State Employee Health Benefits

Frequently Asked Questions (FAQs)

Subject List

• COBRA  
• Deferred Compensation Plan  
• Dental Plan  
• Family Medical Leave Act (FMLA)  
• Group Health Plans Membership and Enrollment  
• HealthQuest  
• KanElect  
• Medical Plans  
• Prescription Drug Plan  
• Vision Plan  
• Workers Compensation    

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COBRA

Question: What is COBRA an acronym for?

Answer:  COBRA is an acronym for Consolidated Omnibus Budget Reconciliation Act of 1986.

Question: What does COBRA mean to me?

Answer:  This federal law requires certain employers to offer continued health insurance coverage when a former employee or their qualified dependent loses such coverage for one of the following events:

a.  Termination
b.  Reduction in hours
c.  Death of employee
d.  Divorce
e.  Loss of dependent status
f.   Member ’s entitlement to Medicare

The State and Non-State Member Plans require the Employer to offer COBRA coverage.

Question: How long may I continue on COBRA?

Answer:  A member may continue on COBRA for a maximum of 18 months for termination or reduction in hours; all other dependent qualifying events allow for a maximum of 36 months of continuation.

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Question: What type of coverage is the employer required to offer?

Answer:  The employer is required to provide coverage which, as of the time coverage is being provided, is identical to the coverage provided under the plan to similarly situated active employees or dependents.

Question:  How much does it cost for COBRA coverage?

Answer:  The member/dependent pays the full cost of COBRA coverage.  
See:

• 2007 COBRA Rates

DEFERRED COMPENSATION PLANS

What is a 457 deferred compensation plan?

What is the maximum amount I can contribute to the Plan?

You may be eligible for increased contributions:

• During the three consecutive years prior to attaining Normal Retirement Age under a special catch-up provision.

• On and after you attain age 50 under an age 50+ catch-up provision.

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Question: How many investment options are available?

Answer:  Currently, there are 23 "Best of Class" investment options. You may visit the ING Financial Services website for a detailed list.  Also, a self-directed brokerage account is a supplement to the core options, providing an additional 10,000 mutual fund choices.

Question: How can I change direction on my investments or receive information regarding my account?

Answer:  A toll-free number, 1-800-525-4225 is set up to make these transfers. Also, a toll-free number in Topeka is available for current unit value information and customer service 1-800-232-0024. You may also visit ING Aetna Financial Services website. You will receive a confirmation of activity within two weeks of any account transaction.

Question: How often can I make changes to my deferred compensation deductions?

Answer:  You can increase or decrease every 90 days, or suspend at anytime.

Question: How long does it take for a change in my deduction to take effect?

Answer:  Changes must be made in the month prior to the beginning of a payroll period.

Question: Can I withdraw funds while still employed with the state?

Answer:  In accordance with Federal Regulations, payment prior to separation from service is permitted only if you qualify for an unforeseen emergency withdrawal severe financial hardship, or if the account balance is under $5000 and you have not contributed to the plan for two years prior to this distribution.

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Question: What are the withdrawal fees?

Answer:  None in the event of separation from service, hardship or death.

Question: Can I take a lump sum distribution when I separate from service?

Answer:  Yes. There are several distribution options available to you. For more information, contact your ING Aetna Financial Services representative.

Question: When are the statements sent?

Answer:  Statements are mailed quarterly, showing all transactions within your account for the quarter. This would include contributions, fund transfers and interest earnings.  Daily account valuations are available through the ING Financial Services website.

Question: When are contributions credited and how is interest compounded?

Answer:  Contributions are credited to your account(s) on payday. Interest is compounded daily.

Question: Where can I get more information?

Answer:  State of Kansas Deferred Compensation Plan Office:

212 W. 8th Street, Suite 100
Topeka, KS 66603

Telephone (785) 296-7095
Outside Topeka (800) 232-0024

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DENTAL PLAN

Question: What does Delta Dental cover?

Answer:  Two examinations by a contracting dentist which include diagnostic and preventative procedures are covered at 100% of allowable charges; regular restorative dentistry, endodontics, periodontics and oral surgery are covered at 60%; major restorative procedures are covered at 50% when they are provided by a Premier provider. Highest coverage is provided when services are provided by a PPO provider (although there is limited availability).

Oral surgery, endodontics, periodontics, special restorative, prosthodontics and TMJ are subject to a deductible.

Question: When does the deductible apply?

