Description of Medical Benefits (CONTINUED) by dZb6J59n

VIEWS: 5 PAGES: 91

									LOWER KUSKOKWIM SCHOOL
   DISTRICT EMPLOYEE
   HEALTHCARE PLAN


           Including the
   SUMMARY PLAN DESCRIPTION

          Restated May 2012
                                                TABLE OF CONTENTS
Introduction .................................................................................................................... 1
Summary Plan Description General Information ....................................................... 2
Summary of Medical Benefits ....................................................................................... 3
Summary of Vision Benefits .......................................................................................... 9
Summary of Dental Benefits........................................................................................ 10
Pre-Admission Certification ........................................................................................ 11
Preferred Provider Network ....................................................................................... 15
Claim Submission ......................................................................................................... 16
Description of Medical Benefits .................................................................................. 21
Description of Prescription Benefits ........................................................................... 29
Medical Plan Limitations and Exclusions .................................................................. 33
Description of Dental Benefits ..................................................................................... 38
Dental Plan Limitations and Exclusions .................................................................... 40
Description of Vision Benefits ..................................................................................... 42
Vision Plan Limitations and Exclusions ..................................................................... 42
Description of Hearing Benefits .................................................................................. 43
Hearing Plan Limitations and Exclusions .................................................................. 43
Definition of Terms ...................................................................................................... 44
Pre-Existing Conditions ............................................................................................... 56
Enrollment and Eligibility ........................................................................................... 58
Coordination of Benefits .............................................................................................. 63
Third Party Recovery Provision ................................................................................. 69
COBRA Continuation .................................................................................................. 70
General Plan Provisions ............................................................................................... 77
Administration .............................................................................................................. 80
Plan Participants' Rights ............................................................................................. 82
HIPAA Privacy ............................................................................................................. 84
Health Care Reform Notices………………………………………………………….87
                                                                         INTRODUCTION




                        Lower Kuskokwim School District
                           Employee HealthCare Plan


Welcome to the Lower Kuskokwim School District Employee HealthCare Plan. This health
care Plan is designed to provide comprehensive medical, dental, vision and audio coverage for
our employees and their covered dependents. At the same time, the Plan has been designed to
encourage the careful use of health care services.
This Summary Plan Description has been designed to assist you in understanding the benefits
available. Some terms are defined in the Definition of Terms beginning on page 44 of this
document. Please take the time to review this document carefully and become familiar with
the benefits the Plan offers.
Failure to follow the eligibility or enrollment requirements of this Plan may result in delay of
coverage or no coverage at all. Reimbursement from the Plan can be reduced or denied
because of certain provisions in the Plan, such as coordination of benefits, subrogation,
exclusions, timeliness of COBRA elections, utilization review or other cost management
requirements, lack of medical necessity, lack of timely filing of claims, or lack of coverage.
These provisions are explained in summary fashion in this document; additional information
is available from the Plan Administrator at no extra cost.
This Plan is administered by Integrity Administrators, Inc. If you have questions regarding
your coverage or eligibility, we encourage you to contact Integrity Administrators, Inc. using
the phone numbers shown below and a representative will assist you.
Integrity Administrators, Inc. may be contacted at:



                                        Integrity Administrators, Inc.
                                                P.O. Box 13128
                                         Sacramento, CA 95813-3128

                                            Toll-Free (800) 562-9383
                                              Fax (916) 921-3383




   Lower Kuskokwim School District Employee HealthCare Plan                         page   1
             SUMMARY PLAN DESCRIPTION GENERAL INFORMATION


Name of the Plan:                                            The Plan shall be known as the Lower
                                                             Kuskokwim School District Employee
                                                             HealthCare Plan
Address of the Plan:                                         Lower Kuskokwim School District
                                                             PO Box 305
                                                             Bethel, Alaska 99559
Group Number:                                                1180
Plan Effective Date:                                         July 1, 2002
Plan Renewal Date:                                           July 1
Plan's Fiscal Year End:                                      June 30
Contract Administrator:                                      Integrity Administrators, Inc.
                                                             P.O. Box 13128
                                                             Sacramento, CA 95813-3128
                                                             Phone: (800) 562-9383 Toll-Free

                                                             Fax:      (916) 921-3383
Contributions:                                               The employer contributes 100%              for
                                                             employee and dependent coverage
Effective Date of Coverage:                                  Per the relevant Negotiated Agreement - see
                                                             Enrollment and Eligibility section of this
                                                             document
Termination Date of Coverage:                                Per the relevant Negotiated Agreement - see
                                                             Enrollment and Eligibility section of this
                                                             document
Pre-Admission Notification:                                  Hines & Associates
                                                             Phone: (800) 559-5257




  Lower Kuskokwim School District Employee HealthCare Plan                                   page   2
                                                              SUMMARY OF MEDICAL BENEFITS
Verification of Eligibility (800) 562-9383
Call this number to verify eligibility for Plan benefits before a charge is incurred.
Medical Benefits
All benefits described in this Schedule are subject to the exclusions and limitations described more fully
herein including, but not limited to, the Plan Administrator's determination that: care and treatment is
Medically Necessary; that charges are Usual and Reasonable; that services, supplies and care are not
Experimental and/or Investigational. The meanings of these capitalized terms are in the Defined Terms
section of this document.
Note: The following services must be pre-notified or reimbursement from the Plan may be reduced.
        Inpatient Hospitalization
        Chemical Dependency Treatment
        Skilled Nursing Facility Stay
        Home Health Care
        Hospice Care
        Organ and/or Tissue Transplant Services
____________________________________________________________________________________
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 delivery. However,
Federal law generally does not prohibit the mother’s or newborn’s attending provider (see NOTE), after
consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96
hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider
obtain authorization from the Plan or the issuer for prescribing a length of stay not in excess of 48 hours
(or 96 hours).
NOTE: An “attending provider” does not include a plan, hospital, managed care organization or other
issuer.
____________________________________________________________________________________
_
MENTAL HEALTH PARITY & ADDICTION EQUITY ACT
Under Federal law, group health plans that already provide coverage for mental health conditions and/or
substance addictions (referred to in the law as “substance use disorders”) must provide coverage for such
covered conditions in the same manner as coverage is provided for Sickness. This law applies to group
health plans on their Plan Year anniversary beginning on or after October 3, 2009.
NOTE: The Plan is not required to provide coverage for mental health conditions or substance use
disorders. Also, the Plan (and not the Act) determines what will be a covered mental health condition
and/or a covered substance use disorder. This legislation does not apply to employers with fewer than 51
employees.


CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP)



   Lower Kuskokwim School District Employee HealthCare Plan                             page   3
                                                          SUMMARY OF MEDICAL BENEFITS (CONTINUED)

Effective April 1, 2009, Employees and Dependents who are eligible but not enrolled for the Employer’s
group health plan, may enroll for coverage there under in the following instances:
       Loss of Medicaid or CHIP Eligibility: If the Employee’s or Dependent’s Medicaid or Children’s
        Health Insurance Program (CHIP) coverage is terminated as a result of loss of eligibility, the
        Employee may request coverage under the Employer’s group health plan coverage within sixty
        (60) days after Medicaid or CHIP coverage terminates.
       Eligibility for State Premium Assistance: Where a State has chosen to offer premium assistance
        subsidies for qualified employer-sponsored benefits (see NOTES) and if the Employee or
        Dependent becomes eligible for such subsidy under Medicaid or CHIP, then the Employee may
        request coverage under the Employer’s group health plan within sixty (60) days after eligibility
        for the subsidy is determined.
Also, if an Employee’s child(ren) become eligible for CHIP, Employee has the ability to drop the
child(ren) from the group health coverage.
NOTES: CHIPRA, Children’s Health Insurance Program Reauthorization Act, allows states to elect to
offer premium assistance subsidies to qualified individuals. Such subsidies are not mandated.


GENETIC INFORMATION AND NON-DISCRIMINATION ACT
GINA (Genetic Information and Non-discrimination Act) applies to a group health plan on its Plan Year
beginning after May 12, 2009. The Act makes it illegal for group health plans to deny coverage or charge
a higher rate or premium to an otherwise health individual found to have a potential genetic condition or
genetic predisposition towards a disease or disorder. The Plan’s eligibility and coverage provisions
exclude denial of benefits or increased rates due to a potential or predisposition of a genetic condition of
covered employees and their families.
The Act defines genetic information as that obtained from an individual’s genetic test results, as well as
genetic test results of family members and the occurrence of a disease or disorder in family members.
____________________________________________________________________________________
_
NOTICE OF RIGHT TO RECEIVE A CERTIFICATE OF CREDITABLE COVERAGE
Under the health insurance Portability and Accountability Act of 1996 (commonly known as HIPAA), an
individual has the right to receive a certificate of prior health coverage, called a “certificate of creditable
coverage: or “certificate of group health plan coverage,” from the Plan Sponsor or its delegate. If Plan
coverage or COBRA continuation coverage terminates the Plan Sponsor will automatically provide a
certificate of creditable coverage. The certificate is provided at no charge and will be mailed to the
person at the most current address on file. A certificate of creditable coverage will also be provided, on
request, in accordance with the law (i.e., a request can be made at any time while coverage is in effect and
within twenty-four (24) months after termination of coverage). Written procedures for requesting and
receiving certificates of creditable coverage are available from the Plan Sponsor.




   Lower Kuskokwim School District Employee HealthCare Plan                           page   4
                                                          SUMMARY OF MEDICAL BENEFITS (CONTINUED)

The following is a Summary of Medical Benefits. For additional coverage details, please refer to the
Description of Medical Benefits beginning on page 21. All services must be medically necessary, and
benefits are subject to Usual, Customary and Reasonable (UCR) allowances. All benefits are subject to
Medical Plan Limitations and Exclusions as explained beginning on page 33 of this document.
MAXIMUM ANNUAL BENEFIT AMOUNT:                                 $1,000,000
LIFETIME MAXIMUM                                               UNLIMITED
DEDUCTIBLE, PER CALENDAR YEAR:
   Preferred and Non-Preferred Providers                     $150 per covered person
                              (combined):                        $300 per family
MAXIMUM OUT-OF-POCKET AMOUNT, PER CALENDAR YEAR (in addition to
the deductible):
 Preferred Facility, Professional Services                   $250 per covered person
             and Other Covered Services:                         $750 per family
                   Non-Preferred Facility:          No maximum out-of-pocket, all services
                                                    remain at steerage coinsurance level (the
                                                      level shown on the following pages).
                                                   Non-PPO facility expenses do not apply to
                                                          the out-of-pocket maximum.
  The Plan will pay the designated percentage of covered charges. For professional services
  and Preferred Provider Facilities, the Plan will pay 100% of contractually covered charges
  when the out-of-pocket maximum is reached, for the remainder of the calendar year,
  unless stated otherwise.
 The following expenses do not apply to the out-of-pocket maximum:
       Deductibles,
       Non-Compliance penalties,
       Facility services furnished outside of the PPO Network, including Non-PPO
        facilities' copayments and coinsurance, (except for care of an Emergency Medical
        Condition at a Non-PPO hospital emergency room),
       Expenses covered at 100% by the Plan,
       Dental, vision and hearing services,
       Services and supplies not covered (in whole or in part) by the Plan, and
    Outpatient mental health and chemical dependency treatment.
 Note: All maximums listed are the total for Preferred and Non-Preferred expenses. For
 example, if a maximum of 60 days is listed under a service, the maximum is 60 days total,
 which may be split between Preferred and Non-Preferred Providers. Please refer to the
 Pre-Existing Conditions portion of this document for a description of Pre-Existing
 Conditions. Expenses subject to Plan pre-notification are subject to a $250 Non-
 Compliance penalty per incident.
 It is the intent of this Plan that benefits are to be provided when services are medically
 necessary and required in the diagnosis and treatment of an illness or injury, unless not
 included in this Plan as a covered benefit.




   Lower Kuskokwim School District Employee HealthCare Plan                        page   5
                                                          SUMMARY OF MEDICAL BENEFITS (CONTINUED)


                                              PREFERRED       ALASKA                       NON-ALASKA
                                                 (PPO)       NON-PPO                         NON-PPO
    COVERED SERVICES                           PROVIDER     PROVIDER*                       PROVIDER*
                                            FACILITY BENEFITS
                    $200 per admission copayment applies to all Non-PPO inpatient services
                               and Non-PPO outpatient surgical facility charges
 Inpatient Services                              Deductible, then     $200 copayment,        Deductible, then
 Semi-private rate, unless confined in               90%               deductible, then          70%*
 Intensive Care Unit                                                       60%*
 Outpatient Surgical Facility                    Deductible, then     $200 copayment,        Deductible, then
                                                     90%               deductible, then          70%*
                                                                           60%*
 Outpatient Diagnostic Lab &                    Deductible, then      Deductible, then       Deductible, then
 X-Ray (Hospital Facility)                          90%                   60%*                   70%*
 Chemotherapy and Radiation                      Deductible, then     Deductible, then       Deductible, then
 Therapy (Hospital Facility)                         90%                  60%*                   70%*
 Emergency Room                               Emergency Medical      Emergency Medical     Emergency Medical
 Treatment of an Emergency Medical               Condition:             Condition:            Condition:
 Condition at a Non-PPO facility will          Deductible, then       Deductible, then      Deductible, then
 apply to the out-of-pocket maximum,                90%                    90%                   90%
 refer to the definition of Emergency
                                               Non-Emergency          Non-Emergency         Non-Emergency
 Medical Condition on page 47 of the
                                              Medical Condition:     Medical Condition:    Medical Condition:
 Summary Plan Description                      Deductible, then       Deductible, then      Deductible, then
                                                    90%                   60%*                  70%*
 Pre-Admission Testing                               100%*                 100%*                 100%*
                                               (deductible waived)   (deductible waived)   (deductible waived)
 Birthing Center                                     100%*                 100%*                 100%*
                                               (deductible waived)   (deductible waived)   (deductible waived)
 Sleep Disorder Diagnosis and                   Deductible, then      Deductible, then       Deductible, then
 Treatment (Facility Fees)                          90%                   60%*                   70%*
 Medical necessity must be established
 Mental Health Care Facility Fees
 Inpatient                        Deductible, then                    $200 copayment,        Deductible, then
                                                       90%             deductible, then          70%*
                                                                           60%*
 Partial Hospitalization                         Deductible, then     $200 copayment,        Deductible, then
 Two days count as one day toward                     90%              deductible, then          70%*
 the lifetime maximum                                                      60%*
*Indicates a copayment, deductible or coinsurance percentage that does not apply to the out-of-pocket
 maximum. Coinsurance does not increase to 100% when the out-of-pocket maximum has been satisfied.




