Term and Long-Term Disability income benefits for an approved disability. These benefits assist you in taking care of your expenses, and your family’s, if there is an approved reason why you cannot work due to a non work-related illness or injury.

Plan Highlights

Short-term Disability Long-term Disability

When am I eligible? On the 1st day of the month following 6

months of employment with John Knox Village as a benefits-eligible associate.

If you enroll during Open Enrollment, effective 01/01/12, subject to requirements stated below.

Who pays for my coverage? John Knox Village provides this benefit at no cost to you.

Premiums for the LTD insurance benefits will be paid with after-tax payroll deductions. In the event that you are enrolling for the first time, and you are not a newly hired associate, you will have to provide Evidence of Insurability in order to qualify.

When do benefits begin? After 7 calendar days of approved absence due to injury, sickness or pregnancy.

On the 91st day of approved absence

due to injury, sickness or pregnancy.

What is my monthly benefit? 50% of your regularly scheduled earnings.

60% of your pre-disability earnings, up to a maximum of $5,000 per month.

How long will I receive disability benefits?

Up to 90-days. Benefits may continue as long as you remain disabled up to your Social Security Normal Retirement Age.

What if I have banked disability or illness hours accumulated from previous years? May I use them?

Yes, they can be used to supplement your earnings during disability – up to a maximum of 100% of your pre-disability earnings.

What happens to my unused banked disability and/or illness hours in the event that I no longer work for John Knox Village?

Banked hours will be paid upon separation according to the policy in effect as of 12/31/08 at the rate of pay AND years of service effective on that date.

How do I submit a claim? Claims are submitted by you over the phone to Hartford Life Insurance company for approval. Call 1-800-707-5333 (Monday – Friday) or visit them online at www.TheHartfordAtWork.com

Did you know…?

Nearly 50% of bankruptcies in the U.S. are due to an unexpected long-term illness. Long-term disability benefits can help you keep your home if there is a time when you can’t work due to an approved illness or injury.

Basic Life and AD&D Insurance John Knox Village provides full-time and part-time associates with group life and accidental death and dismemberment (AD&D) insurance, and pays the full cost of this benefit. Coverage amounts are as follows:

Full-time associates 1 times your annual base salary

Part-time employees $10,000 NOTE: This is a good time to review your beneficiaries and make any needed changes.

Voluntary Supplemental Life Insurance Associates who want to supplement their Basic Life insurance benefits may purchase additional coverage. When you enroll yourself and/or your dependents in this benefit, you pay the full cost through bi-weekly payroll deductions:

You can purchase coverage on yourself in $10,000 increments. The maximum coverage amount you may buy is up to five times your annual base salary.

Coverage for your spouse is also available in $10,000 increments with a minimum coverage

amount of $10,000 and a maximum of $100,000.

Coverage is also available for your children ages 6 months to 19 years old (or age 23 if they are a full-time student). You may purchase coverage amounts of $5,000 or $10,000.

Premiums for these additional life insurance benefits will be paid with after-tax payroll deductions. The premium amounts for your coverage as well as that you may elect for your spouse will be based on your ages. In the event that you are enrolling yourself and/or your dependent for the first time, or are increasing the amount of your coverage, you and/or your spouse may have to provide Evidence of Insurability in order to qualify.

Did you know…? Voluntary Supplemental Life Insurance can provide you with significant financial protection for a reasonable cost. And, the life insurance funds will be available just when they’re needed the most.

Section 125 Cafeteria Plan Health Care and Dependent Care Flexible Spending Accounts

John Knox Village provides you the opportunity to pay for out-of-pocket medical, dental, vision and dependent care expenses with pre-tax dollars through Flexible Spending Accounts (FSAs). A health care FSA is used to reimburse out-of-pocket medical expenses incurred by you and/or your dependents. A dependent care FSA is used to reimburse expenses related to care of eligible dependents while you and/or your spouse work. Contributions to your FSA come out of your paycheck before any taxes are taken out. This means that you don’t pay federal income tax, Social Security taxes, or state and local income taxes on the portion of your paycheck you contribute to your FSA. You should contribute the amount of money

you expect to pay out of pocket for eligible expenses in 2012. If you do not use the money you contribute it will not be refunded to you or carried forward to a future plan year. This is the “use-it-or-lose-it” rule. The maximum that you can contribute to the Health Care FSA is $5,000 for 2012. The maximum that you can contribute to the Dependent Care FSA is $5,000 ($2,500 if you are married and filing separately on your federal income tax return).