Answer:  The annual deductible applies towards any dental treatment greater than regular restorations (fillings).  Preventive visits, emergency pain relief, fillings, and orthodontic work are not subject to the deductible.

Question: What happens if I have a dental accident?

Answer:  Claims are processed first by the dental plan. Any services not covered by the dental plan may be submitted to your medical plan for processing provided the services are a covered benefit under the medical plan.  If you are in an HMO, your PCP’s referral will be required. The medical plan needs to be notified of payments made for dental treatment before it will provide any additional coverage. The amount paid by the dental plan for accident treatment does not apply to the annual maximum for other services.

Question: If I end my enrollment in the dental plan, will my dental work continue to be covered?

Answer: specific procedures started under this plan will be covered after termination of coverage only for those procedures completed within 30 days of termination and submitted for payment within 6 months.  The member will need to contact the plan to  see which procedures are covered after termination.

Question: What is the difference between the Premier network and the PPO Delta Preferred network?

Answer: The Premier network is the largest group of dentists who contract with Delta Dental. Delta Preferred Option (PPO) dentists are a smaller group of providers who take greater discounts and generally cost you less to use.

Question: What is the DeltaUSA network?

Answer: This is a national network of Delta Dental PPO and Premier network providers. State of Kansas members are eligible for PPO  and Premier coverage anywhere in the United States by using a DeltaUSA provider.

Question: What happens if my crown breaks through no fault of my own?

Answer: Individual crowns on the same tooth are covered only once in any five-year period. Only two repairs are allowed in a 12-month period, and recementation is allowed once in a 12 consecutive month period.  Discuss options with your dentist if a crown is damaged.

Question: Can I find out in advance how much of my dental treatment will be covered?

Answer: Yes. Your dentist can request a predetermination of benefits for you so that you will know approximately what will be covered and what you will be expected to pay.

FAMILY MEDICAL LEAVE ACT (FMLA)

Question: Which employees are eligible to take FMLA leave?

Answer:  Employees are eligible to take FMLA leave if they have worked for their employer for at least 12 months and have worked for at least 1,250 hours over the previous 12 months, and work at a location where at least 50 employees are employed by the employer within 75 miles. See C.F.R. 825.110

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Question: Do the 12 months of service with the employer have to be continuous or consecutive?

Answer:  No. The 12 months do not have to be continuous or consecutive; all time worked for the employer is counted. See C.F.R. 825.110(b)

Question: Do the 1,250 hours include paid leave time or other absences from work?

Answer:  No. The 1,250 hours include only those hours actually worked for the employer. Paid leave and unpaid leave, including FMLA leave, are not included.

Question: How much leave am I entitled to under FMLA?

Answer:  If you are an "eligible" employee, you are entitled to 12 weeks of leave for certain family and medical reasons during a 12-month period. See C.F.R. 825.200

Question: Does workers compensation leave count against an employee’s FMLA leave entitlement?

Answer:  It can. FMLA leave and workers compensation leave can run together, provided the reason for the absence is due to a qualifying serious illness or injury and the employer properly notifies the employee in writing that the leave will be counted as FMLA leave. See C.F.R. 825.207(2)

Question: Can the employer count leave taken due to pregnancy complications against the 12 weeks of FMLA leave for the birth and care of my child?

Answer:  Yes. An eligible employee is entitled to a total of 12 weeks of FMLA leave in a 12-month period. If the employee has to use some of that leave for another reason, including a difficult pregnancy, it may be counted as part of the 12-week FMLA leave entitlement. See C.F.R. 825.112(a)(4) & (c)

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Question: Can the employer count time on maternity leave or pregnancy disability as FMLA leave?

Answer:  Yes. Pregnancy disability leave or maternity leave for the birth of a child would be considered qualifying FMLA leave for a serious health condition and may be counted in the 12 weeks of leave so long as the employer properly notifies the employee in writing of the designation. See C.F.R. 825.207(d)(1)

GROUP HEALTH PLANS MEMBERSHIP AND ENROLLMENT

Question: Which State of Kansas employees are eligible for the Health Plan?

Answer:  Employees are eligible for the Health Plan if they are working in a position which is not temporary or seasonal and which requires at least 1,000 hours of work per year. Refer to K.A.R. 108-1-1 for additional information.

Question: What is the effective date of coverage in the Health Plan?

Answer:  The effective date of coverage is generally the first day of the month following the completion of a 60-day waiting period from date of hire in a benefits eligible position.

Question: When can an employee change their Health plan coverage during the year?