   Lower Kuskokwim School District Employee HealthCare Plan                                       page   6
                                                          SUMMARY OF MEDICAL BENEFITS (CONTINUED)


                       PREFERRED        ALASKA                                         NON-ALASKA
                           (PPO)       NON-PPO                                           NON-PPO
   COVERED SERVICES     PROVIDER      PROVIDER*                                         PROVIDER*
                FACILITY BENEFITS - CONTINUED
                   $200 per admission copayment applies to all Non-PPO inpatient services
                              and Non-PPO outpatient surgical facility charges
Chemical Dependency Facility Fees
Inpatient                       Deductible, then                  $200 copayment,           Deductible, then
                                                      90%          deductible, then             70%*
                                                                       60%*
Partial Hospitalization                        Deductible, then   $200 copayment,           Deductible, then
Two days count as one day toward                    90%            deductible, then             70%*
lifetime maximum                                                       60%*

                COVERED SERVICES               ALL PROVIDERS
                      PROFESSIONAL SERVICE BENEFITS
Office Visit                                                               Deductible, then 90%
Office Laboratory and X-Ray Services                                       Deductible, then 90%
Office or Outpatient Surgery                                               Deductible, then 90%
Inpatient Visit                                                            Deductible, then 90%
Inpatient Surgery                                                          Deductible, then 90%
Inpatient, Outpatient or Independent Lab & X-                              Deductible, then 90%
Ray (Professional Fees)
Outpatient Non-Surgical Services (Professional                             Deductible, then 90%
Fees)
Chemo and Radiation Therapy (Professional Fees)                            Deductible, then 90%
Therapeutic Injections and Allergy Injections                              Deductible, then 90%
Mental Health Care Outpatient (Professional Fees)                         Deductible, then 90%*
Chemical Dependency Outpatient (Professional Fees)                        Deductible, then 90%*
Chiropractic – Spinal Manipulation                                         Deductible, then 90%
Routine Newborn Care                                                       Deductible, then 90%
Routine Well Baby Care                                                 See Preventive Care Services
Routine Well Child and Adult Care                                      See Preventive Care Services
Routine Women’s Health Care                                            See Preventive Care Services
Rehabilitation Services                                                     Deductible, then 90%
Includes physical therapy, occupational therapy and speech therapy
All Rehabilitation Services are subject to medical necessity and Usual, Customary and Reasonable
                          OTHER COVERED EXPENSES
Sleep Disorder Diagnosis and Treatment (Non-     Deductible, then 90%
Facility Fees)
Medical necessity must be established
Home Health Care                                                         100% (deductible waived)
Limited to one visit per day
Limited to 100 visits per calendar year
Hospice Care                                                              90% (deductible waived)

   Lower Kuskokwim School District Employee HealthCare Plan                                       page   7
                                                          SUMMARY OF MEDICAL BENEFITS (CONTINUED)

Skilled Nursing Facility                                                   100% (deductible waived)
Semi-private rate, unless only private rooms are available
Limited to 90 days per calendar year
Outpatient Non-Surgical Facility Fees                                        Deductible, then 90%
Ambulance Service                                                            Deductible, then 90%
Audio Care                                                             80%* (deductible waived)
Limited to maximum benefit of $400 per 36-month period
Limited to one hearing exam and purchase of one hearing aid per 36-month period
Durable Medical Equipment                                                    Deductible, then 90%
Prosthetics                                                                  Deductible, then 90%
Special Equipment/Supplies                                                    Deductible, then 90%
Includes casts, surgical appliances, ostomy supplies, catheters, syringes, needles, dressings, etc.
All Other Covered Services                                                   Deductible, then 90%
Preventive Care Services:
      Benefits for preventive diagnostic services are not subject to the calendar year
      deductible or coinsurance. Preventive diagnostic services are defined as laboratory
      and imaging services done for preventive or screening purposes, based on the U.S.
      Preventive Services Task Force (USPSTF) guidelines. (These guidelines are
      available at http://www.healthcare.gov/center/regulations/prevention/taskforce.html
      or by contacting your claims administrator.)

        Examples of preventive care services are cholesterol screening, home colon cancer
        test, colorectal cancer screening and pap smears. Benefits for all other diagnostic
        services are subject to the calendar year deductible and coinsurance.




   Lower Kuskokwim School District Employee HealthCare Plan                                       page   8
                                                                     SUMMARY OF VISION BENEFITS
The following is a Summary of Vision Benefits. All benefits are subject to all Medical Plan
Limitations and Exclusions as described beginning on page 33 of this document, as well as the
Vision Plan Limitations and Exclusions listed on page 42.
Eligible vision expenses are covered when performed by a licensed ophthalmologist, optometrist or
optician.

                       VISION CARE                                              ALL PROVIDERS
 Eye Exam                                                                            100%
 Limited to one exam per calendar year
 Lenses                                                                              100%
 Limited to one pair per calendar year
 Includes one pair of: single vision lenses, bifocals, trifocals or contact lenses
 ~ or ~ a 12-month supply of disposable contact lenses
 Frames                                                                              100%
 Limited to one frame per 24-month period

Vision Plan Limitations and Exclusions are listed on page 42.




   Lower Kuskokwim School District Employee HealthCare Plan                                 page   9
                                                                                 SUMMARY OF DENTAL BENEFITS
Dental Calendar Year Maximum Benefit:
The following is a Summary of Dental Benefits. For additional coverage details, please refer to the
Description of Dental Benefits beginning on page 38. All benefits are subject to Usual, Customary
and Reasonable (UCR) and to all Plan limitations and exclusions. Dental benefits are also subject
to the Dental Plan Limitations and Exclusions as described beginning on page 40 of this document.

    The annual maximum dental benefit for each covered person is $1,000 per Calendar Year.
Dental Deductible: .............................................................................................................. None

      DENTAL                1ST YEAR OF                2ND YEAR OF                 3RD YEAR OF                  4TH &
       CARE                 COVERAGE                   COVERAGE                    COVERAGE                 SUBSEQUENT
                                                                                                               YEARS
 Class A                         70% until                  80% until                  90% until                     100%
    Diagnostic and           December 31st of           December 31st of           December 31st of
    Preventive               the calendar year         the second calendar         the third calendar
    Services                that benefits begin          year of benefits           year of benefits
 Class B                         70% until                  80% until                  90% until                     100%
    Basic and                December 31st of           December 31st of           December 31st of
    Restorative              the calendar year         the second calendar         the third calendar
    Services                that benefits begin          year of benefits           year of benefits
 Class C                            50%                         50%                        50%                        50%
    Major Services

     In order to qualify for the increased benefit percentages shown in the above Summary, the covered
      person must have an oral examination each calendar year. If the covered person does not have an
      oral examination in any one calendar year, or does not follow the treatment recommended by his or
      her dentist or physician, the benefit percentage will be reduced by 10%; however, in no event will
      the benefit percentage be less than 70%.
     If, during the second year of coverage, a covered person provides documentation that he or she had
      an oral examination during the preceding year prior to his or her effective date of coverage, such
      participant shall be eligible for the 80% benefit shown above for the second year of coverage.
Estimate of Benefits
If dental care will be extensive (over $500) the covered person should ask the dentist to submit a pre-
treatment estimate of benefits. This will assist the patient and the dentist by estimating the patient
liability in advance, as the Plan will determine its liability for the treatment, and notify the patient and
dentist of available benefits. A pre-treatment estimate of benefits is not a guarantee of coverage or
payment; final benefit payment will depend on the covered person's eligibility and the Plan benefits
available at the time of service.




      Lower Kuskokwim School District Employee HealthCare Plan                                                       page   10
                                                              PRE-ADMISSION CERTIFICATION
Pre-Admission Certification is required for all Inpatient Hospital admissions. The intent of
this service is to promote the most cost-effective use of Hospitalization and health care
without sacrificing the quality of Medical care.
Hines & Associates must be contacted 7 business days (or as soon as possible) before a
Hospital admission. In the case of an emergency, Hines & Associates must be contacted
within 48 hours of an Emergency Inpatient Hospital admission.
Hines & Associates may be contacted at (800) 559-5257.
Failure to follow this procedure may result in a $250 Non-Compliance Penalty being
applied to the Hospital claim. This Non-Compliance Penalty does not apply to the Deductible
or the Out-of-Pocket Maximum.
Here's how the program works.
Before a Covered Person enters a Medical Care Facility on a non-emergency basis or
receives other listed medical services, the utilization review administrator will, in
conjunction with the attending Physician, certify the care as appropriate for Plan
reimbursement. A non-emergency stay in a Medical Care Facility is one that can be
scheduled in advance.
The utilization review program is set in motion by a telephone call from the Covered Person
or provider. Contact the utilization review administrator at least 48 hours before services are
scheduled to be rendered with the following information:
    -        The name of the patient and relationship to the covered Employee
    -        The name, Social Security number and address of the covered Employee
    -        The name of the Employer
    -        The name and telephone number of the attending Physician
    -        The name of the Medical Care Facility, proposed date of admission, and proposed
             length of stay
    -        The diagnosis and/or type of surgery
    -        The proposed rendering of listed medical services
If there is an emergency admission to the Medical Care Facility, the patient, patient's family
member, Medical Care Facility or attending Physician must contact the utilization review
administrator within 48 hours of the first business day after the admission.

UTILIZATION REVIEW
Utilization review is a program designed to help insure that all Covered Persons receive
necessary and appropriate health care while avoiding unnecessary expenses.
The program consists of:
            (a)   Precertification of the Medical Necessity for the following non-emergency
                  services before Medical and/or Surgical services are provided:
                  Inpatient Hospitalizations
                  Chemical Dependency Treatment
                  Skilled Nursing Facility Stays
                  Home Health Care
                  Hospice Care
                  Organ and/or Tissue Transplant Services
            (b)   Retrospective review of the Medical Necessity of the listed services
                  provided on an emergency basis;
   Lower Kuskokwim School District Employee HealthCare Plan                         page   11
                                                           PRE-ADMISSION CERTIFICATION

           (c) Concurrent review, based on the admitting diagnosis, of the listed services
           requested by the attending Physician; and
           (d) Certification of services and planning for discharge from a Medical Care
           Facility or cessation of medical treatment.
The purpose of the program is to determine what charges may be eligible for payment by the
Plan. This program is not designed to be the practice of medicine or to be a substitute for the
medical judgment of the attending Physician or other health care provider.

If a particular course of treatment or medical service is not certified, it means that either the
Plan will not pay for the charges or the Plan will not consider that course of treatment as
appropriate for the maximum reimbursement under the Plan. The patient is urged to find out
why there is a discrepancy between what was requested and what was certified before
incurring charges.
The attending Physician does not have to obtain precertification from the Plan for prescribing
a maternity length of stay that is 48 hours or less for a vaginal delivery or 96 hours or less for
a cesarean delivery.
In order to maximize Plan reimbursements, please read the following provisions carefully.

The utilization review administrator will determine the number of days of Medical Care
Facility confinement or use of other listed medical services authorized for payment. Failure
to follow this procedure may reduce reimbursement received from the Plan.

If the Covered Person does not receive authorization as explained in this section, the
benefit payment will be reduced by $250.

Concurrent review, discharge planning. Concurrent review of a course of treatment and
discharge planning from a Medical Care Facility are parts of the utilization review program.
The utilization review administrator will monitor the Covered Person's Medical Care Facility
stay or use of other medical services and coordinate with the attending Physician, Medical
Care Facilities and Covered Person either the scheduled release or an extension of the
Medical Care Facility stay or extension or cessation of the use of other medical services.
If the attending Physician feels that it is Medically Necessary for a Covered Person to receive
additional services or to stay in the Medical Care Facility for a greater length of time than has
been precertified, the attending Physician must request the additional services or days.

PREADMISSION TESTING SERVICE
The Medical Benefits percentage payable will be for diagnostic lab tests and x-ray exams
when:
(1)   performed on an outpatient basis within seven days before a Hospital confinement;
(2)   related to the condition which causes the confinement; and
(3)   performed in place of tests while Hospital confined.




    Lower Kuskokwim School District Employee HealthCare Plan                          page   12
                         PRE-ADMISSION CERTIFICATION
SECOND AND/OR THIRD SURGICAL OPINION
Certain surgical procedures are sometimes performed inappropriately or unnecessarily. In
some cases, surgery is only one of several treatment options; in other cases, surgery will not
help the condition.
In order to prevent unnecessary or potentially harmful surgical treatments, the second and/or
third opinion program fulfills the dual purpose of protecting the health of the Plan's covered
persons and protecting the financial integrity of the Plan.
Benefits will be provided for a second (and third, if necessary) opinion consultation to
determine the medical necessity of an elective surgical procedure. An elective surgical
procedure is one that can be scheduled in advance; that is, it is not an emergency or of a life-
threatening nature.
The patient may choose any board-certified specialist who is not an associate of the attending
physician and who is affiliated in the appropriate specialty.
While any surgical treatment is allowed a second opinion, the following procedures are ones
for which surgery is often performed when other treatments are available.
 Appendectomy                                 Hernia repair                   Spinal surgery
 Cataract surgery                             Hysterectomy                    Tympanotomy (inner
                                                                              ear surgery)
 Cholecystectomy (gallbladder                 Mastectomy                      Tonsillectomy and/or
 removal)                                                                     adenoidectomy
 Deviated septum repair (nasal                Salpingo-oophorectomy           Surgery to knee,
 surgery)                                     (removal of ovaries/fallopian   shoulder, elbow or
                                              tubes)                          toe
 Hemorrhoidectomy                             Prostate surgery                Varicose vein
                                                                              ligation


CASE MANAGEMENT
When a catastrophic condition, such as spinal cord injury, cancer, AIDS or a premature birth
occurs, a person may require long-term, perhaps lifetime care. After the person’s condition is
diagnosed, he or she might need extensive services or might be able to be moved into another
type of care setting-even to his or her own home.
Case Management is a program whereby a case manager monitors patients and explores,
discusses and recommends coordinated and/or alternate types of appropriate medically
necessary care. The case manager consults with the patient, the family and the attending
physician in order to develop a plan of care for approval by the patient's attending physician
and the patient. This plan of care may include some or all of the following:
    --      Personal support to the patient;
    --      Contacting the family to offer assistance and support;
    --      Monitoring hospital or skilled nursing facility;
    --      Determining alternative care options; and
    --      Assisting in obtaining any necessary equipment and services.




   Lower Kuskokwim School District Employee HealthCare Plan                             page   13
                                                          PRE-ADMISSION CERTIFICATION
Case Management occurs when this alternate benefit will be beneficial to both the patient
and the Plan. Only Medically Necessary care will be covered under Case Management;
Custodial Care will be covered only when authorized by the Plan, Case Manager, attending
Physician and the patient, and would be considered to be an exception to Benefits.

The case manager will coordinate and implement the Case Management program by
providing guidance and information on available resources and suggesting the most
appropriate treatment plan. The Plan Administrator, attending physician, patient and patient's
family must all agree to the alternate treatment plan.
Once agreement has been reached, the Plan Administrator will direct the Plan to reimburse
for medically necessary expenses as stated in the treatment plan, even if these expenses
normally would not be paid by the Plan.

Note: Case Management is a voluntary service. There are no reductions of benefits or
penalties if the patient and family choose not to participate.

Each treatment plan is individually tailored to a specific patient and should not be seen as
appropriate or recommended for any other patient, even one with the same diagnosis.




