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John Knox Village

Healthy Lifestyles Begin With Opportunities

2012 Associate Benefits Enrollment Guide

Design 2008-2011 Zywave, Inc. All rights reserved.

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 spouses employer offers a comparable health plan, but elects to use John Knox Villages health insurance. (See the enclosed Spousal Surcharge Waiver form.)
Benefits for eligible associates include:

Full-Time Associate Benefits


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

Part-Time Associate Benefits


- 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 selfservice 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 childs 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 spouses benefits or employment status.

Health and Wellness Opportunities


John Knox Villages Associate Wellness Center
Good health doesnt 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 dont eat), the amount of exercise we get (or dont get), and the amount of stress we allow to take hold in our lives. Its time to take charge of your health, and were 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 Allergies Cold and flu symptoms Ear infections Skin conditions Sore throat Vaccinations School, sports and camp physicals

The nurse practitioner can also provide care, treatment and prescriptions for conditions such as:
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).

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 Centers 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.

Fulfill These Requirements, and Youll 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.

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 & Caf.

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 theyre taking action to stay healthy.

Get Your Preventive Care Its 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 thats the reason for your visit so dont go tacking on a bunch of
extra stuff to have the doctor do while youre there).

Whats 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 Routine Gynecological Care Exams
(Includes routine tests and related lab fees; limited to 1 routine exam per calendar year.) (7 exams in first 12 months of life, 3 exams in the 13 -24 month of life, and 1 exam per calendar year thereafter to age 18.)
th th

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 Lukes Health System (816) 931-3073 or 1-(800) EAP-1223 Whenever you need help balancing your personal or work life, the Saint Lukes 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 Villages 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 dont 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 plans 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


Heres 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 plans 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 Anas insurance usage, assuming she uses in-network providers:

Ana Individual Coverage


Health fund - $250 contribution by John Knox Village (in two $125 installments) Office Visit/Lab tests for urinary tract infections - $150 Prescription drugs - $50 Annual physical, Pap test, mammogram, flu shot Preventive care services are covered 100% by Cigna health plan.

Amount Charged

Fund Balance $250

Ana Pays

$200

$50*

$0

$0 $ 50

$50 $ 50

$0

Health Fund Rollover to 2013

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
Health fund - $500 contribution by John Knox Village (in two $250 installments) 2 Annual physicals 2 Flu shots 2 Vision exams Preventive care services are covered 100% by Cigna health plan. 3 Office visits * ER visit for laceration

Fund Balance
$500

Juan & Anita Pay

$0

$500

$0

$150 $600 $0

$350 $0

$0 $50 co-pay $200 out of pocket

Health Fund Rollover to 2013

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


Whats 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 plans 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, heres what you can expect: Plan Administration / Claims / Customer Service
FMH/CoreSource will now be the Plans 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. 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

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 Cignas managed care network of medical providers and Cignas 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 well 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 familys Member ID Card(s).

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
Annual Health Fund Amount

BUY-UP PLAN

Individual $250 Family $500

$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)* $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 plans 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 Annual Deductibles


Individual Family

Out-of-Network
$3,000 $6,000

In Network

Out-of-Network
$2,000 $4,000

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

Out-of-Pocket Maximum
Individual Family $4,500 $9,000 $3,500 $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% Not Applicable 60% 80% 90% Not Applicable 70% 90% For services within the Network where no In-Network Provider is available 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 Not Applicable Not Applicable 80% 80% Not Applicable Not Applicable 90% 90%

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

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 Villages health plan, you may incur a $50 monthly surcharge. See the Working Spouse Surcharge Waiver form in your Benefits Enrollment Packet for more information.

BASE PLAN
In Network Preventive/Routine Care
Preventive Services 100% Deductible Waived 60% after Deductible

BUY-UP PLAN
In Network
100% Deductible Waived

Out-of-Network

Out-of-Network
70% after Deductible

Including but not limited to exams, diagnostics and other services as required by the Patient Protection and Affordable Care Act. Mammograms Pap Smear Prostate Specific Antigen Test (PSA) Digital Rectal Exam (DRE) Sigmoidoscopy Double contrast Barium Enema (DCBE) Colonoscopy Routine Eye Exam (Includes refraction) 100% Deductible Waived One per Benefit Period One per Benefit Period Age 40 and over - one per Benefit Period Age 40 and over - one per Benefit Period Age 50 and over - one every five (5) years Age 50 and over - one every five (5) years Age 50 and over - one every ten (10) years 60% after Deductible 100% Deductible Waived 70% after Deductible