Answer:  Coverage can be changed if the member experiences a qualified status change event and requests the change within 31 days.  If approved, the effective date of the change is generally the first day of the month following the date of the qualified event. Please see the current Employee Benefits Guidebook [PDF version] [Word version] for additional information and restrictions.  In an HMO, a plan change cannot be made simply because your PCP discontinues participation.

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Question: Who can a member cover on their health insurance?

Answer:  A member may cover their spouse and unmarried children up to age 23 (includes natural or adopted children, stepchildren, or legal custody children). Subject to certain restrictions, the employee may also cover grandchildren or handicapped children over age 23. Please see the current Employee Benefits Guidebook online.

Question: If a member terminates employment, when will their Health Plan coverage end?

Answer:  Coverage will end the last day of the month of the member ’s last day at work.  The member will then be offered COBRA continuation coverage. 

Question: How do I change my Primary Care Physician (PCP).

Answer:  A PCP is required if you are enrolled in an HMO. To change your PCP, telephone your medical plan Customer Service. The telephone number is on your medical insurance card.

HEALTHQUEST

Question: I’m nervous about calling LIFELINE. What will happen when I call in? Who will know if I call LIFELINE?

LIFELINE also offers one-on-one life coaching, healthy weight teleclasses (5 in a series), consultations with an attorney,  financial experts or geriatric care specialists, and many more personal services - all free for state of Kansas employees and Nonstate participant groups.  For more information about these programs and to sign up for life coaching or the Healthy Weight program:  http://www.khpa.gov.state.ks.us/healthquest/lifeline/

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How often does the HealthQuest newsletter come out? If I miss getting a copy, whom should I contact?

Answer:  The HealthQuest newsletter is now available bi-monthly on-line only. Human Resource Managers are sent an email to forward to employees informing them that the new issue is online. Issues are available in February, April, June, August, October, and December.

Individuals can easily print the newsletter by selecting Text Version. Employees can access the current and past issues directly from the HealthQuest web page: http://www.khpa.gov.state.ks.us/healthquest/newsletters.htm (Select HTML to see graphic rich version; Select Text Version to print it.)

Tell me about HealthQuest Wellness and how I can sign up.

Answer:  HealthQuest Wellness is a popular online program running year round.  It started as Winterfit but has grown into a year-round wellness program. As a participant you can request a FREE wellness calendar in November and receive an on-line fitness log. You get bi-weekly emails of new posts to the wellness blog on health and wellness topics.  The articles feature interesting ideas, useful resources, and simple steps to take toward wellness.  Participants are also invited to participate in free teleclasses (wellness classes that take place on the phone).    Currently 4,200 employees subscribe.   For more details go to the following web page: http://www.khpa.gov.state.ks.us/healthquest/blog.htm. 

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KANELECT

Question: What is KanElect?

Answer:  KanElect is offered by the State of Kansas for the benefit of its members and is an Internal Revenue Code (IRS) Section 125 plan. It allows the member to pay for unreimbursed health care expenses, and dependent day care expenses with pretax dollars. A member can save an estimated 25-40% in taxes on that portion of their salary that is used for qualifying expenses.

Question: If I leave the State of Kansas what happens to my KanElect account?

Answer:  Accounts end at the end of the month in which termination occurs. If a member ends their employment with the State or stops making deposits when they have a change in status, they have until April 15th following the end of the plan year to file claims which were incurred up to the end of the month of their termination or status change.

Question: If I have funds in my health care account when I leave the State and no eligible expenses, is there any way to claim those funds?

Answer:  The period the member was covered on the health care account may be extended on an after tax basis if the member elects continuation of coverage under Flexible Spending Account COBRA. If IRS regulations are met, the member can continue to file dependent care claims for the remaining funds in their account until the end of the plan year.

Question: If a member is rehired by the State in the same calendar year can they enroll in the flexible spending accounts?

Answer:  No, our plan document only allows one enrollment per calendar year.

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Question: If a member goes on FMLA leave, what options are available for the KanElect accounts?

Answer:  The member has three options:

1. The account(s) may stop at the end of the month in which the member goes on FMLA (if paperwork is completed at that time) and start when they return from leave. If this option is selected there would be no payment for claims incurred during the time the account was inactive.
2. The second option is to continue their contribution to their health care account (no dependent care continuation) by making payments on an after tax basis.
3. The third option on FMLA is to terminate the account for the remainder of the year.

Note:  The dependent care account may not be continued while on FMLA because claims are not eligible if a member is not working.

Question: Do I have to cover my dependents on the State of Kansas health plan to use their claims on my flexible spending accounts?