   Lower Kuskokwim School District Employee HealthCare Plan                        page   14
                                    PREFERRED PROVIDER NETWORK (FACILITY ONLY)
First Choice Health Network
Lower Kuskokwim School District has contracted with First Choice Health Network to provide a
network of preferred hospitals throughout the service area.
       PPO name: First Choice Health Network
       Address:       c/o Integrity Administrators, Inc.
                      P.O. Box 13128
                      Sacramento, CA 95813-3128
       Claims Status:         (800) 562-9383
        To Find a Provider: (800) 231-6935 or www.fchn.com
This Plan contains a Preferred Provider Organization (PPO) for hospital facilities. The Plan has entered
into an agreement with certain hospitals, which are called Preferred Providers. Because these Preferred
Providers have agreed to charge reduced fees to persons covered under the Plan, the Plan can afford to
reimburse a higher percentage of their fees.
When a covered person uses a Preferred Provider facility, that person will receive a higher benefit from
the Plan than when a Non-Preferred Provider facility is used. It is the covered person's choice as to
which facility to use.
Exceptions
Under the following circumstances, the higher in-network payment will be made for certain non-
network services:
 If a covered person is referred to a Non-Preferred Provider facility by a Preferred Provider facility,
    or
 If a covered person requires immediate treatment for an Emergency Medical Condition (as defined
    by this Plan).
Participating Provider Organization – Out of Area Services
This Plan has an agreement with Multiplan for facility services rendered outside of Alaska. When care
or services are needed while traveling or residing outside of the First Choice Network area, these
services will be covered at the in-network rate if received from a Multiplan Facility. To find a
Participating Facility, the Covered Person can contact Multiplan at (800) 677-1098 or
www.multiplan.com.




   Lower Kuskokwim School District Employee HealthCare Plan                       page   15
                                                                           CLAIM SUBMISSION
Medical, Dental, Vision and Hearing Claims
Medical, dental, vision and hearing claims must be submitted to Integrity Administrators, Inc. for
processing. No special claim forms are required; the only item that is required for claim submission is
an itemized billing statement that can be obtained from the health care provider. An itemized billing
includes the following:
1. The name of the employer, employee and patient;
2. A description of the service(s), including the amount charged for each service or supply;
3. The diagnosis;
4. The date(s) of service;
5. The name, address, and telephone number of the physician or provider; and
6. The federal tax identification number and credentials (for example MD or DDS) of the physician
    or provider.

Timely Filing
Written notice of injury or illness upon which claim may be based should be provided to the Contract
Administrator within 30 days of the date of the commencement of the first loss for which benefits
arising out of such injury or illness may be claimed, or thereafter as is reasonably possible.
Notice given by or on behalf of the claimant to the Contract Administrator with particulars sufficient to
identify the covered person, shall be deemed to be notice. Failure to furnish notice within the time
provided in the Plan shall not invalidate any claim if it shall be shown not to have been reasonably
possible to furnish such notice and that such notice was furnished as soon as was reasonably possible.
However, when a covered person's coverage terminates for any reason, written proof of claim must be
given to the Plan within 90 days of the date of termination of coverage, provided that the Plan remains
in force. Upon termination of the Plan final claims must be received within 30 days of termination.
In no event will any claim be considered for payment of benefits that is presented more than six
months from the date that such claim was incurred.
All claims should be filed within 90 days from the date of service. Claims filed over six months from
the date of service are not eligible for benefits and will be denied.
Requests for Additional Information
Occasionally, additional information is required to complete the processing of a claim. If this occurs,
Integrity Administrators, Inc. will send the employee an inquiry indicating the information needed.
When this happens, the employee should provide Integrity Administrators, Inc. with the requested
information as quickly as possible. As soon as Integrity Administrators, Inc. receives the requested
information, the claims will continue to be processed.
To help avoid this type of delay, certain information should be included with the original claim. For
example, if another health plan is the primary plan for a claim, enclose a copy of the other plan's
explanation of benefits. If the claim involves an accidental injury, provide a brief description of the
accident, including the date, place, and circumstances.




  Lower Kuskokwim School District Employee HealthCare Plan                         page   16
                                                                      CLAIM SUBMISSION (CONTINUED)
For Claim Submission, Eligibility Verification or Benefit Information Please Contact:
                                              Integrity Administrators, Inc.
                                                      P.O. Box 13128
                                               Sacramento, CA 95813-3128
                                                  Toll-Free (800) 562-9383
                                                    Fax (916) 921-3383
Integrity Administrators, Inc. is responsible for processing all benefit claims under the Plan. To obtain
benefits, a claim must be submitted to Integrity Administrators, Inc. Integrity Administrators, Inc. will
process the claim within a reasonable time after it is received. Integrity Administrators, Inc. has the
right to secure independent medical evidence and to require such other evidence as it deems necessary
to determine available benefits.

Claims Procedures
Following is a description of how the Plan processes claims for benefits. A claim is defined as any
request for a Plan benefit, made by a claimant or by a representative of a claimant that complies with
the Plan's reasonable procedure for making benefit claims. The times listed are maximum times only.
A period of time begins at the time the claim is filed. Decisions will be made within a reasonable
period of time appropriate to the circumstances. "Days" means calendar days.
There are different kinds of claims and each one has a specific timetable for either approval, payment,
request for further information, or denial of the claim. If you have any questions regarding this
procedure, please contact the Plan Administrator.
The definitions of the types of claims are:
Urgent Care Claim
An Urgent Care Claim is any claim for medical care or treatment where using the timetable for a non-
urgent care determination could seriously jeopardize the life or health of the claimant; or the ability of
the claimant to regain maximum function; or in the opinion of the attending or consulting physician,
would subject the claimant to severe pain that could not be adequately managed without the care or
treatment that is the subject of the claim.
A physician with knowledge of the claimant's medical condition may determine if a claim is an Urgent
Care Claim. If there is no such physician, an individual acting on behalf of the Plan applying the
judgment of a prudent layperson who possesses an average knowledge of health and medicine may
make the determination.
In the case of an Urgent Care Claim, the following timetable applies:
     Notification to claimant of benefit determination:                      72 hours
     If there is insufficient information on the claim, or failure to follow
     the Plan's procedure for filing a claim:
         Notification to claimant, orally or in writing                      24 hours
         Response by claimant, orally or in writing                          48 hours
         Benefit determination, orally or in writing                         48 hours




   Lower Kuskokwim School District Employee HealthCare Plan                             page   17
                                                              CLAIM SUBMISSION (CONTINUED)

    Notification of ongoing courses of treatment:
         Reduction or termination before the end of                 72 hours
         treatment
         Determination as to extending course of                    24 hours
         treatment
If there is an adverse benefit determination on an Urgent Care Claim, a request for an expedited appeal
may be submitted orally or in writing by the claimant. All necessary information, including the Plan's
benefit determination on review, may be transmitted between the Plan and the claimant by telephone,
facsimile, or other similarly expeditious method.
Pre-Service Claim
A Pre-Service Claim is a written or oral request for benefit determination where the terms of the Plan
condition benefits, in whole or in part, on prior approval of the proposed care. This is, for example,
utilization review requirement prior to hospitalization. The following timetable applies to a pre-
service claim:

    Notification to claimant of benefit determination:              15 days
    Extension due to matters beyond the control of                  15 days
    the Plan:
    Insufficient information on the claim:
         Notification of                                            15 days
         Response by claimant                                       45 days
    Notification, orally or in writing, of failure to               5 days
    follow the Plan's procedures for filing a claim:
    Ongoing courses of treatment:
         Reduction or termination before the end of the             15 days
         treatment
         Request to extend course of treatment                      15 days
    Review of adverse benefit determination                         15 days per benefit
                                                                    appeal
Post-Service Claim
A Post-Service Claim is any claim for a Plan benefit that is not a claim involving Urgent Care or a Pre-
Service Claim; in other words, a claim that is a request for payment under the Plan for covered medical
services already received by the claimant.
In the case of a Post-Service Claim, the following timetable applies:
    Notification to claimant of benefit determination:              30 days
    Extension due to matters beyond the control of                  15 days
    the Plan:




   Lower Kuskokwim School District Employee HealthCare Plan                        page   18
                                                                CLAIM SUBMISSION (CONTINUED)

     Insufficient information on the claim:
         Notification of                                               15 days
         Response by claimant                                          45 days
     Review of adverse benefit determination:                          30 days per benefit
                                                                       appeal

Notice to Claimant of Adverse Benefit Determinations
Except with Urgent Care Claims, when the notification may be orally followed by written or electronic
notification within three days of the oral notification, the Plan Administrator shall provide written or
electronic notification of any adverse benefit determination. The notice will state, in a manner meant to
be understood by the claimant:
1. The specific reason or reasons for the adverse determination.
2. Reference to the specific Plan provisions on which the determination was based.
3. A description of any additional material or information necessary for the claimant to perfect the
   claim, and an explanation of why such material or information is necessary.
4. A description of the Plan's review procedures, incorporating any voluntary appeal procedures
   offered by the Plan, and the time limits applicable to such procedures.
5. A statement that the claimant is entitled to receive, upon request and free of charge, reasonable
   access to, and copies of, all documents, records, and other information relevant to the claim. You
   and your Plan may have other voluntary alternative dispute resolution options, such as mediation.
   One way to find out what may be available is to contact your local U.S. Department of Labor
   Office.
6. If the adverse benefit determination was based on an internal rule, guideline, protocol, or other
   similar criterion, the specific rule, guideline, protocol, or criterion will be provided free of charge.
   If this is not practical, a statement will be included that such a rule, guideline, protocol, or criterion
   was relied upon in making the adverse benefit determination and a copy will be provided free of
   charge to the claimant upon request.
7. If the adverse benefit determination is based on the medical necessity              or experimental or
   investigational treatment determination or similar exclusion or limit, an           explanation of the
   scientific or clinical judgment for the determination, applying the terms           of the Plan to the
   claimant's medical circumstances, will be provided. If this is not practical,       a statement will be
   included that such explanation will be provided free of charge, upon request.
Appeals
When a claimant receives an adverse benefit determination, the claimant has 180 days following
receipt of the notification in which to appeal the decision. A claimant may submit written comments,
documents, records, and other information relating to the claim. If the claimant so requests, he or she
will be provided, free of charge, reasonable access to, and copies of, all documents, records, and other
information relevant to the claim.
The period of time within which a benefit determination on review is required to be made shall begin
at the time an appeal is filed in accordance with the procedures of the Plan. This timing is without
regard to whether all the necessary information accompanies the filing.




   Lower Kuskokwim School District Employee HealthCare Plan                            page   19
                                                              CLAIM SUBMISSION (CONTINUED)

Appeals (continued)
A document, record, or other information shall be considered relevant to a claim if it:
1. Was relied upon in making the benefit determination;
2. Was submitted, considered, or generated in the course of making the benefit determination, without
   regard to whether it was relied upon in making the benefit determination;
3. Demonstrated compliance with the administrative processes and safeguards designed to ensure and
   to verify that benefit determinations are made in accordance with Plan documents and Plan
   provisions have been applied consistently with respect to all claimants; or
4. Constituted a statement of policy or guidance with respect to the Plan concerning the denied
   treatment option or benefit.
The review shall take into account all comments, documents, records, and other information submitted
by the claimant relating to the claim, without regard to whether such information was submitted or
considered in the initial benefit determination. The review will not afford deference to the initial
adverse benefit determination and will be conducted by a fiduciary of the Plan who is neither the
individual who made the adverse determination nor a subordinate of that individual.
If the determination was based on a medical judgment, including determinations with regard to
whether a particular treatment, drug, or other item is experimental, investigational, or not medically
necessary or appropriate, the fiduciary shall consult with a health care professional who was not
involved in the original benefit determination. This health care professional will have appropriate
training and experience in the field of medicine involved in the medical judgment. Additionally,
medical or vocational experts whose advice was obtained on behalf of the Plan in connection with the
initial determination will be identified.
Voluntary Appeals, Including Voluntary Arbitration
During voluntary dispute resolution, any statute of limitations or other defense based on timeliness is
tolled during the time any voluntary appeal is pending.
The Plan waives any right to assert that a claimant has failed to exhaust administrative remedies
because he or she did not elect to submit a benefit dispute to the voluntary appeal provided by the Plan.
A claimant may elect a voluntary appeal after exhaustion of appeals of an adverse benefit
determination as explained in the previous section entitled "Appeals." However, this voluntary appeal
may be conducted as one of the two appeals available to the claimant.
Voluntary Appeals, Including Voluntary Arbitration (continued)
The Plan will provide to the claimant, at no cost and upon request, sufficient information about the
voluntary appeal to enable the claimant to make an informed judgment about whether to submit a
benefit dispute to the voluntary level of appeal. This information will include a statement that the
decision will have no effect on the claimant's rights to any other benefits under the Plan; will list the
rules of the appeal; state the claimant's right to representation; enumerate the process for selecting the
decision maker; and give circumstances, if any, that may affect the impartiality of the decision maker.
No fees or costs will be imposed on the claimant as part of the voluntary level of appeal, and the
claimant will be told this.




   Lower Kuskokwim School District Employee HealthCare Plan                          page   20
                                                              DESCRIPTION OF MEDICAL BENEFITS
Annual Deductible
The deductible amount for each covered person is the amount of covered expense which must be
incurred in a calendar year before benefits are payable, as shown in the Summary of Medical Benefits.
A copy of all bills must be submitted to Integrity Administrators, Inc. for verification and record
keeping so benefit payment may begin as soon as possible.
Family Limit on Deductible
The maximum deductible amounts to be applied each calendar year to a covered employee and his or
her covered dependents will not be more than the maximum family limit as shown in the Summary of
Medical Benefits.
Deductible Carryover
Expenses incurred during the last three months of a calendar year that are applied toward the annual
deductible will carry forward and will be used to help satisfy the annual deductible for the following
calendar year.
Common Accident Deductible
If a single accident causes injuries to two or more family members, only one deductible will be taken for
services relating to the accident.
Co-Insurance/Out-Of-Pocket Maximum
The out-of-pocket maximum is the maximum dollar amount a participant will pay for covered Preferred
Provider facility expenses in any one benefit period, unless otherwise specified in the Summary of
Medical Benefits.
The following charges do not apply towards the out-of-pocket maximum:
1. Deductibles;
2. Non-Compliance penalties;
3. Facility services furnished outside of the PPO Network, including Non-PPO facilities' copayments
   and coinsurance, (except for care of an Emergency Medical Condition at a Non-PPO hospital
   emergency room);
4. Expenses covered at 100% by the Plan;
5. Dental, vision and hearing services;
6. Services and supplies not covered (in whole or in part) by the Plan; and
7. Outpatient mental health and chemical dependency treatment.

Covered Expenses
Covered medical expenses means the Usual, Customary and Reasonable Fee (UCR) expenses incurred
by a covered person for hospital or other medical services which are:
1. Ordered by a physician;
2. Medically necessary for the treatment of the illness or injury;
3. Not of a luxury or personal nature; and
4. Not excluded under the Medical Plan Limitations and Exclusions beginning on page 33 of this
    document.