Physician Services
Office Visit All Other Services in Physicians 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 Ambulance 80% after Deductible 80% after Deductible 80% after Deductible 80% after Deductible 80% after Deductible 80% after Deductible 80% after Deductible 60% after Deductible 60% after Deductible 60% after Deductible 60% after Deductible 60% after Deductible 60% after Deductible 60% after Deductible 90% after Deductible 90% after Deductible 90% after Deductible 90% after Deductible 70% after Deductible 70% after Deductible 70% after Deductible 70% after Deductible 70% after Deductible 70% after Deductible 70% after Deductible

90% after Deductible 90% after Deductible 90% after Deductible

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

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

BASE PLAN
In Network
Private Duty Nursing (Outpatient) Hospice Care Home Health Care 80% after Deductible

BUY-UP PLAN
In Network
90% after Deductible 70% after Deductible 70% after Deductible 70% after Deductible 70% after Deductible 70% after Deductible 70% after Deductible

Out-of-Network
60% after Deductible 60% after Deductible 60% after Deductible 60% after Deductible 60% after Deductible 60% after Deductible

Maximum: 70 Visits per Benefit Period 80% after Deductible 80% after Deductible 90% after Deductible 90% after Deductible

Maximum: 120 Visits per Benefit Period Skilled Nursing Facility 80% after Deductible 90% after Deductible

Maximum: 60 Days per Benefit Period Outpatient Physical, Speech & Occupational Therapy Chiropractic Care 80% after Deductible 90% after Deductible

80% after Deductible

90% after Deductible

Mental and Nervous Disorder & Substance Abuse


Inpatient Outpatient Office / Clinic (Includes Hospital or other Clinic) Durable Medical Equipment Prosthetics Wig after Cancer Treatment 80% after Deductible 80% after Deductible 80% after Deductible 60% after Deductible 60% after Deductible 60% after Deductible 60% after Deductible 60% after Deductible 90% after Deductible 90% after Deductible 90% after Deductible 70% after Deductible 70% after Deductible 70% after Deductible 70% after Deductible 70% after Deductible

80% after Deductible 80% after Deductible

90% after Deductible 90% after Deductible

100% - Deductible Waived 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 Lukes 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

BASE PLAN
In Network PRESCRIPTION DRUG BENEFITS Deductible: For most medications For chronic conditions and to prevent certain illnesses1 Co-payments Retail Pharmacy (Up to a 30-day supply)
Generic Brand Name Preferred Brand Name NonPreferred $15 $25 $40
Subject to the Base Plan Deductible. Once met, you then pay only the applicable copay shown below for the remainder of the year.

BUY-UP PLAN
In Network Out-of-Network

Out-of-Network

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

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.

Mail Order (Up to a 90-day supply)


Generic Brand Name Preferred Brand Name NonPreferred $30 $50 $80 Not Applicable Not Applicable Not Applicable $30 $50 $80 Not Applicable Not Applicable 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

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.

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 Dentals Customer Service Center at 1-800-335-8266

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 Dentals 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.

Dental Benefits
D e lta P P O N e tw o rk Based on a reduced fee schedule with the dentist no balance billing
Based on Deltas maximum plan allowance balance billing is possible $50 per person / Up to $150 per family $1,500 per covered person

S u m m a r y o f D e n ta l B e n e fits

Delta Premier N e tw o rk Based on a contractual agreement with the dentist no balance billing

N o n -n e tw o r k

D e d u c tib le A n n u a l B e n e fit M a x im u m D ia g n o s tic a n d P r e v e n tiv e 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 st nd non-decayed 1 and 2 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%

O r th o d o n tic S e r v ic e s 1 , 2
For eligible dependents to age 19 who begin treatment while covered by this plan

50%

50%

50%

S e p a r a te O r th o d o n tic L ife tim e M a x im u m B e n e fit


1

$2,000 per eligible dependent child up to age 19

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 familys, if there is an approved reason why you cannot work due to a non work-related illness or injury. Plan Highlights
Short-term Disability When am I eligible? On the 1 day of the month following 6 months of employment with John Knox Village as a benefits-eligible associate. John Knox Village provides this benefit at no cost to you.
st

Long-term Disability If you enroll during Open Enrollment, effective 01/01/12, subject to requirements stated below. 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. On the 91 day of approved absence due to injury, sickness or pregnancy. 60% of your pre-disability earnings, up to a maximum of $5,000 per month. Benefits may continue as long as you remain disabled up to your Social Security Normal Retirement Age.
st

Who pays for my coverage?