Answer:  No, they just need to be dependents as defined by the IRS dependent definition.

Question: If the date of service for the expense occurs during the current plan year but is not paid for until the following year, can I use that expense on my account during the following year?

Answer:  No, all expenses for the current plan year must be incurred between January 1 and December 31 of the current plan year.

Question: If I am divorced may I claim dependent care for my child?

Answer:  Please refer to IRS Publication 503 under the qualifying person test subheading child of divorced or separated parents. You must first meet the qualification of being the custodial parent.

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Question: The dependent care maximum is $5,000 (for single or married filing jointly status). Can that expense be for only one child?

Answer:  Yes, the maximum is for expenses for one or more children.

Question: If both spouses work for the State of Kansas, can they each contribute $5,000 per year to the dependent care account?

Answer:  No, per IRS regulation, $5,000 is the maximum per couple filing a joint tax return.

Question: If both spouses work for the State of Kansas can they each contribute $3,480 a year to the health care FSA (Flexible Spending Account)?

Answer:  Yes.

Question: If the member enrolls mid-year in the dependent care account, can they still contribute $5,000?

Answer:  No, they are limited to a maximum deduction of $208.33 per semi-monthly paycheck.

Question: When will my medical claim reimbursement be paid?

Answer:  Medical claims are paid daily, Monday – Friday.   See KanElect Claim Forms [PDF version] [Word version]

Question: What types of health care expenses qualify for the flexible spending account?

Answer:  According to IRS regulations, expenses which are eligible for reimbursement are those which would generally be deductible on a federal income tax return (please refer to IRS Publication 502 for further information on Qualifying expenses or visit the ASI website.)  An employee may not use this account to pay health insurance premiums for any individual, group coverage, or long term care expenses, even though these expenses are considered tax deductible on their federal income tax return.  

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Question: Does LASIK eye surgery qualify as an eligible health care expense?

Answer:  Yes.

Question: Can I claim the entire orthodontic fee when I pay it at the time the braces are placed on the teeth?

Answer:  No, you may only claim the expense that was incurred for the procedure completed that day. You can claim the amount you paid to have the braces placed on the teeth but not the amount for services to be incurred in the future - monthly fees for maintenance. The IRS will not allow advance reimbursement of future or projected expenses from the Health Care Account. If you wish to pay for the whole year and submit the receipt with a copy of your contract, ASI will take the total divided by 24 paycheck periods and reimburse you for that amount semi-monthly.

Question: How long do I have to file my claims?

Answer:  For eligible expenses incurred January 1 through December 31,  claims may be filed until April 15.  See KanElect Claim Forms [PDF version] [Word version]

For additional claim forms or copies of Publication 502 and 503, please refer to the ASI website at www.asiflex.com.

Question: If I pay my dependent care expenses the first of each month, can I be reimbursed for the whole month the first week?

Answer:  No, dependent care services must have been provided (incurred) before you file a claim for the expenses.

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MEDICAL PLANS

Question: Why can’t I change my Health plan option during the middle of the year?

Answer:  Certain changes are allowed during the Plan Year for a qualifying event. Generally, the changes follow the Internal Revenue Code 125 guidelines. Please refer to the current Employee Benefits Guidebook [PDF version] [Word version].

Question: Which plans require a Primary Care Physician (PCP)?

Answer:  Each of the Health Maintenance Organization (HMO) Plans require member(s) to select a PCP. 

Question: If I change my Primary Care Physician, when can I go to my new PCP?

Answer:  Members can change their PCP by calling the plan Customer Service (telephone number on ID card). A PCP change is effective the first day of the month following the request for change.

Question: If my physician no longer participates in the network, such as Coventry, can I change to Premier Blue during the Plan Year?

Answer:  Generally, you will remain in the same HMO for the remainder of the Plan Year even if some of the providers move in and out of the network during the year. However, if you move to a county in which your plan is not available, you will need to change to another plan from those which are available for enrollment in that county.

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Question:  What number do I call if I have questions on my health plan?

Answer:  The health plan phone numbers are listed on the back of the identification card. In addition, they are on the inside cover of the Health Plan Summary (Open Enrollment) for Active Employees Booklet [PDF version] and they are also available on our website at: http://www.khpa.ks.gov

Question:  Do the State health plans have a pre-existing condition waiting period?

Question:  What is the difference between the two PPO plans offered?

Question:  If the PPO plans have the same benefits, why are premiums different?