How Much Money Can You Save by Deducting FSA Contributions

from Your Paycheck Before Taxes? Bob and Jane’s combined gross income is $30,000. They have two children and file their income taxes jointly. Since Bob and Jane expect to spend $2,000 in orthodontia and $3,300 for day care in 2012, they decide to direct a total of $5,300 into their FSAs.

Without FSAs

With FSAs

Gross income: $30,000 $30,000

FSA contributions: 0 -5,300

Gross income: 30,000 24,700

Estimated taxes:

Federal -2,550* -1,755*

State -900** -741**

FICA -2,295 -1,890

After-tax earnings: 24,255 20,314

Eligible out-of-pocket Medical and dependent care expenses:

-5,300 0

Remaining spendable income: $18,955 $20,314

Spendable income increase: $0 $1,359

*Assumes standard deductions and four exemptions. ** Varies, assume 3%.

The example above is for illustrative purposes only. Every situation varies and we recommend that you consult a tax advisor for all tax advice.

You can save approximately 25% of each dollar spent on these

expenses when you participate in a FSA.

Section 125 Cafeteria Plan Health Care and Dependent Care Flexible Spending Accounts

Plan Highlights:

YOU MUST RE-ENROLL EACH YEAR.

You may use the FSA benefit whether or not you enroll in the John Knox Village medical, dental or vision benefit.

Learn more about what expenses qualify for reimbursement from your FSA at www.asiflex.com

You can start submitting reimbursement requests as soon as services are provided. However, eligible expenses can only be incurred on/after January 1, 2012.

For the Health care FSA, your full annual election amount is available on the date your enrollment begins.

For the Dependent Care FSA, you are allowed to be reimbursed only up to the amount you have had deducted from your paycheck at that point in time. Requests in excess of this amount will be reimbursed as additional deductions are taken from your paycheck.

You may submit reimbursement requests for either FSA as frequently as you like.

If you are new to the FSA program, our administration firm, ASIFlex, will reimburse you by mailing you a check after you have submitted a reimbursement request form and supporting documentation. You also have the option to receive your reimbursements by direct deposit to a checking or savings account. ASIFlex will include a direct deposit form in the welcome packet you receive after you enroll. This form is also on-line at www.asiflex.com

Have Questions?

Contact the ASIFlex Customer Service Team

Phone: 1-(800)-659-3035 TTY Phone: 1-866-908-6043

Monday - Friday, 7 a.m. - 7 p.m. Central

Saturday, 9 a.m. - 1 p.m. Central

Email: [email protected]

Web: www.asiflex.com

But Wait, There’s More!

Additional Benefit Offerings

As a John Knox Village associate, you also receive the following benefits paid for by the company:

Preventive Health Programs Health and wellness education

Free or reduced cost flu vaccinations

Weight loss program reimbursement

Smoking cessation program reimbursement

On-Site Fitness Center FREE to associates

Available Monday through Saturday

Fitness classes available for associates

Discount for Long-Term Associates Moving to John Knox Village We love our associates! And after you have given 10 years or more of hard work for our

residents, patients, clients and customers, we think you should be able to sit back and let us

serve you. So, the longer you work for the Village, the greater this discount you can earn off of

the monthly service fee on a home at John Knox Village – so you can move in when YOU

retire! The best part: After 40 years of continuous service, you could move into one of our small

studio apartments for FREE. (Or get an equivalent discount off of a larger unit.) That saves you

up to $10,000!

Improve U Training Program Based on the philosophy that every John Knox Village associate is a leader, the program builds

skills and develops talent inside the company for current and future business and personal

needs. Improve U meets this challenge by offering classes for all associates in three focus

areas: organization, management and individual development.

Paid Time Off Paid Time Off benefits are provided based on years of service and scheduled hours.

Employee Assistance Program (EAP): Saint Luke’s – (816) 931-3073 or 1-(800) EAP-1223 The Saint Luke’s employee assistance program (EAP) provides free counseling services and a

wealth of free online resources, as well as referral services for legal, financial, and child care

needs.