When do benefits begin?

After 7 calendar days of approved absence due to injury, sickness or pregnancy. 50% of your regularly scheduled earnings. Up to 90-days.

What is my monthly benefit? How long will I receive disability benefits? What if I have banked disability or illness hours accumulated from previous years? May I use them? What happens to my unused banked disability and/or illness hours in the event that I no longer work for John Knox Village? How do I submit a claim?

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

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.

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 cant 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 Part-time employees 1 times your annual base salary $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 theyre 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 dont 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 Janes 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
Gross income: FSA contributions: Gross income: Estimated taxes: Federal State FICA After-tax earnings: Eligible out-of-pocket Medical and dependent care expenses: Remaining spendable income: Spendable income increase: -2,550* -900** -2,295 24,255 -5,300 $18,955 $0 $30,000 0 30,000

With FSAs
$30,000 -5,300 24,700

-1,755* -741** -1,890 20,314 0 $20,314 $1,359

You can save approximately 25% of each dollar spent on these expenses when you participate in a FSA.
*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.

Section 125 Cafeteria Plan


Plan Highlights:
YOU MUST RE-ENROLL EACH YEAR.

Health Care and Dependent Care Flexible Spending Accounts

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: asi@asiflex.com Web: www.asiflex.com

But Wait, Theres 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 Lukes (816) 931-3073 or 1-(800) EAP-1223

The Saint Lukes 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 (Missouris 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 taxdeferred payroll deductions. Even better, once youve been here for two years, the Village will match 50 cents for each dollar you put in (up to 2.5% of your pay).

Dont 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 MassMutuals RetireSmartSM tools on their website: www.massmutual.com/retire to figure out how much youll need for retirement and the best investment strategy for you. Or you can call them at 1-800-743-5274.

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.

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 SM Use RetireSmart tools to figure out how much youll 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. WOMENS 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 Womens Health and Cancer Rights Act of 1998. This notice serves as the annual notice required by the Department of Labor. The Womens 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 mothers or newborns 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 Plans 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 theres 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 Plans Summary Plan Description or get a copy of the Plan Document from the Plan Administrator. The Plan Administrator is: John Knox Village 400 NW. Murray Rd. Lees Summit, MO 64081 1-800-255-5555 The COBRA Administrator is: Taben Group P.O. Box 7330 Overland Park, KS 66215-0330 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 spouses hours of employment are reduced; (3) Your spouses 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-associates hours of employment are reduced; (3) The parent-associates 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 associates 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 childs 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 Administrators 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 associates 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 Administrators 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. 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 Administrators 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 Labors Associate Benefits Security Administration (EBSA). Addresses and phone numbers of Regional and District EBSA Offices are available through EBSAs website at www.dol.gov/ebsa. Keep Your Plan Informed of Address Changes In order to protect your familys 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 CHILDRENS 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 employers 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 employers 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 Website: http://www.medicaid.alabama.gov Phone: 1-800-362-1504 ALASKA Medicaid Website: http://health.hss.state.ak.us/dpa/programs/medicaid/ Phone (Outside of Anchorage): 1-888-318-8890 Phone (Anchorage): 907-269-6529 CALIFORNIA Medicaid Website: http://www.dhcs.ca.gov/services/Pages/ TPLRD_CAU_cont.aspx Phone: 1-866-298-8443 COLORADO Medicaid and CHIP Medicaid Website: http://www.colorado.gov/ Medicaid Phone (In state): 1-800-866-3513 Medicaid Phone (Out of state): 1-800-221-3943