Answer:  Premiums are based upon the plan experience. Plan experience includes the amount paid for claims and administrative expenses. So it is possible to have two plans with identical benefits to have different claims experience and therefore, different rates.

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Question:  I have had some pain and I went to see my doctor. I thought this would be paid under the PPO $450 preventive care service allowance but instead it was applied to my coinsurance. Why?

Answer:  The preventive care service allowance is designed to encourage people to see their physician while they are still healthy to assist them in finding potential problems before they become full blown disease states. The services covered under the preventive care allowance are all routine screening services and do not include codes that are filed with claims when people visit their physician's office with a complaint, or illness or any type of diagnosis. To receive the preventive care benefit, you must use a network provider.

Question:  How do I find out if my doctor is in the network for the plan I am considering?

Answer:  A complete list of providers participating in each of the medical plans is available on the web at Health Plan Providers. For most plans, you will need to click on the plan name to be transferred to the plan’s website then follow the link to the provider directory. Each directory operates a little differently. Directions for using the search function are provided on each site. You may also call the customer service center for assistance.  Provider networks change so check each time you have services.

Question:  What happens if my doctor sends me to a non network provider for lab, xrays, anesthesia or other medical treatment?

Under the HMO plans, it is your primary care physician’s responsibility to refer member's to contracting providers. If you primary care physician refers you to an out of network provider, the referral must be prior authorized by the Health Plan.

The Kansas Choice PPO Plan utilizes the Blue Cross Blue Shield PPO network that contracts with approximately 85% of providers nationwide. When you use a non network provider with Kansas Choice, non network benefits apply.

Coventry PPO has a smaller provider network both locally and nationally and for that reason will make an exception for "invisible providers". For example, you have surgery at a network hospital with a network surgeon, but the anesthesiologist is non network. This "invisible providers'" claim will be processed at the network level of benefits. However, since there is no contract with this provider, they may bill you any amount above the plan allowance.

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Question:  What happens if there is a medical emergency and I am taken to a non-network hospital?

Answer:  Under Kansas Choice and Coventry PPO, if your doctor refers you to another doctor for services, the benefits will be paid based on whether or not that provider is in the plan’s networks. If a non network provider is used then non network benefits will be provided. It is up to the member to communicate with their provider(s) in the health plan in which they are enrolled to enable the provider to provide as much assistance as possible. The PPO plans allow members to receive reimbursement from both network and non network providers.

Benefits under Kansas Choice and Coventry PPO are based upon the network status of the provider. If a non network provider is used, non network benefits will be provided.

Under an HMO contract, you are covered for initial treatment of a medical emergency. The PCP and the HMO should be contacted as soon as possible regarding treatment options.

Question:  Will my HMO pay for out of area emergencies?

Answer:  You are covered for the initial treatment of a medical emergency but you must contact your PCP and HMO before proceeding with any additional services.

Question:  For an HMO, must  everyone in the family have the same PCP? Where do you find the PCP numbers requested on the application?

Answer:  No. Each family member will need to select a PCP. The PCP numbers are available on the web (Health Plan Providers) under the provider directory feature of each plan or by calling the HMO.

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Question:  I enrolled in Kansas Choice because my physician was participating in the health plan. Their office has since decided not to continue in the Kansas Choice network. Can I make a mid-year election to switch to another health plan that my doctor does participate in?

Answer:  No. Changes in the provider network can occur at anytime on any of the health plans. Since the provider contracts are between the plan and the provider, the State can not guarantee access to specific providers. Under Kansas Choice and Coventry PPO you can continue to see the provider under the out of network benefit or chose another provider who does participate in the network. Members with an HMO need to select another provider if their PCP leaves the network. Remember, you will have the opportunity during open enrollment in October of each year to switch health plans for the next year should you desire.

Question:  Do the copays for office visits, emergency room, outpatient mental health visits, and hospital stays apply toward my deductible or coinsurance.

Answer:  No. Copays are not credited toward deductibles or coinsurance.  Copays occur each time service is obtained.

Question:  If I go to a non network provider, what will I pay toward the non network deductibles and coinsurance to satisfy my network deductibles and coinsurance?

Answer:  Under the PPO plans, network and non network services accumulate separately.  The non network deductible is $500 for single and $1,500 for family per plan year. 

Coinsurance amounts accumulate separately for network and non network services.  The coinsurance for non network is 50%.

Question:  What is the coinsurance maximum and how is calculated?

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Question:  Does the money I spend out of pocket for the deductible count toward the coinsurance maximum? Do the copays count toward the maximum?