   Lower Kuskokwim School District Employee HealthCare Plan                        page   21
Medical Expenses
The following are covered expenses under this Plan. Benefits for these covered expenses will be
payable as shown in the Summary of Medical Benefits.
1.    Acupuncture
      a) Charges for acupuncture by a physician (MD or DO) when performed in lieu of general
         anesthesia.
2.    Allergy Treatment
      a) Charges for allergy injections, testing, and serums.
3.    Ambulance/Travel Service
      a) Professional ground or air ambulance, if medically necessary; or
      b) Round trip transportation by a commercial airline or professional air ambulance from the place
          where an illness or injury occurred to the nearest hospital where professional treatment can be
          obtained, subject to the following limitations:
          i) The illness or injury must be a life endangering situation that requires immediate transfer
               to a hospital that has special facilities for treating the condition;
          ii) Surgery is needed that can not be performed locally; or
          iii) A condition exists which cannot be treated locally. In such case, transportation benefits for
               any one illness or condition in any one calendar year must be certified in writing from a
               physician and will be limited to:
               a. One visit and one follow-up visit for required therapeutic treatment which cannot be
                    provided locally; or
               b. One pre- or post-surgical visit and one trip for the actual surgical procedure which
                    cannot be provided locally.
     c) If air transportation is required, the physician must provide written certification and detailed
        medical documentation of the existing condition in advance of the trip. The Plan will determine
        how much of the transportation charges, if any, are eligible for coverage under the Plan.
     d) If the patient is a child under 17 years of age, the transportation charges of a parent or legal
        guardian accompanying the child will be allowed, if the attending physician certifies the need
        for such attendance.
     e) Transportation charges for a physician and/or registered nurse may be covered, only when
        deemed medically necessary.
     f) Travel benefits apply only to the conditions covered by the medical Plan. Dental care and vision
        care do not qualify for travel benefits.
     g) Travel pre-authorization will not be given for diagnostic purposes or second opinion diagnosis.
        Post-authorization may be given after a review of the medical documentation of such
        procedures.
     h) An "Air Travel Pre-Authorization Supplement Form" is required in all instances that do not
        involve a genuine life endangering emergency. A sample of this form can be found at the end of
        this document, and photocopied as needed.
4.    Anesthesia
      a) Charges for the cost and administration of an anesthetic.
5.    Birthing Center
      a) Charges for the birthing suite, room and board and other medically necessary services or
          supplies.




     Lower Kuskokwim School District Employee HealthCare Plan                         page   22
                                                     DESCRIPTION OF MEDICAL BENEFITS (CONTINUED)

6.    Blood or Blood Components
      a) Charges for the processing and administration of blood or blood components, but not for the
          cost of the actual blood or blood components, if replaced.
7.    Chemical Dependency
      a) Charges for chemical dependency, subject to the maximums shown on the Summary of
         Medical Benefits. Covered expenses include:
         i) Inpatient services rendered by a licensed general hospital, or a freestanding inpatient
              facility, while the covered person is confined as an inpatient in the hospital or facility;
         ii) Outpatient services rendered in an outpatient setting in a licensed general hospital, a
              physician's, psychologist's office or an alcoholism or drug treatment center;
         iii) Covered services rendered by a physician or psychologist, also includes MSW and MA as
              defined under physician section; and
         iv) Services received as an inpatient or outpatient also include medical and psychiatric
              evaluations, inpatient room and board (including detoxification), group and individual
              psychotherapy, behavior therapy, recreation therapy and family therapy for the patient and
              the covered person's family.
      b) If a combined diagnosis of chemical dependency and mental illness is given, benefits are
          limited to either the limit for chemical dependency or the limit for mental illness, depending
          on which diagnosis is the major illness. This will be determined by the Plan from a review of
          the patient's records.
8.    Chemotherapy/Radiation Therapy
      a) Charges for radiation therapy or treatment and chemotherapy.
9.    Chiropractic Care
      a) Charges for chiropractic treatment, furnished by a chiropractor practicing within the scope of
          his or her license as defined by state law.
10. Cornea Transplant
    a) Cornea transplants and all related covered services, when incurred by a covered enrollee who is
       the recipient of the transplant. This benefit includes organ and tissue procurement from a donor
       consisting of removal, surgical storage, and transportation costs incurred which are directly
       related to the donation of an organ used in a covered transplant procedure. Benefits are not
       provided for travel expenses or services, chemotherapy, supplies, drugs and aftercare for or
       relating to artificial or non-human organ implant or transplants.
11. Cosmetic Surgery
    a) Charges for cosmetic surgery, under only the following circumstances:
       i) Treatment within 24 months of an accidental bodily injury, provided that treatment begins
            within 90 days of the accident;
       ii) Reconstructive surgery which is incidental to, or follows an injury or illness, provided that
            the surgery is not performed mainly to improve the mental or emotional state of the patient;
       iii) The surgical correction of a congenital anomaly in a child which impairs bodily function; or
       iv) Reconstructive breast surgery following a mastectomy. See Reconstructive Breast Surgery
            in this section for more information.
12. Diabetic Instruction
    a) Charges for medically necessary diabetic instruction, provided by a hospital on an outpatient
       basis.




     Lower Kuskokwim School District Employee HealthCare Plan                      page   23
                                                      DESCRIPTION OF MEDICAL BENEFITS (CONTINUED)

13. Diabetic Supplies
    a) Insulin, needles and Clinitest for the treatment of diagnosed diabetes mellitus.
14. Diagnostic X-Ray and Laboratory
    a) Charges for x-rays, microscopic tests and laboratory tests;
    b) Outpatient pre-admission testing prior to a hospital admission; and
    c) Amniocentesis.
15. Durable Medical Equipment and Supplies
   a) Charges for rental of a wheelchair, hospital bed, ventilator, or other durable medical equipment
      required for therapeutic use, or the purchase of such equipment if economically justified.
16. Extended Care/Skilled Nursing Facility
    a) Charges incurred for confinement in an Extended Care/Skilled Nursing Facility, subject to the
       maximum shown in the Summary of Medical Benefits. Covered expenses include:
       i) Room and board for confinement in the facility;
       ii) Ancillary services furnished by the facility while the patient is confined therein, including
            rental of durable medical equipment which is used solely for treating an illness or injury;
       iii) Physical, occupational and speech therapy; and
       iv) Oxygen and other gas therapy;
    b) Service must begin within seven days of discharge from a hospital confinement of at least three
       days for the same or related condition(s) and must be ordered by the attending physician.
    c) No benefits will be provided for custodial care, maintenance, non-medical self-help,
       recreational, vocational or educational therapy, mental health care, chemical dependency
       rehabilitative treatment and gym or swim therapy.
17. Hearing/Audio Therapy
     a) Charges for treatment and services rendered by a registered hearing therapist under the
        supervision of a physician in an institution whose primary purpose is to provide medical care
        for an illness or injury.
18.     Hospice Care
        a) Charges relating to hospice care for a patient with a life expectancy of six months or less,
          subject to the maximums shown in the Summary of Medical Benefits. Covered hospice
          expenses are limited to:
          i) Room and board for confinement in a hospice;
          ii) Ancillary services furnished by the hospice while the patient is confined therein, including
               rental of durable medical equipment which is used solely for treating an illness or injury;
          iii) Medical supplies and medicines prescribed by the attending physician, but only to the extent
               such items are necessary for pain control and management of the condition;
          iv) Physician services and/or nursing care by a registered nurse (RN), a licensed practical nurse
               (LPN), or a licensed vocational nurse (LVN);
          v) Home health aide services;
          vi) Home care charges for home care furnished by a hospital or home health care agency under
               the direction of a hospice. Custodial care will be included if it is provided during a regular
               visit by a registered nurse, a licensed practical nurse or a home health aide;
          vii) Medical social services by licensed or trained social workers, psychologists or counselors;
          viii) Nutrition services provided by a licensed dietitian;
          ix) Respite care; and
          x) Bereavement counseling.




      Lower Kuskokwim School District Employee HealthCare Plan                         page   24
                                                   DESCRIPTION OF MEDICAL BENEFITS (CONTINUED)

19. Hospital
    a) The actual room and board expenses incurred for a ward or semi-private room;
    b) The actual expense incurred for confinement in an intensive care unit, cardiac care unit or burn
       unit;
    c) Hospital nursery and physician expenses (including circumcision) of a healthy newborn.
       Healthy newborn expenses will be paid as the newborn’s claim as long as the newborn is
       enrolled within 31 days after birth.
       i) If the newborn is ill, suffers an injury, premature birth, congenital abnormality or requires
           care other than routine care, benefits will be provided on the same basis as for any other
           eligible expense, provided that application for dependent coverage is made within 31 days of
           the birth. Benefits will be considered under the baby's own claim.
    d) Miscellaneous hospital services and supplies during hospital confinement;
    e) Outpatient hospital services and supplies; or
    f) Outpatient emergency room charges.
20. Hospitalization for Dentistry and Dental Services Covered by the Medical Plan
    a) When hospitalization is required for a dental procedure because of a concurrent hazardous
       medical condition such as serious blood dyscrasia, unstable diabetes or severe cardiovascular
       disease, charges for the hospital, anesthesiologist and physician's assistant will be allowed.
    b) Certain medical expenses associated with dental procedures may be covered by the Medical Plan.
       Such dental procedures include, but are not limited to: excision of tumors and cysts of the jaws,
       cheeks, lips, tongue, roof and floor of the mouth; emergency repair due to injury to sound natural
       teeth; surgery needed to correct accidental injuries to the jaws, cheeks, lips, tongue, floor and roof
       of the mouth; excision of benign bony growths of the jaw and hard palate; external incision and
       drainage of cellulitis; incision of sensory sinuses, salivary glands or ducts; and removal of
       impacted teeth.
    c) Charges for the dentist's services will be covered under the Dental Plan only.
    d) No charge will be covered under the Medical Plan for dental and oral surgical procedures
       involving orthodontic care of the teeth, periodontal disease and preparing the mouth for the fitting
       of or continued use of dentures.
21. Maternity
    a) Charges for maternity care, on the same basis as any illness are covered under this Plan.
    b) This benefit includes elective abortion.
    c) This benefit includes testing for infertility, but not infertility treatment.
       i) Note: Dependent children are not eligible for benefits under this provision, even for a
          complication of pregnancy.
22. Medical Supplies
    a) Charges for dressings, sutures, casts, splints, trusses, crutches, braces or other necessary medical
       supplies.
23. Mental Health
    a) Charges for mental health care, subject to the maximums shown in the Summary of Medical
       Benefits. Covered expenses include:
       i) Inpatient benefits when rendered in a licensed general hospital; or
       ii) Outpatient benefits only when services are rendered by a physician (MD or DO),
           psychiatrist (MD), psychologist (PhD), or a counselor with the degree of MSW, LCSW,
           MA, MFC, or LPC who is acting under the direct supervision of a physician (MD or DO)
           and whose expenses are billed through that physician.



   Lower Kuskokwim School District Employee HealthCare Plan                          page   25
                                                   DESCRIPTION OF MEDICAL BENEFITS (CONTINUED)
24. Occupational Therapy
    a) Charges for treatment and services rendered by a registered occupational therapist under the
       supervision of a physician in an institution whose primary purpose is to provide medical care for
       an illness or injury.
 25. Organ and/or Tissue Transplant
     a) Pre-authorization is a requirement for organ transplants. Expenses incurred in connection with
        any organ or tissue transplant listed in this provision will be covered subject to referral to and
        pre-authorization by the Plan.
     b) As soon as reasonably possible, but in no event more than ten days after a covered person's
        attending physician has indicated that he or she is a potential candidate for a transplant, the
        covered person or physician should contact the Contract Administrator for pre-authorization.
        A comprehensive treatment plan must be developed for this Plan's review, and must include
        such information as the diagnosis, the nature of the transplant, the setting of the procedure and
        any secondary medical need for the procedure, as well as a description and the estimated cost
        of the proposed treatment.
      c) All potential transplant cases will be assessed for their appropriateness through Individual
         Case Management.
      d) The term "covered expenses" with respect to transplants include the UCR expenses for
         services and supplies which are covered under this Plan, or which are specifically identified
         as covered only under this provision and which are medically necessary and appropriate to
         the transplant. Covered expenses include:
         i) Charges incurred in the evaluation, screening and candidacy determination process;
         ii) Charges incurred for organ transplantation;
         iii) Charges for organ procurement, including donor expenses not covered under the donor's
               plan of benefits;
         iv) Coverage for organ procurement from a non-living donor will be provided for costs
               involved in removing, preserving, and transporting the organ;
         v) Coverage for organ procurement from a living donor will be provided for the costs
               involved in screening the potential donor, transporting the donor to and from the site of
               the transplant, as well as for medical expenses associated with removal of the donated
               organ and the medical services provided to the donor in the interim and for follow up
               care;
         vi) If the transplant procedure is a bone marrow transplant, coverage will be provided for
               the cost involved in the removal of the patient's bone marrow (autologous) or donated
               marrow (allogenic). Coverage will also be provided for treatment storage costs of the
               marrow up to the time of reinfusion and search charges to identify an unrelated match;
         vii) Charges incurred for follow up care, including immuno-suppressant therapy; and
         viii) Charges for transportation to and from the site of the covered organ transplant procedure
               for the recipient and one other individual, or in the event that the recipient or the donor is
               a minor, two other individuals.
      e) Donor Expenses
         i) Medical expenses of the donor will be covered under this provision to the extent that
               they are not covered elsewhere under this Plan or any other benefit plan covering the
               donor. In addition, medical expense benefits for a donor who is not a participant under
               this Plan are limited to a maximum of $10,000 per transplant benefit period; or
         ii) If the donor is a covered person under this Plan but the recipient is not, no benefits are
               available, however complications and unforeseen effects from a covered person's organ
               donation will be covered as any other illness.



   Lower Kuskokwim School District Employee HealthCare Plan                           page   26
                                                 DESCRIPTION OF MEDICAL BENEFITS (CONTINUED)

26. Oxygen
    a) Charges for oxygen and other gases and their administration.
27. Parenteral Nutrition (Intravenous Feeding)
     a) Charge for hyperalimentation or total parenteral nutrition (TPN) for persons recovering from
        or preparing for surgery.
28. Physician
    a) Charges for the services of a legally qualified physician for medical care and/or surgical
       treatment including office or home visits, hospital inpatient care, hospital outpatient care,
       exams, clinical care and surgical opinion consultations.
29. Physical Therapy
    a) Charges for the treatment or services rendered by a physical therapist under supervision of a
       physician in a home setting or a facility or institution whose primary purpose is to provide
       medical care for an illness or injury, or at a freestanding duly licensed outpatient therapy
       facility, subject to the maximum shown in the Summary of Medical Benefits.
30. Pre-Admission Testing
    a) Outpatient pre-admission testing within seven days prior to a hospital admission, for
       diagnostic tests which would otherwise be performed while confined.

31. Preventive Care Services
     Preventive diagnostic services are defined as laboratory and imaging services done for
     preventive or screening purposes, based on the U.S. Preventive Services Task Force (USPSTF)
     guidelines. (These guidelines are available at
     http://www.healthcare.gov/center/regulations/prevention/taskforce.html or by contacting your
     claims administrator.)

32. Prosthetics
    a) Charges for artificial limbs or eyes to replace a missing body part. The loss of the body part or
       an organ's function, must have resulted from an accidental injury, a surgery, or a congenital
       anomaly of a child. Repair or replacement will only be covered when required due to
       physiological changes.
33. Reconstructive Breast Surgery
      a) Reconstructive breast surgery following mastectomy, including reimbursement for
         reconstruction of the breast on which a mastectomy has been performed, surgery and
         reconstruction of the other breast to produce a symmetrical appearance, and coverage
         of prostheses and physical complications during all stages of mastectomy, including
         lymphedemas, in a manner determined in consultation with the attending physician and the
         patient;
    b) Pre-authorization from the Plan is required for repair, replacement or removal of breast
         prosthesis.
34. Rehabilitation Therapy
    a) Covered services include multi-disciplinary inpatient and outpatient treatment furnished by a
        physician or licensed or certified therapist. Covered services include, but are not limited to:
        physical, speech, and occupational therapy; and
    b) Rehabilitative treatment for a congenital anomaly for a child.
35. Routine Care
         See Preventive Care Services.