MOST (Missouri’s 529 College Savings Program) or Kansas Learning Quest Payroll deducted savings for college tuition

Earnings grow tax free and remain tax free when used for college expenses

Tax deductible in the state program where you live

Jury Duty

Bereavement Time Off

Unemployment

Workers Compensation

Credit Union

403(b) Tax-Sheltered Annuity Retirement Plan

Save for your retirement with MassMutual

The John Knox Village retirement savings plan provides you a way to save for retirement with tax-deferred payroll deductions. Even better, once you’ve been here for two years, the Village will match 50 cents for each dollar you put in (up to 2.5% of your pay).

Sign Up or Make Changes – ANY TIME.

You do not need to wait for Open

Enrollment. This is one benefit you can opt into or make changes to at any time of the year. Contact MassMutual at 1-800-743-5274 or www.massmutual.com/retire.

Don’t Know Which Funds are Best for You? MassMutual provides you with a wide variety of investment options so you can choose the options that are just right for your stage in life and comfort level with investment risk. You can use MassMutual’s RetireSmartSM tools on their website: www.massmutual.com/retire to figure out how much you’ll need for retirement and the best investment strategy for you. Or you can call them at 1-800-743-5274.

Already Participating? You can make changes to your account at any time via the telephone or the Web.

Change your contribution percentage Change your investment election Use RetireSmart

SMtools to figure out how much

you’ll need for retirement

Figure out the best investment strategy for you.

Important Notices

PROOF OF DEPENDENT STATUS

John Knox Village, its insurance providers, and other claims administrators may verify the eligibility of your

covered dependents, at any time, for any reason. You might be asked to provide proof of dependent

status by providing a marriage certificate, birth certificate, tax return, etc.

QUALIFIED MEDICAL CHILD SUPPORT ORDERS

Coverage will be provided to any of your dependent child(ren) if a Qualified Medical Child Support

Order (QMCSO) is issued, regardless of whether the child(ren) currently reside with you. A QMCSO may

be issued by a court of law or issued by a state agency as a National Medical Support Notice (NMSN),

which is treated as a QMCSO. If a QMCSO is issued, the child or children shall become an alternate

recipient treated as covered under the Plan and are subject to the same limitations, restrictions, provisions

and procedures as all other plan participants.

WOMEN’S HEALTH AND CANCER RIGHTS ACT OF 1998

As required by the Department of Labor and the Department of Health and Human Services, the

Company is providing this notice about the Women’s Health and Cancer Rights Act of 1998. This notice

serves as the annual notice required by the Department of Labor.

The Women’s Health and Cancer Rights Act of 1998 provides certain benefits for mastectomy related

services. These benefits include coverage for: Reconstruction of the breast on which the mastectomy has

been performed, Surgery and reconstruction of the other breast to produce symmetrical appearance,

and Prosthesis and physical complications for all stages of the mastectomy, including lymphedema. --

Please contact FMH Customer Service for more information: (913) 685-4740

NEWBORNS’ AND MOTHERS’ HEALTH PROTECTION ACT

As required by the Department of Labor, the Company is providing this notice about the Newborns’ and

Mothers’ Health Protection Act. 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 as applicable). In any case, plans and issuers may not, under federal law, require that a

provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in

excess of 48 hours (or 96 hours as applicable). – Please contact FMH Customer Service for more

information: (913) 685-4740

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)—PRIVACY NOTICE

Federal regulations describe how medical information about you and your covered family members may

be used and disclosed and how you can get access to this information. For purposes of administering the

plans, information may be shared between the John Knox Village Employee Health Plan, the medical

provider, the Plan’s administrators at FMH/CoreSource. Detailed HIPAA information can be obtained from

Human Resources.

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)—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 the JKV plan if you or your dependents lose eligibility for that other coverage (or if the other employer

stops contributing toward your or your dependents’ other coverage). However, you must request

enrollment within at least 30 days after your, or your dependents’, other coverage ends.

In addition, 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 30 days after the marriage, birth, adoption, or placement for adoption. -- To request

special enrollment or obtain more information, contact the Benefits Office at 816-347-2164.

NOTICE OF COBRA CONTINUATION COVERAGE RIGHTS

You and your covered spouse (if any) should read this information notice as it provides you with

information regarding your COBRA rights as an active associate or dependent if covered under a John

Knox Village group plan. The receipt of this correspondence DOES NOT indicate that there’s been a

change in your employment status with John Knox Village.