Answer:  No. The deductible is the amount of covered services you must pay out of pocket before the plan begins to pay benefits. This amount does not count toward the coinsurance maximum.

Copays are a flat dollar cost sharing amount for certain services like office visits. Amounts paid for copays do not count toward the coinsurance maximum.

Question:  Is chiropractic coverage included in the health plans?

Answer:  Chiropractic care is considered a physical rehabilitation benefit and is covered, subject to medical necessity for up to 30 visits per year.  The health plans will request medical records from the chiropractor, just as they would from a physician or physical therapist. Medical records must show continued improvement in condition. HMO members will need a referral from their PCP. 

PRESCRIPTION DRUG PLAN

Question: What is a Preferred Drug List?

Answer:  A Preferred Drug List  identifies those prescription drug products that are preferred by the plan for dispensing to members when appropriate. This list is subject to periodic review and modification.

Question: How is the State of Kansas Prescription Drug Preferred Drug List determined?

Answer:  The State of Kansas group Health Plan uses the Caremark National Formulary list with limited exceptions:

All forms of insulin and covered diabetic supplies will be paid by the member at 20% coinsurance level if generic, and 35% coinsurance level for preferred brand name drugs (whether or not they are on the Caremark national formulary).

Question: What are Special Case Medications?

Answer:  Special Case Medications are high costing medications used for treatment of catastrophic conditions.  A list of special case medications is on the website and is subject to review.  There is a $75 copay per standard fill for 2007.

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Question:  Does the prescription drug plan cover diabetic supplies?

Answer:  Yes. The prescription drug plan does cover diabetic supplies that are medically necessary and prescribed by a physician. Diabetic testing equipment (glucometers, etc) are covered under the health plans.  For members enrolled in Kansas Senior Plan C, diabetic supplies are covered by the medical plan after Medicare pays first.

Question:  How can I save money on my prescription drugs?

Answer:  When your physician gives you a prescription, ask if a generic is available and if it would be appropriate for you. If the physician says you must take a brand name drug, ask if there is a drug listed on the Preferred Drug List that you can take. You can find the Preferred Drug List on Caremark's website or by calling them at 1-800-294.6324. Print off a copy to share with your physician at each office visit.

Question:  How do I use the prescription drug mail order program?

Answer:  To participate in the mail order program, you will need to complete the Mail Service Profile form available on the Caremark website. Submit this form along with an original prescription from your physician to Caremark.  Please allow 2 weeks for processing.  The initial fill will be 30 days.  For faster refills order from the Caremark website or call 1-800-294-6324.

Question:  What are lifestyle prescription medications?

Answer:  Lifestyle medications are primarily used for weight loss, smoking cessation, infertility, erectile dysfunction, medications for cosmetic purposes, dental preparations (toothpaste, mouthwash, etc.) and Drug Efficacy Study Implementation (DESI-5) medications. DESI-5 medications are older medications that require a prescription but which the Food and Drug Administration (FDA) have approved for safety only and not safety and effectiveness. Also included in this category are Reserve RX medications (medications whose active ingredient does not require a prescription but whose manufacturer has decided to sell only with a prescription) and ostomy supplies.

Question:  Since the prescription drug plan does not pay for lifestyle medications, why is this a benefit?

Answer:  The benefit to members is that they receive the same discount the State has negotiated for the prescription drug plan on these items. So the member pays the negotiated discount plus a dispensing fee instead of the retail price of the product.

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Question:  What are special case drugs?

Answer:  They are high cost medications used for treatment of catastrophic conditions.  A list of Special Case Medications is on the Health Plan Providers under Caremark and is subject to review.  There is a $75 copay per fill for 2007. 

Question:  My physician has prescribed Glucagon, a medication that I will inject myself with each day. Is that covered under the medical or prescription drug plan?

Answer:  This self-injectible medication is covered under the Caremark prescription drug plan. A complete list of all self-injectible medications is available at  Health Plan Providers

Question:  I have tried several of the Preferred Drug List medications and they have not been effective in treating my conditions. I have used a non preferred medication in the past that was effective. Is there anyway to add this to the Preferred Drug List?

Answer:  No. The State plan utilizes Caremark’s Preferred Drug List (PDL). Members are not able to request that Caremark change the PDL. However, the PDL override process addresses this situation since it allows the non preferred medication to be processed at the preferred brand medication coinsurance rate.

Prescription overrides are available in the following instances.