CHIP Website: http:// www.CHPplus.org CHIP Phone: 303-866-3243 ARIZONA CHIP Website: http://www.azahcccs.gov/applicants/default.aspx Phone (In state): 1-877-764-5437 ARKANSAS CHIP Website: http://www.arkidsfirst.com/ Phone: 1-888-474-8275 GEORGIA Medicaid Website: http://dch.georgia.gov/ Click on Programs, then Medicaid Phone: 1-800-869-1150 IDAHO Medicaid and CHIP Medicaid Website: www.accesstohealthinsurance.idaho.gov Medicaid Phone: 1-800-926-2588 CHIP Website: www.medicaid.idaho.gov CHIP Phone: 1-800-926-2588 INDIANA Medicaid 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 KANSAS Medicaid Website: https://www.khpa.ks.gov Phone: 800-766-9012 KENTUCKY Medicaid 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 MAINE Medicaid 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 MINNESOTA 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 MISSOURI Medicaid Website: http://www.dss.mo.gov/mhd/index.htm Phone: 573-751-6944 FLORIDA Medicaid Website: http://www.fdhc.state.fl.us/Medicaid/index.shtml Phone: 1-866-762-2237 MONTANA Medicaid Website: http://medicaidprovider.hhs.mt.gov/clientpages/ clientindex.shtml Telephone: 1-800-694-3084 NEBRASKA Medicaid Website: http://www.dhhs.ne.gov/med/medindex.htm Phone: 1-877-255-3092 NEVADA Medicaid and CHIP Medicaid Website: http://dwss.nv.gov/ Medicaid Phone: 1-800-992-0900 CHIP Website: http://www.nevadacheckup.nv.org/ CHIP Phone: 1-877-543-7669 NEW HAMPSHIRE Medicaid Website: www.dhhs.nh.gov/ombp/index.htm Phone: 603-271-4238 NEW JERSEY Medicaid and CHIP Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/ medicaid/ Medicaid Phone: 1-800-356-1561 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710 NEW MEXICO Medicaid and CHIP Medicaid Website: http://www.hsd.state.nm.us/mad/index.html Medicaid Phone: 1-888-997-2583 CHIP Website: http://www.hsd.state.nm.us/mad/index.html Click on Insure New Mexico CHIP Phone: 1-888-997-2583 NEW YORK Medicaid Website: http://www.nyhealth.gov/health_care/medicaid/ Phone: 1-800-541-2831 NORTH CAROLINA Medicaid Website: http://www.nc.gov Phone: 919-855-4100

NORTH DAKOTA Medicaid Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-800-755-2604 OKLAHOMA Medicaid Website: http://www.insureoklahoma.org Phone: 1-888-365-3742 OREGON Medicaid and CHIP Medicaid & CHIP Website: http://www.oregonhealthykids.gov Medicaid & CHIP Phone: 1-877-314-5678

UTAH Medicaid Website: http://health.utah.gov/medicaid/ Phone: 1-866-435-7414 VERMONT Medicaid Website: http://ovha.vermont.gov/ Telephone: 1-800-250-8427 VIRGINIA Medicaid and CHIP Medicaid Website: http://www.dmas.virginia.gov/rcpHIPP.htm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.famis.org/ CHIP Phone: 1-866-873-2647 WASHINGTON Medicaid Website: http://hrsa.dshs.wa.gov/premiumpymt/Apply.shtm Phone: 1-800-562-3022 ext. 15473 WEST VIRGINIA Medicaid Website: http://www.wvrecovery.com/hipp.htm Phone: 304-342-1604 WISCONSIN Medicaid Website: http://dhs.wisconsin.gov/medicaid/publications/p10095.htm Phone: 1-800-362-3002 WYOMING Medicaid Website: http://www.health.wyo.gov/healthcarefin/index.html Telephone: 307-777-7531

PENNSYLVANIA Medicaid Website: http://www.dpw.state.pa.us/partnersproviders/medicalassista nce/doingbusiness/003670053.htm Phone: 1-800-644-7730 RHODE ISLAND Medicaid Website: www.dhs.ri.gov Phone: 401-462-5300 SOUTH CAROLINA Medicaid Website: http://www.scdhhs.gov Phone: 1-888-549-0820 TEXAS Medicaid Website: https://www.gethipptexas.com/ Phone: 1-800-440-0493

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 Associate Benefits Security Administration www.dol.gov/ebsa 1-866-444-EBSA (3272)
OMB Control Number 1210-0137 (expires 09/30/2013)

U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, Ext. 61565

Who to Call
Benefit/Vendor Phone
FMH/CoreSource Customer Service Center Effective January 2, 2012 Monday - Friday 8 a.m. - 7 p.m. Central Time

Online
www.f-m-h.com www.mycignaforhealth.com

JKV/Cigna Health Plan Plan Administrator Claims Processing Customer Service

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


National Pharmaceutical Services Customer Service 1-800-546-5677 24 hours/365 days a year Delta Dental Customer Service Center 1-800-335-8266 Hartford Life Insurance 1-800-707-5333 (Monday - Friday) www.pti-nps.com

Pharmacy Benefit Manager Retail Pharmacies Mail Order Pharmacy

Dental Plan

www.deltadentalmo.com

Long-Term and Short-Term Disability

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 Villages 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.