 Lower Kuskokwim School District Employee HealthCare Plan                         page   27
                                                 DESCRIPTION OF MEDICAL BENEFITS (CONTINUED)
36. Second Surgical Opinion
    a) Charges for a second surgical opinion when performed by a physician not financially or
      otherwise associated with the physician recommending surgery. A third surgical opinion will be
      allowed if the first two opinions are conflicting.
37. Sleep Disorder Diagnosis and Treatment
  a) Expenses for sleep disorder diagnosis and treatment will be covered subject to approval of the
      Plan. Medical necessity must be established.
  b) Covered expenses include the reasonable and customary expenses for services and supplies that
      are medically necessary and appropriate treatment for the condition.
38. Speech Therapy
   a) Services of a licensed speech therapist under the supervision of a physician for restorative
      speech therapy for speech loss or impairment due to an illness or injury, or due to surgery
      performed on account of an illness or injury, other than a functional nervous disorder.




 Lower Kuskokwim School District Employee HealthCare Plan                      page   28
                                                    DESCRIPTION OF PRESCRIPTION BENEFITS
Prescription Drugs
Prescription Drug benefits are provided by National Pharmaceutical Services (NPS). This means that
it is mandatory that you present your benefit ID card and pay co-payments at your local participating
NPS pharmacy. Co-payments are not reimbursed by the Plan. Maintenance medications can be filled
once locally. After the initial fill, it is mandatory that you utilize mail order services.

Legend drugs are those drugs that cannot be purchased without a prescription written by a physician or
dentist.

Generic Substitution
Over 400 commonly prescribed drug products are now available in a generic form at an average cost of
50% less than the brand name products. This Plan encourages the use of generic prescription drugs. By
law, generic and brand name drugs must meet the same standards of safety, purity, strength and
effectiveness. Brand name drugs are often two to three times more expensive than generic drugs. Use
of generics with this benefit will save money for both the covered person and the Plan. We encourage
the covered person to ask his or her physician to prescribe a generic whenever possible.
Retail Prescription Program
This Plan provides benefits for prescriptions purchased at a NPS retail pharmacy.
Covered charges include drugs requiring the written prescription of a licensed physician; such drugs
must be necessary for the treatment of an illness or injury, including insulin and syringes and allergy
serums.
Mail Order Prescription Program
This Plan participates in the NPS Mail Order Program through the Integrated HMO Pharmacy
(IHMO). The Mail Order Pharmacy Benefit is provided to assist covered persons in obtaining their
maintenance medications (ongoing medications) at a lesser cost by delivering the medications via the
U.S. Mail system directly to their mailing address.

NPS can be reached at 1-800-546-5677 or on its website: www.pti-nps.com

Dispensing Limitations
Payment will be limited to no more than a 120-day advance supply or 360 unit/doses, whichever is
greater.
DAW means that the pharmacist will dispense a prescription to the member based on the doctor’s
orders. The pharmacist will dispense the prescription in an amount prescribed in the written order by
the doctor for up to 120 days.




   Lower Kuskokwim School District Employee HealthCare Plan                         page   29
                                                     NPS Prescription Plan
                                                         April 1, 2009
                                                      Group # FTA 1180
                                                       1.800.546.5677


                                                       Member goes to the
                                                      doctor and receives a
                                                          prescription



           If the prescription is for a
         medication that will be on-
          going (maintenance) then                                                If the prescription is for
           the member may fill the                                                medications that will be
        medication initially at a local                                         short term (i.e. antibiotics)
        retail pharmacy. Thereafter it                                          the member goes to local
              is mandatory that the                                              retail pharmacy to fill the
         medication be filled through                                                    medication
                   mail order.

    If member is
                                        If member has
utilizing mail order                                                         Member presents Rx and
                                      previously utilized
 for the first time                                                           Benefit ID card to the
                                       mail order their
member will send                                                             NPS network pharmacy
                                      doctor’s office can
  in the Rx along
                                       call in their Rx to
       with the                                                                 Group #FTA 1180
                                              IHMO
completed IHMO
     order form.


         http://ihmo.pti-
         nps.com/
                                                                               Network pharmacy
                                                                                  processes the
              IHMO processes the                                              prescription order and
             prescription order and                                            provides to member
               sends to member’s
                     home                                                         1.800.546.5677




               Lower Kuskokwim School District Employee HealthCare Plan                          page   30
                                                      DESCIPTION OF PRESCRIPTION BENEFITS (CONTINUED)


Covered, Not Covered and Prior Authorization Requirements
The following is a summary of covered and excluded drugs under the Prescription Program.

        RETAIL BENEFITS
        DAY SUPPLY LIMITS:                      120 DAY SUPPLY
        MEMBERS MAY OBTAIN A 4-MONTH SUPPLY OF MEDICATION AT A NPS LOCAL PHARMACY
        BUT WILL PAY 1 COPAY FOR EACH MONTH.

        MEMBER COPAY/COINSURANCE/RETAIL BENEFITS
        NON-PREFERRED BRAND                     $40 COPAY
        PREFERRED BRAND                         $20 COPAY
        GENERIC                                 $10 COPAY

        MAIL ORDER BENEFITS
        DAY SUPPLY LIMITS:                        120 DAY SUPPLY
        IT IS MANDATORY THAT MEMBERS ORDER MAINTENANCE MEDICATION THROUGH MAIL
        ORDER. HOWEVER THE INITIAL MAINTENANCE PRESCRIPTION MAY BE FILLED AT NPS LOCAL
        PHARMACY WITH RETAIL COPAY

        MEMBER COPAY/COINSURANCE/MAIL ORDER
        NON-PREFERRED BRAND                                             $0 COPAY
        PREFERRED BRAND                                                 $0 COPAY
        GENERIC                                                         $0 COPAY

        TABLET SPLITTING PROGRAM
        OVER THE COUNTER MEDICATIONS
        THE FOLLOWING MEDICATIONS CAN BE SPLIT: ACEON, LEXAPRO, LIPITOR, NORVASC,
        PRAVACHOL, TOPROL XL, ZOCOR, ZOLOFT. TABLET SPLITTING IS CUTTING A HIGHER
        STRENGTH TABLET IN HALF, RESULTING IN YOUR PRESCRIBED DOSE OF MEDICATION. FOR
        EXAMPLE, IF YOU TAKE LIPITOR 10MG, YOU COULD TALK TO YOUR DOCTOR AND
        PHARMACIST ABOUT GETTING 20MG AND SPLITTING THEM IN HALF TO GET YOUR 10MG DOSE.
        MEMBERS WHO CHOOSE TO UTILIZE THE TABLET SPLITTING PROGRAM WILL ONLY PAY ½ OF
        THEIR NORMAL COPAYMENT.

        THE PLAN WILL ALSO OFFER COVERAGE FOR PRILOSEC OTC. FOR MEMBERS THAT CHOOSE TO
        UTILIZE PRILOSEC OTC, THEY WILL ONLY PAY A GENERIC COPAYMENT.

        INCLUSIONS/EXCLUSIONS

         DRUG CATEGORY                                        COVERED    REQUIRES PRIOR     NOT
                                                                         AUTHORIZATION    COVERED
         INSULIN                                                 X
         INSULIN SUPPLIES                                        X
         TEST STRIPS                                             X
         BLOOD GLUCOSE MONITORS                                  X
         LANCETS AND LANCET DEVICES                              X
         DIABETIC SUPPLIES                                       X
         ORAL CONTRACEPTIVES                                     X
         POST COITALS                                                          X
         SURGERY SUPPLIES                                                      X
         ALLERGY AND SELF ADMIN. SYRINGES                        X
         OTHER SYRINGES                                                        X
         ENTERAL AND PARENTERAL SUPPLIES                                       X
         DURABLE HOME MEDICAL EQUIPMENT                                        X
         GI & GU OSTOMY SUPPLIES                                               X
         ASTHMA AND RESPIRATORY SUPPLIES                                       X
         SURGERY SUPPLIES INJECTABLE                                           X
         BLOOD COMPONENTS AND PRODUCTS                                         X
         BLOOD COMPONENTS INJECTABLES                                          X
         DIAGNOSTIC AGENTS                                                     X
   Lower Kuskokwim School District Employee HealthCare Plan                               page   31
                                                 DESCRIPTION OF PRESCRIPTION BENEFITS (CONTINUED)
      BLOOD AND URINE TEST STRIPS                          X
      DIAGNOSTIC AGENTS INJECTABLES                                    X
      ANESTHETIC AGENTS                                                X
      ANESTHETIC AGENTS INJECTABLES                                    X
      FERTILITY AGENTS                                                              X
      FERTILITY AGENTS INJECTABLES                                                  X
      ANOREXIC AGENTS                                           X
      MULTI-VITAMINS                                                                X
      MULTI-VITAMINS INJECTABLES                                                    X
      HOME INJECTABLES                                     X
      IMITREX, EPIPEN, GLUCAGON                            X
      OTHER HOME INJECTABLES                               X
      VACCINES, SERUMS, TOXOIDS AND ALLERGENS              X
      OTHER SPECIALTY INJECTABLES                          X
      OTHER INJECTABLES                                                X
      HEMANTINIC VITAMINS                                  X
      PRENATAL VITAMINS                                                             X
      ANTIRETROVIRALS                                      X
      ANTIRETROVIRALS INJECTABLES                          X
      ANTI-ASTHMA MEDICATIONS                              X
      BULK CHEMICALS                                                   X
      BREAST CANCER MEDICATIONS                            X
      ANTI-EMETIC MEDICATIONS                              X
      LESS EXPENSIVE DRUG AVAILABLE                                    X
      COSMETIC ALTERATION                                              X
      ACCUTANE                                             X
      COSMETIC HAIR PRODUCTS                                           X
      RETIN- PRODUCTS                                      X
      CARDIOVASCULAR MEDICATIONS                           X
      ANTI-DEPRESSANTS                                     X
      ANTI-DEPRESSANTS INJECTABLES                         X
      ORAL DIABETES MEDICATIONS                            X
      DIALYSIS SUPPLIES                                                X
      MULTI-VITAMINS WITH FLUORIDE                         X
      PEDIATRIC MULTI-VITAMINS W/ FLUORIDE                 X
      GROWTH HORMONES                                                  X
      GROWTH HORMONES INJECTABLE                                       X
      HYPNOTIC/SEDATIVE AGENTS                             X
      HYPNOTIC/SEDATIVE AGENTS INJECTABLES                 X
      MULTI-VITAMINS W/ IRON                               X
      MULTI-VITAMINS W/IRON INJECTABLES                    X
      NON-ORAL SYSTEMIC CONTRACEPTIVES                                 X
      CONTRACEPTIVE OTHER                                              X
      IMMUNOSUPPRESSANTS                                   X
      IMMUNOSUPPRESSANTS INJECTABLES                       X
      CHEMICAL DEPENDENCY AGENTS                           X
      ANTI-NARCOLEPSY/ADHD AGENTS                          X
      OSTEOPOROSIS MEDICATIONS                             X
      OTC EQUIVALENTS                                      X
      ANTI-PSYCHOTICS                                      X
      ANTI-PSYCHOTICS INJECTABLES                          X
      SMOKING CESSATION AGENTS                                         X
      ANABOLIC STEROIDS                                    X
      ANABOLIC STEROIDS INJECTABLES                                    X
      SPECIALTY ORAL MEDICATIONS                           X
      ANTI-ANXIETY AGENTS                                  X
      ANTI-ANXIETY AGENTS INJECTABLES                      X
      THYROID AGENTS                                       X
      ERECTILE DYSFUNCTION                                                          X
      ERECTILE DYSFUNCTION INJECTABLES                                              X

     NOTES: RETIN-A AND ACCUTANE PRODUCTS ARE COVERED TO AGE 25. PRIOR
     AUTHORIZATION IS REQUIRED BEGINNING AT AGE 25.



Lower Kuskokwim School District Employee HealthCare Plan                         page   32
                               MEDICAL PLAN LIMITATIONS AND EXCLUSIONS
Certain services and supplies are not covered at all under this Plan. Other items are only
covered under certain conditions. Please read this section thoroughly. Please note:
Additional Limitations and Exclusions are listed on beginning on page 40 under Dental
Plan Limitations and Exclusions and on page 42 under Vision Plan Limitations and
Exclusions.
1. Acupressure, services of a massage therapist, rolfing, reflexology or faith healing services,
   even if rendered by participating providers.
2. Adoption expenses or any expenses related to surrogate parenting.
3. Any illness or injury arising in the course of illegal activity by a covered person. This
   exclusion includes charges which occur as a result of a covered person's illegal use of
   alcohol, and charges which occur as a result of a covered person's voluntarily taking or
   being under the influence of any controlled substance, drug, hallucinogen or narcotic not
   administered on the advice of a physician. Expenses will be covered for covered persons
   other than the person using alcohol or controlled substances. Expenses will be covered for
   medically necessary chemical dependency treatment as shown in the Summary of Medical
   Benefits, unless such treatment is court-ordered or related to deferred prosecution,
   deferred or suspended sentencing or driving rights.
   This exclusion also includes care of inmates while in the custody of any state or federal
   law enforcement authority in jail or prison. Charges resulting from or occurring (1) during
   the commission of a crime by the covered person; or (2) while engaged in an illegal act,
   illegal occupation or aggravated assault.
   This exclusion does not apply if the illness or injury resulted from an act of domestic
   violence or a medical (including both physical and mental health) condition.
4. Any illness or injury arising out of an act of military service, declared or undeclared war,
   riot, insurrection, or invasion.
5. Audio services, except as specifically included. This exclusion includes charges for
   batteries or other ancillary equipment other than that obtained upon the purchase of the
   hearing aid device, charges for repairs, servicing or alterations of a hearing aid device, and
   charges for a hearing aid device more expensive than the one prescribed by the examining
   physician.
6. Benefits payable under any automobile medical, personal injury protection, automobile
   no-fault, homeowner, commercial premises coverage or similar contract or insurance
   when such contract or insurance is issued to or makes benefits available to the covered
   person. This also includes treatment of illness or injury for which a third party is liable.
7. Care, treatment or operations which are performed for cosmetic purposes, except as
   specifically included elsewhere in this document.
8. Charges for broken appointments, telephone calls, completion of forms and medical
   records.
9. Charges for travel, except as specifically included elsewhere in this document, even if
   recommended by a physician.
10. Charges for which a claim was not submitted to the Contract Administrator within six
    months of the date that the service was incurred.



