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Alternative versions of most forms are available on HR Forms

Health Insurance

Effective January 1, 2008:

NOTE: Enrollment and change forms found on the various medical plan homepages are not applicable for State of Kansas employees. Please contact Benefits Administration, Division of Human Resources of Kansas State University, for the appropriate enrollment and change forms for these programs.

NOTE: Employees desiring to enroll dependents are required by the State of Kansas to provide proof of relationship/dependency for each dependent. Appropriate documentation would include such items as marriage license for spouse or birth certificate for children.

The State of Kansas group health insurance plans for plan year 2008 are provided by Blue Cross/Blue Shield, Coventry Health Care and Preferred Health Systems.

For a complete listing of the rules regarding health insurance benefits, employees should refer to the additional information in the current Employee Benefits Guidebook at the State of Kansas website: http://www.khpa.ks.gov/benefitsdocuments/EEBenefitGuide2007.pdf (pdf).

The following is a summary description of the health insurance plans available to most KSU employees:

Plan A Blue Cross/Blue Shield, Coventry Health Care of Kansas or Preferred Health Systems (Preferred Provider Organization)

Network

• Deductible - None.
• Copayment - Insured pays $20 medical home/$40 medical specialist
• Coinsurance - Insured pays 10% coinsurance of allowable charges to maximum of $1,000 per person, $2,000 per family per plan year.

Non Network

Plan B Blue Cross/Blue Shield, Coventry Health Care of Kansas or Preferred Health Systems (Preferred Provider Organization)

Network

• Deductible - None.
• Copayment - Insured pays $20 medical home/$40 medical specialist.
• Coinsurance - Insured pays 35% coinsurance of allowable charges to maximum of $2,200 per person, $4,400 per family per plan year.

Non Network

• Deductible - Insured pays $500 per person, $1,500 per family per plan year.
• Coinsurance - Insured pays 50% coinsurance of allowable charges to a maximum of $3,650 per person, $7,300 per family per plan year.

Coventry - Qualified High Deductible Health Plan with Health Savings Account (Preferred Provider Organization)

Network

• Deductible - Insured pays $1,500 per person, $3,000 per family.
• Coinsurance - Insured pays 20% coinsurance of allowable charges to maximum of $5,000 per person, $10,000 per family per plan year.

Non Network

• Deductible - Insured pays $2,000 per person, $4,000 per family per plan year.
• Coinsurance - Insured pays 40% coinsurance of allowable charges to a maximum of $6,000 per person, $12,000 per family per plan year.
• NOTE: When selecting any level of dependent coverage, the entire family deductible must be met before claims are paid for any covered person.

When Eligible: First day of month following 60 days of employment, during annual open enrollment, or within 31 days of a qualifying event.

Who Pays: The university and employee (full-time and part-time) both contribute toward the cost of employee medical coverage. The university and employee (full-time and part-time) both contribute toward the cost of dependent medical coverage.

Website: All health insurance plans have information at a common website: http://www.khpa.ks.gov/.

Related Forms:

• Affidavit of Common Law Marriage and Request for Enrollment of Common Law Spouse (PDF)
• Application for Coverage of Handicapped Dependent Child (PDF)
• Dependent Grandchild Affidavit (PDF)
• Health Insurance Communication Form (pdf)
• Health Care Selection Form (pdf)
• HealthyKIDS
  • HealthKIDS Fact Sheet (pdf)
  • HealthKIDS Application (pdf)
• Health Savings Account Enrollment and Change Form (pdf)
• Health Savings Account Enrollment Form UMB Bank (pdf)
• HIPAA-Authorization for Release of Medical Information (pdf)
• Prescription Drug Advance Purchase Certificate (pdf)
• Prescription Drug Advance Purchase Policy (pdf)

Related KSU Policy and Procedures Manual Chapter: 4820 Insurance Programs

State of Kansas Active Employee Benefits Guidebook - http://www.khpa.ks.gov/benefitsdocuments/EEBenefitGuide2007.pdf (pdf)

Website: State of Kansas 2008 Health Insurance Information

Eligibility Table: Health Insurance Eligibility Table

Other Health Insurance

• Dental
• Prescription
• Vision