You are receiving this notice because you are eligible to be covered under a COBRA eligible benefit

offered to you by John Knox Village (the Plan). This notice contains important information about your right

to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. The right

to COBRA continuation coverage was created by a federal law, Consolidated Omnibus Budget

Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and

to other members of your family who are covered under the Plan when you would otherwise lose your

group coverage. This notice generally explains COBRA continuation coverage, when it may become

available to you and your family, and what you need to do to protect the right to receive it. This notice

gives only a summary of your COBRA continuation coverage rights. For more information about your

rights and obligations under the Plan and under federal law, you should either review the Plan’s Summary

Plan Description or get a copy of the Plan Document from the Plan Administrator.

The Plan Administrator is: The COBRA Administrator is:

John Knox Village Taben Group

400 NW. Murray Rd. P.O. Box 7330

Lee’s Summit, MO 64081 Overland Park, KS 66215-0330

1-800-255-5555 1-800-675-7341

COBRA Continuation Coverage

COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end

because of a life event known as a “qualifying event.” Specific qualifying events are listed later in the

notice. COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.”

A qualified beneficiary is someone who will lose coverage under the Plan because of a qualifying event.

Depending on the type of qualifying event, associates, spouses of associates, and dependent children of

associates may be qualified beneficiaries. Under the Plan, qualified beneficiaries who elect COBRA

continuation coverage must pay for COBRA continuation coverage.

If you are an associate, you will become a qualified beneficiary if you will lose your coverage under the

Plan because either one of the following qualifying events happens:

(1) Your hours of employment are reduced, or

(2) Your employment ends for any reason other than your gross misconduct.

If you are the spouse of an associate, you will become a qualified beneficiary if you will lose your

coverage under the Plan because any of the following qualifying events happens:

(1) Your spouse dies;

(2) Your spouse’s hours of employment are reduced;

(3) Your spouse’s employment ends for any reason other than his or her gross misconduct;

(4) Your spouse becomes enrolled in Medicare (Part A, Part B, or both); or

(5) You become divorced or legally separated from your spouse.

Your dependent children will become qualified beneficiaries if they will lose coverage under the Plan

because any of the following qualifying events happens:

(1) The parent-associate dies;

(2) The parent-associate’s hours of employment are reduced;

(3) The parent-associate’s employment ends for any reason other than his or her gross misconduct;

(4) The parent-associate becomes enrolled in Medicare (Part A, Part B, or both);

(5) The parents become divorced or legally separated; or

(6) The child stops being eligible for coverage under the plan as a “dependent child.”

Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying

event. If a proceeding in bankruptcy is filed with respect to John Knox Village, and that bankruptcy results

in the loss of coverage of any retired associate covered under the Plan, the retired associate is a qualified

beneficiary with respect to the bankruptcy. The retired associate’s spouse, surviving spouse, and

dependent children will also be qualified beneficiaries if bankruptcy results in the loss of their coverage

under the Plan.

The plan will offer COBRA continuation to qualified beneficiaries only after the Plan Administrator has

been notified that a qualifying event has occurred. When the qualifying event is the end of employment

or reduction of hours of employment, death of the associate, or enrollment of the associate in Medicare

(Part A, Part B, or both), the employer must notify the Plan Administrator of the qualifying event. In

addition, if the Plan provides retiree health coverage, then commencement of a proceeding in a

bankruptcy with respect to the employer is also a qualifying event where the employer must notify the

Plan Administrator of the qualifying event.

For the other qualifying events (divorce or legal separation of the associate and spouse or a dependent

child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator. The

Plan requires you to notify the Plan Administrator within 60 days after the qualifying event occurs. You must

provide notice to the Plan Administrator’s address as listed on page 1 of this notice. Failure to provide

notice to the plan administrator within the above named time periods will result in a loss of eligibility for

COBRA Continuation of Coverage.

Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation

coverage will be offered to each of the qualified beneficiaries. For each qualified beneficiary who elects

COBRA continuation coverage, COBRA continuation coverage will begin either (1) on the date of the

Qualifying event or (2) on the date that Plan coverage would otherwise have been lost, depending on

the nature of the Plan.

COBRA continuation coverage is a temporary continuation of coverage. When the qualifying event is the

death of the associate, enrollment of the associate in Medicare (Part A, Part B, or both), your divorce or

legal separation, or a dependent child losing eligibility as a dependent child, COBRA continuation

coverage lasts for up to 36 months.