1. The member has tried two Preferred medications and medical evidence indicates the Preferred mediations were ineffective.
2. The member could not tolerate the Preferred medication.
3. There is not a generic or brand name Preferred medication available or other plan criteria are met.

The prescribing physician must request the prescription override on the member’s behalf by calling Caremark at 1-800-294-5979. Please note: this telephone number is for use by physicians and their staff only. It is not a customer service line for members. Initial information will be taken by telephone. A form will be faxed to the physician for signature. Approvals may be granted if the member meets the plan criteria state above. The coinsurance paid on drugs with prescription overrides does not apply toward the coinsurance maximum.

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Question:  Explain how the prescription drug coinsurance/copay maximum works.

For 2007, the coinsurance for generic and preferred brand drugs and the copay for special case medications are capped at a set dollar amount. For 2007, the max is $2,580 per person per plan year. Once the member's share of eligible drugs reaches the coinsurance/copayment maximum, any additional generic, preferred or special case drugs will be covered by the plan at 100 percent for the remainder of the plan year. There is no cap on the coinsurance for non preferred drugs or those with a prescription override.

VISION PLAN

Question: I am enrolled in the vision plan and I didn’t get an ID card for the vision plan; should I?

Answer:  If you enrolled, the ID card was included on the bottom of the cover letter sent with your enrollment packet. The ID card is not required to access care. Advise your provider of your Superior Vision coverage and they can call to verify coverage.

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Question: Who can be covered in the vision plan?

Answer:  Members may elect any coverage on either the Basic or Enhanced vision plan regardless of enrollment in a health plan. Coverage levels include: member only; member and spouse only; member and child(ren) only; member and family (spouse and children); or waive.

Question:  Why is the deductible for a routine eye exam so high on the vision insurance?

Answer:  The deductible is set at $50 for the vision insurance because all of the health plans except Kansas Senior Plan C include coverage for a routine eye exam as part of the medical coverage. If you are covered under vision, be sure to advise your physician's office of both insurance plans when seeking treatment.

Question: What is the difference between the Basic Vision Plan and the Enhanced Vision Plan? 

Answer:  The Enhanced plan covers everything the Basic plan does plus basic progressive (no-line bifocals), high index lenses, polycarbonate lenses, scratch coating and ultraviolet protective coating.

Question:  What are progressive power lenses?

Answer:  Progressive power lenses are an alternative to the typical bifocal and trifocal lens designs that have small "windows" in the lower half of the lens. The progressive power lens has the power for distance vision at the top of the lens, like bifocal and trifocal lenses, however, the power of the lens then becomes progressively stronger from the mid-point of the lens to the bottom of the lens. Hence, the lens design is described as "progressive power". This lens design is also referred to as a "no line" lens. The power change enables the wearer to focus clearly at distance, at mid-point (arm's length) and all the way through to the near-point (reading area). There are definite advantages to wearing progressive power lenses as opposed to standard bifocal and trifocal lenses. However, because there is some visual distortion at the periphery of the progressive power lens, some people have difficulty adjusting to them.

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Question:  What kinds of progressive power lenses are there?

Answer:  Progressive power lenses are available from a number of different manufacturers with many variations in design and curvature configuration. The lenses are also made in different materials, such as glass, plastic, transitions, High Index, Polaroid, etc. As a result, lens prices can vary greatly depending on these variations.

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Question:  I went to the eye doctor at my local WalMart for an exam but they are not in the network. I thought all of the WalMart stores were in Superior’s network? 

Question:  My physician wrote me a prescription for contact lenses. Does that mean they are considered medically necessary by the plan?

Answer:  No. Medically necessary contacts are contact lenses required due to a medical condition such as cataracts or glaucoma for which glasses are not an alternative treatment.

WORKERS COMPENSATION

Question: What is Workers Compensation?

Answer:  It is compensation for medical treatment or disability provided by the employer for an injury caused by an accident arising out of and in the course of employment. Employees who sustain compensable injuries from an accident, injury or occupational disease may be entitled to:

* Reasonable and necessary medical treatment expenses to treat the job related injury or illness;

* Disability compensation to replace part of the wages lost due to a disability; and

* Survivors’ benefits if death results.

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Question: Who administers Workers Compensation for State of Kansas employees?

Answer:  The State Self-Insurance Fund administers workers compensation claims on behalf of State of Kansas employees. The State Self-Insurance Fund can be reached in Topeka at (785) 296-2364.

Question: What if I have an accident at work?