   Lower Kuskokwim School District Employee HealthCare Plan                         page   33
                MEDICAL PLAN LIMITATIONS AND EXCLUSIONS (CONTINUED)
11. Charges incurred prior to the effective date of coverage under the Plan, or after coverage is
    terminated.
12. Charges incurred for which the covered person is not, in the absence of this coverage
    legally obligated to pay, or for which a charge would not ordinarily be made in the
    absence of this coverage.
13. Charges incurred outside of the United States, if the covered person traveled to such a
    location for the sole purpose of obtaining medical services, drugs or supplies.
14. Complications of non-covered treatments. This exclusion includes care, services or
    treatment required as a result of complications from a treatment not covered under the
    Plan.
15. Contraceptive devices and oral contraceptives.
16. Drugs, medicines or supplies that do not require a physician's prescription.
17. Duplication of benefits provided by any other program sponsored by Lower Kuskokwim
    School District.
18. Exercise programs. This exclusion includes exercise programs for treatment of any
    condition, except for physician-supervised cardiac rehabilitation, occupational therapy, or
    medically necessary physical therapy.
19. Experimental procedures, drugs, or research studies, or for any services or supplies not
    considered legal in the United States.
20. Eye care. This exclusion includes radial keratotomy or other eye surgery to correct
    refractive disorders when vision can be corrected through the use of glasses or contact
    lenses.
   The exclusion does not include routine eye examinations or hardware covered by the
   Vision Plan.
   This exclusion does not include aphakic patients and soft lenses or sclera shells intended
   for use as corneal bandages.
21. Foot care, including callus or corn paring or excision; toenail trimming; any manipulative
    procedure for weak or fallen arches, flat or pronated foot/feet, or foot strain, except for
    open cutting operations. Impression casting for appliances or orthotics; orthopedic shoes
    and supports.
22. Hair loss. This exclusion includes care and treatment for hair loss including wigs, hair
    transplants or any drug that promotes hair grown, whether or not prescribed by a
    physician. This exclusion does not include the purchase of a wig following chemotherapy.
23. Hospital confinement, medical or surgical services or other treatment furnished or paid for
    by or on behalf of the United States, or any state, province or other political subdivision
    unless there is an unconditional requirement to pay such charges whether or not there is
    insurance.
24. Hospital late discharge fees, telephone or television charges for the purpose of patient,
    family or physician convenience.




   Lower Kuskokwim School District Employee HealthCare Plan                         page   34
                    MEDICAL PLAN LIMITATIONS AND EXCLUSIONS (CONTINUED)
25. Hospitalization ordered solely due to the patient's age, apprehension or emotional state, or
    for the convenience of the patient, family, or physician. This exclusion includes care and
    treatment billed by a hospital for a non-emergency admission on Friday or Saturday,
    unless surgery is performed within 24 hours of admission.
26. Hypnosis or hypnotherapy.
27. Infertility. This exclusion includes any care, supplies or services for infertility. Infertility
    testing is covered by the Plan.
28. Inpatient confinement primarily for x-rays, laboratory, diagnostic study, physiotherapy,
    hydrotherapy, medical observation, convalescent or rest care, or any medical examination
    or test not connected with an active illness or injury.
29. Job training or other educational or training services.
30. Maintenance care. Unless specifically mentioned otherwise, the Plan does not provide
    benefits for services and supplies intended primarily to maintain a level of physical or
    mental function.
31. Maternity care for dependent children.
32. Mental examinations or psychological testing and evaluations not provided as an adjunct
    to treatment or diagnosis of a mental disorder (e.g. mental examinations for the purpose of
    adjudication of legal rights, administrative awards or benefits, corrections or social service
    placement or any use except as a diagnostic tool for the provision of mental health or
    chemical dependency services as provided by the Plan.)
33. Motorized transportation equipment, escalators or elevators, saunas, steam baths,
    swimming pools, blood pressure kits or humidifiers.
    This exclusion applies even if supplies of common use are obtained upon the
    recommendation of a physician.
34. Non-medical self-help such as "Outward Bound" or Wilderness Survival", recreational or
    educational therapy.
35. Occupational injury or illness, regardless if such injury or illness is covered by State
    Industrial Insurance, Workers' Compensation, any federal act or similar legislation or
    coverage.
36. Orthognathic surgery, services and supplies to augment or reduce the upper or lower jaw,
    except when necessary due to an accidental injury or cancer. This exclusion includes
    osteotomy, orthognathic surgery and maxillofacial orthopedics.
37. Personal comfort or beautification items, television or telephone use, or charges in
    connection with custodial care, education or training, or expenses actually incurred by
    other persons.
38. Private duty nursing.
39. Professional services billed by a physician or nurse who is an employee of a hospital or
    skilled nursing facility, and paid by that hospital or facility for services rendered.
40. Purchase or rental of supplies of common use such as: exercise cycles, air purifiers, air
    conditioners, water purifiers, hypoallergenic pillows, mattresses and water beds.
41. Replacement of braces or prosthetic devices, unless such replacement is made necessary
    due to physiological changes.


   Lower Kuskokwim School District Employee HealthCare Plan                            page   35
                 MEDICAL PLAN LIMITATIONS AND EXCLUSIONS (CONTINUED)
42. Reversal of sterilization.
43. Routine care, except as specifically included elsewhere in this document.
44. Self-inflicted injury or illness, whether sane or insane. This exclusion does not apply if the
    injury resulted from an act of domestic violence or a medical (including both physical and
    mental health) condition.
45. Separate charges for records or reports.
46. Services and supplies that are not necessary for treatment of an active illness or injury, are
    in excess of reasonable and customary charges, or are not recommended and approved by
    a physician.
47. Services rendered by a physician, nurse or licensed therapist who is a close relative of the
    covered person, or resides in the same household as the covered person.
48. Services, supplies or treatment not commonly and customarily recognized throughout the
    physicians profession or by the American Medical Association as generally accepted and
    medically necessary for the diagnosis and/or treatment of an active illness or injury; or
    charges for procedures, surgical or otherwise, which are specifically listed by the
    American Medical Association as having no medical value.
49. Sexual counseling.
50. Sexual disorders and/or dysfunction, including but not limited to impotency, frigidity, or
    penile implants.
    This exclusion includes all physician examinations and diagnostic laboratory or x-ray
    studies.
51. Smoking cessation programs and nicotine-containing preparations whether absorbed
    through the skin or digestive tract.
52. TMJ. This exclusion includes all treatment of temporomandibular disorders and
    craniofacial muscle disorders.
53. Travel or accommodations, except as specifically included elsewhere in this document.
54. Transsexualism, gender dysphoria or sexual reassignment or change.
55. Treatment by a provider who has not shown proficiency in the procedure, based on
    experience and satisfactory outcome in an acceptable number of cases, or is practicing
    outside the scope of the provider's license, registration, or certification as required by the
    state in which the provider is practicing.
56. Treatment in excess of the least costly service or supply which will produce an acceptable
    result, in the opinion of the Plan.
57. Treatment of a pre-existing condition during the length of the waiting period immediately
    following the enrollment date as explained on page 56 under the Pre-Existing Conditions
    section of this document.
58. Treatment that is court-ordered, or related to deferred prosecution, deferred or suspended
    sentencing, or driving rights.
59. Vitamins or nutritional supplements, except pre-natal vitamins prescribed by a physician.




   Lower Kuskokwim School District Employee HealthCare Plan                          page   36
                 MEDICAL PLAN LIMITATIONS AND EXCLUSIONS (CONTINUED)
60. Weight Control – All expenses for routine treatment or weight loss surgical procedures to
    reduce obesity or any charges for weight reduction programs at health spas or similar
    facilities. This would include but not limited to: Laparoscopic Gastric Bypass, Open
    Gastric Bypass Surgery, Gastric Banding – including Lap Band and Realize Band and
    Duodenal Switch, also known as Biliopancreatic Diversion.


Charges that are not specifically described as a covered service are excluded services. It is
further intended that benefits only be provided when such services are medically required in
the diagnosis and treatment of an illness or injury.




   Lower Kuskokwim School District Employee HealthCare Plan                      page   37
                                                              DESCRIPTION OF DENTAL BENEFITS
When dental care is necessary, the Plan covers the following Preventive, Basic and Major Services. All
benefits are subject to the Medical Plan Limitations and Exclusions. Dental benefits are also
subject to the Dental Plan Limitations and Exclusions beginning on page 40 of this document.
Please refer to the Summary of Dental Benefits for the benefit levels available, based on length of
service.
Class A - Preventive Services
The following Preventive and Basic Services are covered up to the UCR allowance.
1. Diagnostic oral exam.
2. Prophylaxis (cleaning) of the teeth.
3. Bitewing x-rays.
4. Topical application of fluoride for dependent children.
5. Sealants for dependent children.
6. Full-mouth (or panorex) x-ray, but not more than once per 24-month period.
Class B - Basic and Restorative Services
1. Extractions and alveolectomy at the time of tooth extraction.
2. Amalgam, silicate, acrylic and composite restorations (fillings). Silicate, acrylic and composite
    fillings are covered only for teeth in front of the first bicuspid.
3. Oral surgery, including periodontal surgery.
4. X-ray and lab services required for dental procedures.
5. General anesthesia required for dental procedures.
6. Palliative treatment for the relief of dental pain.
7. Drugs that require a dentist's written prescription, including medication provided at the dentist's
    office.
8. Space maintainers for dependent children age 14 or under, when used to maintain space for eruption
    of permanent teeth.
9. Habit-breaking appliances for dependent children age 14 or under.
10. Dental consultations.
11. Reline or rebase of existing dentures.
12. Endodontic services.
13. Periodontal services.
Class C - Major Services
1. Crowns, inlays and onlays necessary to restore the structure of teeth broken down by decay or injury
   when the tooth cannot be restored with filling materials such as amalgam, silicate or plastic. Crowns,
   inlays or onlays on the same teeth are covered once in a five year period.
2. Gold restorations, including inlays, onlays and foil fillings. The cost of gold restorations in excess of
   the cost for amalgam, synthetic porcelain or plastic materials will be allowed only when the teeth
   must be restored with gold.
3. Initial installation of fixed and removable bridgework (including wing attachments, inlays and
   crowns as abutments) to replace natural teeth which were extracted while the covered person was
   covered under this Plan (or another plan sponsored by the employer).
4. Replacement of existing fixed and removable bridgework, dentures or crowns; or the addition of
   teeth, inlays, onlays, crowns or gold restorations to these appliances only if:
   - The existing appliance cannot be repaired or restored to use; and

   Lower Kuskokwim School District Employee HealthCare Plan                          page   38
                                          DESCRIPTION OF DENTAL BENEFITS (CONTINUED)

     -   The patient has been covered under this Plan or another plan sponsored by Lower Kuskokwim
         School District for at least 12 months; and
     - At least five years have passed since the previous placement; or
     - The replacement
         - Replaces an existing temporary appliance that was placed after the date that the patient
              became covered, and
         - Is placed within 12 months after such temporary appliance was placed; or
              - The replacement
                  - Is needed because additional natural teeth were extracted while covered or due to an
                      accidental injury to natural teeth that occurred while covered; and
                  - Is completed within 12 months of the extraction or accidental injury.
     If a covered person has a partial denture or bridge, and a natural tooth adjacent to such denture or
     bridge is extracted while the person is covered, the addition of another tooth to the denture or bridge
     will be covered.
     No benefits will be provided for lost or stolen prosthetic devices. Charges for adjustments of
     prosthetic devices made within six months of installation are not covered.
5.   Initial installation of full or partial dentures to replace natural teeth which were extracted while the
     covered person was covered under this Plan (or another plan sponsored by the employer). Charges
     for adjustments of prosthetic devices made within six months of installation are not covered.
6.   Repairs to existing dentures or bridgework.
7.   Installation of precision attachments for removable dentures.
8.   Addition of clasp or rest to an existing partial removable denture.

If care is transferred from one dentist to another during a course of treatment, the Plan will only pay
benefits up to the amount the Plan would have paid had only one dentist rendered service.
In all cases in which there are optional techniques of treatment which will produce an acceptable result
in the opinion of the Plan, the Plan shall be liable for the amount of the treatment carrying the lesser fee.
Benefits will only be paid for claims incurred while the covered person is eligible under the Plan. A
claim is incurred at the time of treatment (for crowns and prosthetic devices the claim is incurred when
the device is seated).
The Plan has the right to request a second opinion for any treatment prior to benefit payment.




     Lower Kuskokwim School District Employee HealthCare Plan                         page   39
                                      GENERAL DENTAL LIMITATIONS AND EXCLUSIONS
There are certain items specific to the Dental Plan that are not covered. They are listed below. Please
refer to Medical Plan Limitations and Exclusions beginning on page 33 for additional Plan
Limitations and Exclusions.
1. Appliances or restorations to correct vertical dimension or occlusion, study models; night guards or
     occlusal splints. Habit-breaking appliances for dependents age 15 and over.
2. Charges for broken appointments, completion of charts, forms or patient management.
3. Charges for sealants for dependents age 15 or over.
4. Any charges covered by the medical or other portions of this Plan.
5. Rebasing or relining a denture in less than six months from the date of initial placement, or for the
     performance of such service more often than once in any 2-year period.
6. Dental implants, including any appliance and/or crown and the surgical insertion or removal of the
     implant.
7. Gold when billed separately.
8. Hospital costs or any additional fees charged by the dentist because the patient was hospitalized.
9. Myofunctional therapy.
10. Nitrous oxide (N20) or any other sedative or analgesic, except general anesthesia or intravenous
     sedation when done in conjunction with open cutting procedures.
11. Oral hygiene instruction, dietary instruction, sterilization and contamination control, plaque control
     programs, home fluoride kits, or dental care appliances.
12. Orthodontic treatment, except tooth extraction, unless specifically provided for in the Plan.
13. Periodontal probing, charting, splinting or reevaluations, when billed separately.
14. Personalization of dentures.
15. Precision or semi-precision attachments, except as specifically provided for in the Plan.
16. Replacement of lost or stolen appliances.
17. Services for cosmetic or aesthetic reasons including, but not limited to, laminates, restorations due
     to misalignment or discoloration of teeth or bleaching.
18. Services that started prior to the covered person's effective date on the Plan.
19. Services or supplies that are not necessary for the treatment of the dental condition being treated.
20. Services rendered by a dentist beyond the scope of his or her license.
21. Services which are not included in the list of covered dental services.
22. Treatment that is not generally recognized as tested and accepted dental practice by the American
    Dental Association (ADA).
23. Upper or lower jaw augmentation or reduction procedures (orthognathic surgery) regardless of
    illness or injury.
24. Services received outside of the United States or Canada, if travel was for the sole purpose of
    obtaining such services.




   Lower Kuskokwim School District Employee HealthCare Plan                         page   40
                       GENERAL DENTAL LIMITATIONS EXCLUSIONS (CONTINUED)

25. Dental Replacements
    a) A dental appliance or prosthetic device, crown, cast restoration or a fixed bridge within five
        years of the date it was last placed. This exclusion will not apply if replacement is needed due to
        an accidental injury received while covered.
    b) Initial installation of bridgework or dentures whose sole purpose is to replace natural teeth
        extracted prior to becoming covered under this Plan.
26. No benefits will be paid for duplicate bridges or dentures, or any other duplicate dental appliance,
    except if the existing denture is an immediate temporary denture and replacement by a permanent
    denture is placed within 12 months from the date of the initial installation of the temporary denture.
27. Permanent appliances that replace temporary appliances are limited to the maximum reasonable and
    customary charge for the permanent appliance.
If hospital charges are incurred in connection with a course of dental treatment, those charges will be
considered for payment as medical expenses. No coverage shall be provided for such service under the
dental expense benefit.




   Lower Kuskokwim School District Employee HealthCare Plan                          page   41
                                                              DESCRIPTION OF VISION BENEFITS
Covered Services
1. Eye examination by a covered provider, limited to once per calendar year.
2. One pair of lenses (single vision, bifocal, trifocal or lenticular) or one pair of contact lenses in lieu
   of lenses and frames, or a 12-month supply of disposable contact lenses, limited to once per
   calendar year.
3. Frames, limited to once per 24-month period.