When the qualifying event is the end of employment, or reduction of the associate’s hours of

employment, COBRA continuation coverage lasts for up to 18 months. In addition, if the associate who

experienced an end of employment or reduction in hours of employment qualifying event became

eligible for Medicare less than 18 months prior to the date in which the qualifying event of end of

employment or reduction in hours occurred, the spouse and/or children of the associate may be eligible

for up to 36 months of COBRA from the Medicare Entitlement Date. For example, if a covered associate

becomes entitled to Medicare on January 1, 2005, and the associate experienced an end of

employment on July 1, 2005, COBRA Continuation coverage for the associate would be 18 months,

however, COBRA Coverage for the spouse and children can last up to a maximum of 36 months from the

Medicare Entitlement date of January 1, 2005, which is equal to 30 months after the date of the end of

employment qualifying event (36 minus 6 months). Otherwise, when the qualifying event is end of

employment or reduction in hours of employment, COBRA continuation of coverage generally lasts up to

18 months.

There are two ways in which this 18-month period of COBRA continuation coverage can be extended:

o Disability extension of 18-month period of continuation coverage.

If you or anyone in your family covered under the Plan is determined by the Social Security

Administration to be disabled at any time during the first 60 days of COBRA continuation coverage

and you notify the Plan Administrator in a timely fashion, you and your entire family can receive up to

an additional 11 months of COBRA continuation coverage, for a total maximum of 29 months. You

must make sure that the Plan Administrator is notified of the determination and before the end of the

18-month period of COBRA continuation coverage. This notice should be sent to the Plan

Administrator’s address listed above in this notice. If the disability occurred prior to the Qualifying

Event, please send a copy of the Notice of Award along with the enrollment form when electing

continuation of coverage. Failure to provide notice to the plan administrator or COBRA administrator

within the above named time periods will result in a loss of eligibility for the extension of your original

COBRA time period.

o Second qualifying event extension of 18-month period of continuation coverage.

If your family experiences another qualifying event while receiving COBRA continuation coverage,

the spouse and dependent children in your family can get additional months of COBRA continuation

coverage, up to a maximum of 36 months. This extension is available to the spouse and dependent

children if the former associate dies, or gets divorced or legally separated. The extension is also

available to a dependent child when that child stops being eligible under the Plan as a dependent

child.

In all of these cases, you must make sure that the Plan Administrator is notified of the second

qualifying event within 60 days of the second qualifying event. This notice must be sent to the Plan

Administrator’s address listed above in this notice. Failure to provide notice to the plan administrator

or COBRA administrator within the above named time periods will result in a loss of eligibility for the

extension of your original COBRA time period.

If You Have Questions

If you have questions about your rights under COBRA, you should contact the COBRA Administrator or you

may contact the nearest Regional or District Office of the U.S. Department of Labor’s Associate Benefits

Security Administration (EBSA). Addresses and phone numbers of Regional and District EBSA Offices are

available through EBSA’s website at www.dol.gov/ebsa.

Keep Your Plan Informed of Address Changes

In order to protect your family’s rights, you should keep the Plan Administrator informed of any changes in

the addresses of family members. You should also keep a copy, for your records, of any notices you send

to the Plan Administrator.

MEDICAID AND THE CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP)

Offer Free Or Low-Cost Health Coverage To Children And Families

If you are eligible for health coverage from your employer, but are unable to afford the premiums, some

States have premium assistance programs that can help pay for coverage. These States use funds from

their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health

coverage, but need assistance in paying their health premiums.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below,

you can contact your State Medicaid or CHIP office to find out if premium assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your

dependents might be eligible for either of these programs, you can contact your State Medicaid or CHIP

office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, you can

ask the State if it has a program that might help you pay the premiums for an employer-sponsored plan.

Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or

CHIP, your employer’s health plan is required to permit you and your dependents to enroll in the plan – as

long as you and your dependents are eligible, but not already enrolled in the employer’s plan. This is

called a “special enrollment” opportunity, and you must request coverage within 60 days of being

determined eligible for premium assistance.