Answer:  All accidents should be reported to the employer (usually a supervisor) at the very earliest possible time so the injured worker can seek medical attention and to investigate the accident to prevent recurrence. Failure to notify an employer within 10 days of the accident could jeopardize compensation.

Question: Where do I go for medical care?

Answer:  An employee injured at work is entitled to all reasonable and necessary medical treatment needed to cure or relieve the effects of the injury. The employer has the right to choose the treating physician. The State Self-Insurance Fund has designated care with several hospitals and clinics. Please see the list of medical providers. If you are injured, and work in these areas, you must go there first for treatment. If there is no designated provider in your area, please see your PCP. Should you seek medical care from a provider that is not approved by the Fund, you may receive unauthorized medical compensation limited to $500.

Question: Is mileage allowed for treatment I get?

Answer:  You will be entitled to mileage when you drive to your authorized provider’s office if the distance is more than 5 miles roundtrip. A mileage form is available for your use in keeping track of your miles and may be submitted periodically, usually monthly, as you drive.

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Question: How do I get prescriptions?

Answer:  You may purchase prescription drugs from any outlet in your area. The vendor may allow you to charge the drugs and then directly bill the Fund; or you may pay for the drugs and be reimbursed by the Fund. State Self-Insurance Fund usually will not pay for over the counter items, aspirin, Band-Aids, etc. Your claim representative will assist you with such purchases if you have a problem. Please check with your claim representative before purchasing or renting any other items such as walkers, wheelchairs, electrical stimulators or other equipment.

Question: How and when do I get paid if I am off work?

Answer:  You may be compensated at the rate of 2/3 of your gross average weekly wage, subject to a weekly maximum, if a physician restricts you from all work or if your employer can not accommodate physician directed restrictions. This compensation is called Temporary Total Disability, or "TTD". In general, you are not eligible for weekly compensation for the first week (unless you are totally disabled from work 21 consecutive days.) The State Self-Insurance Fund will issue you a separate check in the same time frame (biweekly) as State employees receive regular pay. Your agency will be advised of the State Self-Insurance Fund paid compensation and will make necessary adjustments to your time and leave balances. If you receive State Self-Insurance Fund compensation, please check with your personnel officer about sick leave, vacation leave or FMLA considerations.

Question: Will I be taxed on State Self-Insurance Fund payments?

Answer:  Workers compensation disability payments are not subject to state or federal income tax.

Question: Do I have to use vacation leave or sick leave if I am drawing Temporary Total Disability?

Answer:  No. Some employees do supplement Temporary Total Disability compensation with leave so as to make up pay for any shortage (since TTD is 2/3 of the employee's gross average weekly wage, subject to a weekly maximum.) See your agency personnel office for more details or call your claim representative.

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Question: Am I eligible for shared leave consideration if I have a work related injury?

Answer:  No. Shared leave is not available to employees who are receiving workers compensation. (K.A.R. 1-9-23)

Question: How soon can I try to return to work?

Answer:  Your supervisor, agency and claim representative will begin the process of getting you back to work as soon as possible. The treating physician will determine if you have physical restrictions. You, your supervisor and the representative can then review any restrictions to decide if you can return to duty. This could be in the form of accommodated duty or shortened hours so long as they do not exceed physical restrictions. If the agency can accommodate restrictions, you will be expected to return to work. As your restrictions are adjusted, your accommodations will be evaluated until you are back to regular duty.

Question: What if I have questions about this process?

Answer:  Your primary assistance is the claim representative (or adjuster) at (785) 296-2364. Located in Topeka, the claim representative will advise you and will see that you receive the necessary information and compensation. Another source is in the Division of Worker’s Compensation in Topeka which has claim advisors who can provide you with consultation on a toll free number, 1-800-332-0353. 

Question: What if I see an unsafe act or condition at work?

Answer:  Correct the situation if it is within your scope of responsibility or decision making. Otherwise, report it to your supervisor. Your agency may also contact the State Self Insurance Fund, Health and Safety Specialist at (785) 368-7100 or (785) 296-2069 for accident prevention assistance and consultation.

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Question: What if I think someone is cheating on workers compensation?

Answer:  Please report this with specific detail, to the State Self-Insurance Fund at (785) 296-2364.

Question: Do I need an attorney to handle my claim?

Answer:  Your best source of information about how claims are administered and how they are "settled" comes from your claims representative. You could also call the Division of Workers Compensation’s toll free 1-800-332-0353 or local Topeka number (296-2996) and speak with an advisor. We suggest you try to resolve any situation through this process before considering representation.

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