                                                 VISION PLAN LIMITATIONS AND EXCLUSIONS
There are certain items specific to the Vision Plan that are not covered. These are listed below. Please
refer to the Medical Plan Limitations and Exclusions beginning on page 33 for additional Plan
Limitations and Exclusions.
1. Orthoptics (eye muscle exercises).
2. Vision training or subnormal vision aids.
3. Lenses ordered without a prescription.
4. Safety goggles, sunglasses or artificial eyes including the prescription type.
5. Care, treatment or supplies for which a charge was incurred before a person was covered under the
    Plan.
6. Any charges that are covered under a health plan that reimburses a greater amount than this Plan.
7. Charges for routine eye examinations required by an employer as a condition of employment.
8. Replacement lenses, frames or contact lenses, except as specifically listed as a covered vision
    service.




   Lower Kuskokwim School District Employee HealthCare Plan                          page   42
                                                              DESCRIPTION OF HEARING BENEFITS
Covered Services
1. Hearing examination by a covered provider, limited to once per 36-month period.
2. Hearing aid device prescribed as a result of such hearing examination, limited to one per 36-month
   period.
The maximum benefit available is shown in the Summary of Medical Benefits under "Audio Care."
The covered person must obtain written confirmation from the examining physician stating the individual
is suffering from a hearing loss that may be lessened by use of a hearing aid device. Such written
confirmation must be obtained within a three-month period prior to the purchase of a hearing aid.



                                               HEARING PLAN LIMITATIONS AND EXCLUSIONS
There are certain items specific to the hearing Plan that are not covered. They are listed below. Please
refer to the Medical Plan Limitations and Exclusions beginning on page 33 for additional Plan
Limitations and Exclusions.
1. Charges exceeding the maximum benefit available shown in the Summary of Medical Benefits under
   "Audio Care."
2. Replacement of a hearing aid device, for any reason, more than once in a 36-month period.
3. Batteries or other ancillary equipment, other than that obtained upon purchase of the hearing aid
   device.
4. A hearing aid device more expensive than the one prescribed by the examining physician.
5. Expenses incurred after the termination of coverage under this Plan, except when prescribed by a
   physician and ordered prior to termination was delivered within 30 days after the date of termination.
6. Any charges that exceed the maximum benefit for covered individual in any consecutive 36-month
   period.




   Lower Kuskokwim School District Employee HealthCare Plan                       page   43
                                                                       DEFINITION OF TERMS
Accident
A bodily injury sustained independently of all other causes, that is sudden, direct, unforeseen and is
exact as to time and place.
Active Employee
Any employee who is on the regular payroll of the employer and who has begun to perform the duties
of his or her job on a full-time basis.
Allowable Charge
The fee that the Contract Administrator finds is the UCR (Usual, Customary and Reasonable) charge
for medically necessary covered services. A UCR charge is a charge that is within the range of usual
charges for the same or similar services(s) billed by most providers within the geographical area in
which services are rendered, or is justified by all of the attending circumstances of a particular case.
This amount will not be more than the provider's actual charge. The patient is responsible for any
amount that exceeds the allowable charge.
Ambulatory Surgical Center
An institution or facility, either freestanding or as a part of a hospital with permanent facilities,
equipped and operated for the primary purpose of performing surgical procedures and which a patient is
admitted to and discharged from within a 24 hour period. An office maintained by a physician for the
practice of medicine or dentistry, or for the primary purpose of performing termination of pregnancy,
shall not be considered to be an Ambulatory Surgical Center.
Amendment
A formal document that changes the provisions of the Plan Document, and is duly signed by the
authorized person or persons as designated by the Plan Administrator.
Approved Treatment Plan
A written outline of proposed treatment that is submitted by the attending physician to the Contract
Administrator for review and approval.
Birthing Center
A facility, staffed by physicians, which is licensed as a Birthing Center in the jurisdiction where it is
located.
The Birthing Center must provide facilities for obstetrical delivery and short-term recovery after
delivery (no more than 24 hours); provide care under the full-time supervision of a physician and either
a registered nurse (RN) or a licensed nurse-midwife; and have a written agreement with a hospital in the
same locality for immediate acceptance of patients who develop complications or require pre-or post-
delivery confinement.
Benefit Percentage
That portion of eligible expenses to be paid by the Plan in accordance with the coverage provisions as
stated in the Plan. It is the basis used to determine any out-of-pocket expenses in excess of the annual
deductible which are to be paid by the employee.
Calendar Year
A period of 12 consecutive months that starts each January 1st at 12:01 A.M. and ends on the following
December 31st at midnight.




   Lower Kuskokwim School District Employee HealthCare Plan                        page   44
                                                              DEFINITION OF TERMS (CONTINUED)
Chemical Dependency
A condition characterized by a physiological or psychological dependence, or both, on alcohol or a
state-regulated controlled substance. It is further characterized by a frequent or intense pattern of
pathological use to the point that the user:
1. Loses self-control over the amount and circumstances of use;
2. Develops symptoms of tolerance, psychological and/or physiological withdrawal if use is reduced
    or stopped; and
3. Substantially impairs or endangers his or her health or substantially disrupts his or her social or
    economic function.
Chemical Dependency includes alcohol and drug psychoses, alcohol and drug dependence syndromes.
Chiropractic Care/Spinal Manipulation
Skeletal adjustments, manipulation or other treatment in connection with the detection and correction
by manual or mechanical means of structural imbalance or subluxation in the human body. Such
treatment is done by a chiropractor to remove nerve interference resulting from, or related to, distortion,
misalignment or subluxation of, or in, the vertebral column.
Close Relative
The spouse, mother, father, sister, brother, daughter, son, or father-in-law or mother-in-law of the
covered person.
COBRA
The Consolidated Omnibus Budged Reconciliation Act of 1985, as amended.
COBRA Beneficiary
Any former employee or dependent covered under this Plan, who is continuing participation under the
provisions of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) and its
amendments.
Community Mental Health Agency
A health care provider which is licensed as a mental health agency by a state's Department of Social
and Health Services or comparable state agency, which has in effect a plan for quality assurance, peer
review and supervision by a physician or licensed psychologist.
Complication of Pregnancy
The term "Complication of Pregnancy" means the following:
1. Direct:
    a) Hyperemesis gravidarum (pernicious vomiting of pregnancy) eclampsia of pregnancy (toxemia
        with convulsions), severe antepartum hemorrhaging due to premature separation of the placenta
        for any reason, postpartum hemorrhaging severe enough to require the transfusion of blood,
        missed abortion, or RH incompatibility requiring amniotic fluid test, analysis for intrauterine
        fetal transfusion;
    b) Cesarean section; or
    c) Spontaneous termination of pregnancy which occurs during a period of gestation in which a
        viable birth is not possible.
2. Indirect:
    a) Bodily or mental disorder whose diagnosis is distinct from pregnancy, but which is adversely
        affected by pregnancy or is caused by pregnancy, such as acute nephritis, nephrosis, cardiac
        decompensation and similar medical and surgical conditions of comparable severity; or
    b) Therapeutic abortion necessary as part of the treatment of severe bodily or mental disorder
        included in one above.
In no event shall the term "Complication of Pregnancy" include cesarean section delivery as an
alternative to vaginal delivery after the 35th week of pregnancy, false labor, occasional spotting,
physician prescribed rest, morning sickness, preeclampsia or similar conditions associated with the
   Lower Kuskokwim School District Employee HealthCare Plan                          page   45
                                           DEFINITION OF TERMS (CONTINUED)
management of a difficult pregnancy, but not constituting a classifiable distinct complication of
pregnancy.
Contract Administrator
The person or firm employed by Lower Kuskokwim School District to provide claim processing, billing
and eligibility service to Lower Kuskokwim School District in connection with the operation of the
Plan.
Cosmetic Dentistry
An unnecessary dental procedure performed solely for the improvement of a covered person's
appearance or well-being rather than for the improvement or restoration of dental function.
Cosmetic Procedure
A procedure performed solely for the improvement of a covered person's appearance or well-being
rather than for the improvement or restoration of bodily function.
Covered Person
An employee, a dependent or a participating COBRA beneficiary meeting the eligibility requirements
for coverage as specified in the Plan, and properly enrolled in the Plan.
Creditable Coverage
Most health coverage, such as coverage under a group health plan (including COBRA continuation
coverage), HMO membership, an individual health insurance policy, Medicaid or Medicare.
Creditable coverage does not include coverage consisting solely of dental or vision benefits.
Custodial Care
That type of care or service, wherever furnished and by whatever name called, which is designed
primarily to assist a covered person, whether or not totally disabled, in the activities of daily living.
Such activities include, but are not limited to: bathing, dressing, feeding, preparation of special diets,
assistance in walking or in getting in and out of bed, and supervision of medication which can normally
be self-administered.
Dental Care
Any treatment, operation procedure or service performed by a dental practitioner which is accepted as
or defined as dentistry and meets the standards of dental practice accepted by the American Dental
Association.
Dental Hygienist
a person who is licensed to practice dental hygiene and who is practicing within the scope of an
applicable license.
Dentist
A licensed Doctor of Dental Surgery (DDS) or Dental Medicine (DMD) practicing within the scope of
the applicable license or a licensed dental practitioner authorized by the license to perform the
particular dental service rendered.
Denturist
A person who is licensed to make, fit and repair dentures, and who is practicing within the scope of the
applicable license.
Deductible
A specified dollar amount of covered expenses, which must be incurred during a calendar year before
any other covered expenses can be considered for payment according to the applicable benefit
percentage.




   Lower Kuskokwim School District Employee HealthCare Plan                         page   46
                                                              DEFINITION OF TERMS (CONTINUED)
Dependent
1. The employee's lawful spouse, unless legally separated;
2. Same-sex partner as defined and documented by 2 AAC 38.010 – 2 AAC 38.100.
3. The unmarried natural children, children of same-sex partner (as defined and documented by 2
   AAC 38.010 – 2 AAC 38.100), stepchildren who reside with the employee, adopted children and
   children for whom the employee is the legal guardian or the employee is under a Qualified Child
   Medical Support Order to provide health coverage for a child.
   a) Eligible dependent children must be reliant upon the employee for primary support and
       maintenance, unless under a court order.
   b) Dependent children, including children of same-sex partner (as defined and documented by 2
       AAC 38.010 – 2 AAC 38.100), must be under 26 years of age (i.e., through age 25). The child
       need not: (1) reside with the Employee or any other person, (2) be a student, (3) be a tax-code
       dependent of the Employee or financially dependent on the Employee or any other person, (4)
       be unmarried, or (5) be unemployed. Coverage does not have to be offered to a child who has
       access to coverage under his own employer-sponsored health plan.

   NOTE: Because this is a grandfathered plan, the availability of coverage under another parent’s
   plan does not permit the grandfathered plan to deny coverage to the adult child. In that case, both
   plans must permit coverage. This exception expires in 2014.

   c) Or an unmarried child age 26 or older who is incapable of self-sustaining employment and
      dependent upon the employee for support due to a mental or physical illness or handicap. Proof
      of disability must be submitted to the Plan within 31 days of the date the child becomes 26 or
      the date the coverage would have terminated due to the child's age.
Durable Medical Equipment (DME)
Equipment which is:
1. Able to withstand repeated use;
2. Primarily and customarily used to serve a medical purpose or not generally useful to a person in the
   absence of illness or injury.
Election Period
The 60-day period during which a Qualified Beneficiary who would lose coverage as a result of a
Qualifying Event may elect COBRA Continuation Coverage. This 60-day period begins no later than
the date of termination of coverage as a result of a Qualifying Event and ends not earlier than 60 days
after the later of such date of termination of coverage or the receipt of notice of the right to elect
COBRA Continuation Coverage under this Plan.
Elective Surgical Procedure/Elective Surgery
A non-emergency surgical procedure which is scheduled at the covered person's convenience without
endangering the covered person's life or without causing serious impairment to the covered person's
bodily functions.
Emergency Medical Condition
A sudden, unexpected acute medical condition that, without medical care within 48 hours of onset,
could result in death or cause serious impairment to bodily functions.

         Emergency Services – If a Covered Person requires care for an Emergency Medical Condition
         and must use the services of a Non-Network provider, any such expenses will be paid at the
         Network benefit levels until the patient’s condition has been stabilized to the point that he
         could be transferred to Network-provider care. At that point, the Covered Person must be
         transferred to Network-provider care or Non-Network benefit levels will commence.


   Lower Kuskokwim School District Employee HealthCare Plan                          page   47
                                                              DEFINITION OF TERMS (CONTINUED)
Employee
Any person who is rendering personal services on a full-time basis to Lower Kuskokwim School
District for compensation, please reference the Enrollment & Eligibility section of this document for
work requirements for eligibility.
Employer
Lower Kuskokwim School District
Enrollment Date
The employee's date of hire, or in the case of employees and/or dependents who are enrolled subsequent
to the original eligibility date, the first day of the waiting period or the actual date benefits begin,
whichever is earlier.
Experimental or Investigative
Services, supplies, care and treatment which does not constitute accepted medical practice properly
within the range of appropriate medical practice under the standards of the case and by the standards of
a reasonably substantial, qualified, responsible, relevant segment of the medical community or
government oversight agencies at the time services were rendered.
The Plan Administrator must make an independent evaluation of the experimental/non-experimental
standings of specific technologies. The Plan Administrator shall be guided by a reasonable
interpretation of Plan provisions. The decisions shall be made in good faith and rendered following a
detailed factual background investigation of the claim and the proposed treatment. The decision of the
Plan Administrator will be final and binding on the Plan. The Plan Administrator will be guided by the
following principles:
1. If the drug or device cannot be lawfully marketed without approval of the U.S. Food and Drug
    Administration and approval for marketing has not been given at the time the drug or device is
    furnished; or
2. If the drug, device, medical treatment or procedure, or the patient informed consent document
    utilized with the drug, device, treatment or procedure, was reviewed and approved by the treating
    facility's Institutional Review Board or other body serving a similar function, or if federal law
    requires such review or approval; or
3. If reliable evidence shows that the drug, device, medical treatment or procedure is the subject of
    on-going phase I or phase II clinical trials, is the research, experimental, study or investigational
    arm of on-going phase III clinical trials, or is otherwise under study to determine its maximum
    tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means
    of treatment or diagnosis; or
4. If reliable evidence shows that the prevailing opinion among experts regarding the drug, device,
    medical treatment or procedure is that further studies or clinical trials are necessary to determine its
    maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a
    standard means of treatment or diagnosis.
Drugs are considered experimental if they are not commercially available for purchase and/or they are
not approved by the Food and Drug Administration for general use.
Family Unit
A covered employee and persons covered under this Plan as such covered employee's dependents.
Family Status Change
A status change brought about by the occurrence of one or more of the following events:
1. Birth or adoption of a child;
2. Divorce;
3. Marriage;
4. Change in same-sex partner status under 2 AAC 38.010 – 2 AAC 38.100.