If you live in one of the following States, you may be eligible for assistance paying your employer health

plan premiums. The following list of States is current as of November 3, 2010. You should contact your

State for further information on eligibility –

ALABAMA – Medicaid CALIFORNIA – Medicaid

Website: http://www.medicaid.alabama.gov

Phone: 1-800-362-1504

Website: http://www.dhcs.ca.gov/services/Pages/

TPLRD_CAU_cont.aspx

Phone: 1-866-298-8443

ALASKA – Medicaid COLORADO – Medicaid and CHIP

Website: http://health.hss.state.ak.us/dpa/programs/medicaid/

Phone (Outside of Anchorage): 1-888-318-8890

Phone (Anchorage): 907-269-6529

Medicaid Website: http://www.colorado.gov/

Medicaid Phone (In state): 1-800-866-3513

Medicaid Phone (Out of state): 1-800-221-3943

ARIZONA – CHIP

Website: http://www.azahcccs.gov/applicants/default.aspx

Phone (In state): 1-877-764-5437

CHIP Website: http:// www.CHPplus.org

CHIP Phone: 303-866-3243

ARKANSAS – CHIP FLORIDA – Medicaid

Website: http://www.arkidsfirst.com/

Phone: 1-888-474-8275

Website: http://www.fdhc.state.fl.us/Medicaid/index.shtml

Phone: 1-866-762-2237

GEORGIA – Medicaid MONTANA – Medicaid

Website: http://dch.georgia.gov/

Click on Programs, then Medicaid

Phone: 1-800-869-1150

Website: http://medicaidprovider.hhs.mt.gov/clientpages/

clientindex.shtml

Telephone: 1-800-694-3084

IDAHO – Medicaid and CHIP NEBRASKA – Medicaid

Medicaid Website: www.accesstohealthinsurance.idaho.gov

Medicaid Phone: 1-800-926-2588

CHIP Website: www.medicaid.idaho.gov

CHIP Phone: 1-800-926-2588

Website: http://www.dhhs.ne.gov/med/medindex.htm

Phone: 1-877-255-3092

INDIANA – Medicaid NEVADA – Medicaid and CHIP

Website: http://www.in.gov/fssa/2408.htm

Phone: 1-877-438-4479

IOWA – Medicaid

Website: www.dhs.state.ia.us/hipp/

Phone: 1-888-346-9562

Medicaid Website: http://dwss.nv.gov/


CHIP Website: http://www.nevadacheckup.nv.org/

CHIP Phone: 1-877-543-7669

KANSAS – Medicaid NEW HAMPSHIRE – Medicaid

Website: https://www.khpa.ks.gov

Phone: 800-766-9012

Website: www.dhhs.nh.gov/ombp/index.htm

Phone: 603-271-4238

KENTUCKY – Medicaid NEW JERSEY – Medicaid and CHIP

Website: http://chfs.ky.gov/dms/default.htm

Phone: 1-800-635-2570

LOUISIANA – Medicaid

Website: http://www.lahipp.dhh.louisiana.gov

Phone: 1-888-342-6207

Medicaid Website:

http://www.state.nj.us/humanservices/dmahs/clients/

medicaid/


CHIP Website: http://www.njfamilycare.org/index.html

CHIP Phone: 1-800-701-0710

MAINE – Medicaid NEW MEXICO – Medicaid and CHIP

Website: http://www.maine.gov/dhhs/oms/

Phone: 1-800-321-5557

MASSACHUSETTS – Medicaid and CHIP

Medicaid & CHIP Website:

http://www.mass.gov/MassHealth

Medicaid & CHIP Phone: 1-800-462-1120

Medicaid Website:

http://www.hsd.state.nm.us/mad/index.html


CHIP Website:

http://www.hsd.state.nm.us/mad/index.html

Click on Insure New Mexico

CHIP Phone: 1-888-997-2583

MINNESOTA – Medicaid NEW YORK – Medicaid

Website: http://www.dhs.state.mn.us/

Click on Health Care, then Medical Assistance

Phone (Outside of Twin City area): 800-657-3739

Phone (Twin City area): 651-431-2670

Website: http://www.nyhealth.gov/health_care/medicaid/

Phone: 1-800-541-2831

MISSOURI – Medicaid NORTH CAROLINA – Medicaid

Website: http://www.dss.mo.gov/mhd/index.htm

Phone: 573-751-6944

Website: http://www.nc.gov

Phone: 919-855-4100

NORTH DAKOTA – Medicaid UTAH – Medicaid

Website:

http://www.nd.gov/dhs/services/medicalserv/medicaid/

Phone: 1-800-755-2604

Website: http://health.utah.gov/medicaid/

Phone: 1-866-435-7414

OKLAHOMA – Medicaid VERMONT– Medicaid

Website: http://www.insureoklahoma.org

Phone: 1-888-365-3742

Website: http://ovha.vermont.gov/

Telephone: 1-800-250-8427

OREGON – Medicaid and CHIP VIRGINIA – Medicaid and CHIP

Medicaid & CHIP Website:

http://www.oregonhealthykids.gov

Medicaid & CHIP Phone:

1-877-314-5678

Medicaid Website: http://www.dmas.virginia.gov/rcp-

HIPP.htm


CHIP Website: http://www.famis.org/

CHIP Phone: 1-866-873-2647

PENNSYLVANIA – Medicaid WASHINGTON – Medicaid

Website:

http://www.dpw.state.pa.us/partnersproviders/medicalassista

nce/doingbusiness/003670053.htm

Phone: 1-800-644-7730

Website:

http://hrsa.dshs.wa.gov/premiumpymt/Apply.shtm

Phone: 1-800-562-3022 ext. 15473

RHODE ISLAND – Medicaid WEST VIRGINIA – Medicaid

Website: www.dhs.ri.gov

Phone: 401-462-5300

Website: http://www.wvrecovery.com/hipp.htm

Phone: 304-342-1604

SOUTH CAROLINA – Medicaid WISCONSIN – Medicaid

Website: http://www.scdhhs.gov

Phone: 1-888-549-0820

Website: http://dhs.wisconsin.gov/medicaid/publications/p-

10095.htm

Phone: 1-800-362-3002

TEXAS – Medicaid WYOMING – Medicaid

Website: https://www.gethipptexas.com/

Phone: 1-800-440-0493

Website:

http://www.health.wyo.gov/healthcarefin/index.html

Telephone: 307-777-7531

To see if any more States have added a premium assistance program since November 3, 2010, or for

more information on special enrollment rights, you can contact either:

U.S. Department of Labor U.S. Department of Health and Human Services

Associate Benefits Security Administration Centers for Medicare & Medicaid Services

www.dol.gov/ebsa www.cms.hhs.gov

1-866-444-EBSA (3272) 1-877-267-2323, Ext. 61565

OMB Control Number 1210-0137 (expires 09/30/2013)

Who to Call

Benefit/Vendor Phone Online

JKV/Cigna Health Plan

Plan Administrator

Claims Processing

Customer Service

FMH/CoreSource Customer Service

Center

Effective January 2, 2012

Monday - Friday 8 a.m. - 7 p.m.

Central Time

Toll-Free: 1-(866) 585-1534

www.f-m-h.com

www.mycignaforhealth.com

Pharmacy Benefit Manager

Retail Pharmacies

Mail Order Pharmacy

NPS

National Pharmaceutical Services

Customer Service

1-800-546-5677

24 hours/365 days a year

www.pti-nps.com

Dental Plan

Delta Dental

Customer Service Center

1-800-335-8266

www.deltadentalmo.com

Long-Term

and Short-Term Disability

Hartford Life Insurance

1-800-707-5333 (Monday - Friday) Claims are submitted by you over the

phone to Hartford Life Insurance

company for approval.

www.TheHartfordAtWork.com

Section 125 Flexible Spending

Accounts

Health Care FSA

Dependent Care FSA

ASIFlex Customer Service

1-800-659-3035

Monday - Friday 7 a.m. - 7 p.m.

Saturday 9 a.m. - 1 p.m. Central Time

www.asiflex.com

Note: Once enrolled, some of these websites will enable you to register and login to check the status of your claims, view eligibility information, print or order ID cards, access educational information, view directions, view network listings, and more.

Have questions or need information

from John Knox Village?

Visit www.MyJKV.org to print copies of forms or to check your benefits status.

Or contact any of the following team members in John Knox Village’s human resources

department:

Len Chmelka, Manager of Compensation – 347-2848

Trisha Pepper, human resources manager, Village Care Center – 347-3744

Donna Newland, human resources manager, Administrative Center – 347-4022

The information in this Enrollment Guide is presented for illustrative purposes and is based on information provided by the 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 Human Resources.

jkv 2012 benefits enrollment guide

Documents

john knox village

tax payroll deductions

health risk assessment

twin city area

employee assistance program

human resources manager

actual plan documents

special enrollment rights