   Lower Kuskokwim School District Employee HealthCare Plan                          page   48
                                             DEFINITION OF TERMS (CONTINUED)
5. Death of a spouse or same-sex partner as defined and documented by 2 AAC 38.010 – 2 AAC
38.100; involuntary reduction in employment hours; involuntary loss of a spouse's employment due to
layoff; or employee termination.
Fiduciary
Lower Kuskokwim School District, the board of directors, or the Plan Administrator, but only with
respect to the specific responsibilities of each with respect to the administration of the Plan.
Freestanding Chemical Dependency Treatment Center or Residential Treatment Facility
A facility that meets the following requirements:
1. It is accredited by the Joint Commission on Accreditation of Hospitals or is licensed by the
   appropriate state licensing authority as a Chemical Dependency Treatment Center;
2. It is operated chiefly for the treatment of Chemical Dependency;
3. It provides only treatment which is directly under the supervision of a physician; and
4. It provides 24-hour nursing service by licensed nurses.
Full-Time Employment
A basis whereby an employee is employed by Lower Kuskokwim School District for a minimum of 30
hours per week. Such work may occur either at the usual place of business of Lower Kuskokwim
School District or at a location to which the business of Lower Kuskokwim School District requires the
employee to travel, and for which he or she received regular earnings from Lower Kuskokwim School
District.
Generic Drug
A prescription drug which has the equivalency of the brand name drug with the same use and metabolic
disintegration. This Plan will consider a generic drug a Food and Drug Administration approved generic
pharmaceutical dispensed according to the professional standards of a licensed pharmacist and clearly
designated by the pharmacist as being generic.
Home Health Care Agency
A public or private agency or organization that specializes in providing medical care and treatment in
the home. Such a provider must meet all of the following conditions:
1. It is primarily engaged in and licensed by the Community Health Accreditation Program (CHAP) to
    provide skilled nursing services and other therapeutic services;
2. It has policies established by a professional group associated with the agency or organization. This
    professional group must include at least one physician and at least one registered nurse (RN) to
    govern the services provided and it must provide for full-time supervision of such services by a
    physician or registered nurse;
3. It maintains a complete medical record on each individual; and
4. It has a full-time administrator.
Home Health Care Plan
A program for care and treatment of the covered person established and approved by the covered
person's attending physician, which is in lieu of continued confinement as an inpatient in a hospital in
the absence of the services and supplies provided as part of the home health care plan.
Home Health Care Services and Supplies
Part-time or intermittent nursing care by or under the supervision of a registered nurse; part-time or
intermittent home health aide services provided through a Home Health Care Agency (this does not
include general housekeeping services); physical, occupational and speech therapy; medical supplies;
and laboratory services by or on behalf of the hospital.




   Lower Kuskokwim School District Employee HealthCare Plan                       page   49
                                                              DEFINITION OF TERMS (CONTINUED)
Hospice Agency
An organization whose main function is to provide hospice care services and supplies, which is licensed
by the state in which it is located, if such licensing is required.
Hospice Care
A health care program providing a coordinated set of services rendered at home, in outpatient settings
or in institutional setting for covered persons suffering from a condition that has a terminal prognosis. A
hospice must have an interdisciplinary group of personnel which includes at least one physician and one
registered nurse, and it must maintain central clinical records on all patients. A hospice must meet the
standards of the National Hospice Organization (NHO) and applicable state licensing requirements.
Hospice Care Plan
A plan of terminal patient care that is established and conducted by a hospice agency and supervised by
a physician.
Hospital
An accredited institution which is approved as a hospital by the Joint Commission on the Accreditation
of Health Care Organizations or the American Osteopathic Association, and which meets all of the
following criteria:
1. It is primarily engaged in providing, for compensation from its patients and on an inpatient basis,
    diagnostic and therapeutic facilities for the surgical and medical diagnosis, treatment, and care of
    injured and sick persons by or under the supervision of a staff of physicians. If primarily a facility
    for the treatment of mental health conditions, or chemical dependency, such facility must have a
    bona fide arrangement by contract or otherwise with a hospital to perform such surgical procedures
    as may be required;
2. It continuously provides 24 hour per day nursing service by registered nurses under the supervision
    of physicians; and
3. It is not, other than incidentally a place for rest, the aged, a nursing home, a hotel or the like.
Illness
A bodily disorder, disease, physical illness, or psychiatric disorder of a covered person.
Incurred Date
The incurred date for purposes of determining eligible expenses is as follows:
1. For dental appliances or changes to dental appliances, the date in which the appliance is seated;
2. For a crown, bridge or a cast restoration on the date it is seated;
3. For root canal therapy, the date in which the pulp chamber is opened for therapy; and
4. For all other dental charges, the date the service or procedure is performed or the supplies are
   furnished.
Incurred Expenses
The cost of those services and supplies rendered to a covered person. Such expenses shall be considered
to have been incurred at the time or date the service or supply is actually provided.
Injury
A condition caused by accidental means which results in damage to the covered person's body from an
external force.
Inpatient
Confinement as a registered bed patient in a hospital, skilled nursing facility, hospice, or freestanding
chemical dependency treatment center.
Late Enrollment (Late Enrollee)
An employee or dependent who waives coverage and later wants to enroll but does not qualify for the
Special Enrollment Rights described in the Enrollment and Eligibility section of this document. Late

   Lower Kuskokwim School District Employee HealthCare Plan                          page    50
                                                DEFINITION OF TERMS (CONTINUED)
enrollees may apply for benefits only during the Open Enrollment Period, and will have an 18-month
waiting period for coverage of pre-existing conditions.
Lifetime
For the purposes of this Plan document, lifetime is understood to mean while a person is covered under
this Plan. Under no circumstances does lifetime mean during the entire lifetime of the covered person.
Medically Necessary
Care and treatment that is recommended or approved by a physician; is consistent with the patient's
condition or accepted standards of good medical practice; is medically proven to be effective treatment
of the condition; is not performed mainly for the convenience of the patient or provider of medical
services; is not conducted for research purposes; and is the most appropriate level of services which can
be safely provided to the patient.
All of these criteria must be met; merely because a physician recommends or approves certain care does
not mean that it is medically necessary.
The Plan Administrator has the discretionary authority to decide whether care or treatment is medically
necessary.
Medicare/Medicare Benefits
All benefits under Parts A and/or B of Title XVIII of the Social Security Act of 1965, as amended.
Mental Health Care/Treatment
Treatment for mental health disorders or conditions, as accepted by the general psychiatric community.
Midwife
A licensed professional person deemed as a midwife by state law, who assists in the delivery of
newborns.
Newborn Nursery Care
The hospital charge for the room and board of a newborn child while the mother is hospital confined
due to delivery. Healthy newborn nursery care extends for a maximum of five days.
Non-Emergency Hospital Admission
A hospital admission (including normal childbirth) which may be scheduled at the convenience of a
person without endangering such person's life or without causing serious impairment to that person's
bodily functions.
Nurse
An individual who has received specialized nursing training and is authorized to use the designation
"RN" (Registered Nurse) or "LPN" (Licensed Practical Nurse) and is duly licensed by the state or
regulatory agency responsible for such license in the state in which the individual performs the nursing
services.
Occupational Therapy
A program of care which focuses on the physical, cognitive and perceptual disabilities that influence
the patient's ability to perform functional tasks. The therapist evaluates the patient's ability to use his or
her fingers and hands, (fine motor skills), perceptual skills, cognitive functioning and eye-hand
coordination. Therapy sessions may involve physical movement exercises. Functional tasks may be
used; the therapist may also perform splinting of the patient's arms or hands and may provide the patient
with special equipment. Therapy that is intended to address primarily vocational rehabilitation issues
(i.e. return to work skills) will not be considered covered services under this Plan.
Outpatient
Medical services furnished while not confined as a registered bed patient in a hospital, skilled nursing
facility or hospice.
Out-of-Pocket Maximum
   Lower Kuskokwim School District Employee HealthCare Plan                            page   51
                                               DEFINITION OF TERMS (CONTINUED)
The maximum dollar amount a participant will pay for covered medical expenses in any one benefit
period, unless otherwise specified in the Summary of Medical Benefits.
Physical Therapy
A plan of care provided to return a patient to the highest level of motor functioning possible. The
physical therapist extensively evaluates the patient's muscle tone, movement, balance, endurance,
ability to ambulate, ability to plan motor movements, strength and coordination. If the patient requires
special equipment (such as a wheelchair, walker or splint) the therapist determines the correct size and
type of equipment for the specific patient. The therapist constructs a program of exercises and
movements to maximize the patient's motor skills.
Physician
A legally licensed medical or dental doctor or surgeon, chiropractor, osteopath, podiatrist, certified
consulting psychologist or psychiatrist to the extent that same, within the scope of their license, are
permitted to perform services provided in this Plan. The term "Physician" also includes a certified
licensed nurse midwife, a nurse practitioner and a social worker with the degree "MSW".
Physician Office Visit
All services performed and billed by a physician on the same date as the actual office visit.
Plan
The Plan Document and all amendments and/or riders or waivers now or hereafter attached, signed by
the Plan Sponsor.
Plan Administrator
Lower Kuskokwim School District, which is responsible for the day-to-day functions and arrangements
of the Plan. The Plan Administrator may employ persons or firms to process claims and perform other
Plan-connected services.
Plan Year
An annual period beginning on July 1 and ending June 30 or upon termination of the Plan, whichever
occurs earlier.
Pre-Admission Testing
The charges made by a hospital for services rendered to a covered person on an outpatient basis which
are medically necessary prior to a scheduled inpatient confinement at the same facility.
Pre-Existing Condition
Any injury, illness or related condition of a covered person for which the covered person received
medical care, advice, diagnosis or treatment or has taken prescribed drugs or medicines within the six
consecutive month period preceding the covered person's enrollment date.
The first $1,000 in benefit payment for a pre-existing condition is not limited by this Plan. Charges for
which the benefit payment will exceed $1,000 for pre-existing conditions are not payable unless
incurred 12 consecutive months after the person's enrollment date; this time may be offset if the person
has creditable coverage from a previous plan.
Genetic information is not a "condition" for the purpose of determining pre-existing conditions. The
pre-existing condition limitation does not apply to pregnancy, to a newborn child who is covered under
this Plan within 31 days of birth, or to a child who is adopted or placed for adoption before attaining
age 18 and who, as of the last day of the 31-day period beginning on the date of the adoption or
placement for adoption, is covered under this Plan. A pre-existing condition exclusion may apply to
coverage before the date of the adoption or placement for adoption.
The prohibition on pre-existing condition exclusion for newborn, adopted, or pre-adopted children does
not apply to an individual after the end of the first 63-day period during all of which the individual was
not covered under any creditable coverage.

   Lower Kuskokwim School District Employee HealthCare Plan                         page   52
                                                              DEFINITION OF TERMS (CONTINUED)
Pregnancy
The condition of being pregnant and all conditions and/or complications resulting therefrom. Pregnancy
is covered the same as any other illness for employees and dependent spouses.
Prescription Drug
A Food and Drug Administration-approved drug or medicine which, under Federal law, is required to
bear the legend: "Caution: federal law prohibits dispensing without prescription"; injectable insulin;
hypodermic needles or syringes, but only when dispensed upon a written prescription of a licensed
physician. Such drug must be medically necessary in the treatment of a covered illness or injury.
Psychiatric (Mental Health) Treatment Facility
An administratively distinct governmental, public, private or independent unit or part of such unit that
provides psychiatric services and care; such facility is at all times supervised by a staff of physicians;
provides at all times skilled nursing care by licensed nurses who are directed by a full-time registered
nurse (RN); prepares and maintains a written plan of treatment for each patient based on medical,
psychological and social needs which is supervised by a physician, and meets appropriate licensing
standards.
Qualified Beneficiary (COBRA)
An individual who, on the day before a Qualifying Event, is a covered person under this Plan.
Qualified Medical Child Support Order
A judgment, order or decree (including approval of a divorce settlement agreement) related to child
support, alimony, or the division of marital property, issued pursuant to state law (including certain
state Medicaid laws). Agreements made by the parties but not formally approved by a court are not
acceptable.
Qualifying Event (COBRA)
Any of the following events which result in the loss of coverage of a Qualified Beneficiary:
1. The death of the covered employee;
2. The termination (except by reason of such covered employees gross misconduct) or reduction in
   hours of the covered employee's employment;
3. The divorce or legal separation of the covered employee from such covered employee's spouse or
   the ineligibility of same-sex partner status as defined and documented by 2 AAC 38.010 – 2 AAC
   38.100;
4. The covered employee becoming entitled to benefits under Title XVIII of the Social Security Act
   (Medicare);
5. A dependent child, including children of a same-sex partner (as defined and documented by 2 AAC
   38.010 – 2 AAC 38.100), ceasing to be a dependent child under the terms of this Plan;
6. A child born to the covered member or who is placed for adoption with the covered member during
   a period of COBRA Continuation Coverage is also a Qualified Beneficiary; and
7. Lower Kuskokwim School District filing for Chapter 11 reorganization.
Recipient (Organ and/or Tissue Transplant)
The person who receives an organ transplant from the organ donor. The recipient must be a covered
employee or covered dependent under the provisions of the Plan. Only those organ transplants not
considered experimental in nature and specifically covered herein are eligible for coverage under this
Plan.

Rescission of Coverage
The Plan may not rescind an individual’s coverage under the Plan (e.g., cancelling coverage after a
Covered Person has submitted a claim). However, the Plan may rescind coverage if a Covered Person
commits fraud or makes an intentional misrepresentation of a material fact.
Rehabilitation Facility
   Lower Kuskokwim School District Employee HealthCare Plan                          page   53
                                                   DEFINITION OF TERMS (CONTINUED)
A legally operating institution or distinct part of an institution which has a transfer agreement with one
or more hospitals, and which is primarily engaged in providing comprehensive multi-disciplinary
physical restorative services, hospital and rehabilitative inpatient care and is duly licensed by the
appropriate government agency to provide such services. It does not include institutions which provide
only minimal care, custodial care, ambulatory or part-time care services, or an institution which
primarily provides treatment of a mental disorder, chemical dependency or tuberculosis except if such
facility is licensed, certified or approved as a rehabilitation facility for the treatment of medical
conditions, drug addiction or alcoholism in the jurisdiction where it is located, or is accredited as such a
facility by the Joint Commission, the Accreditation of Health Care Organizations or the Commission
for the Accreditation on Rehabilitation Facilities.
Second Surgical Opinion
The second opinion of a physician or surgeon to determine the medical advisability of a person
undergoing a planned surgical procedure. If the second opinion does not confirm that the planned
surgical procedure is medically advisable, then second surgical opinion shall also mean and include a
third surgical opinion.
Skilled Nursing Facility
An institution or distinct part thereof which meets all the following conditions:
1. It is approved by the Joint Commission on the Accreditation of Health Care Organizations
   (JCAHO) and or Medicare;
2. It provides nursing services by licensed staff under the 24-hour per day direction of a registered
   nurse;
3. It maintains a complete medical record for each individual patient;
4. Skilled nursing or skilled rehabilitation services are provided on a daily basis by appropriately
   licensed personnel; and
5. The facility is not a place for rest, the aged, drug addicts, alcoholics, the mentally incapacitated or
   for the care of mental disorder, nor is the facility meant for custodial care that is provided for the
   primary purpose of assisting an individual in meeting the basic activities of daily living.
Speech Therapy/Pathology
A program of care which evaluates the patient's motor-speech skills, expressive and receptive language
skills, writing and reading skills, and determines if the patient requires an extensive hearing evaluation
by an audiologist. The therapist also evaluates the patient's cognitive functioning, as well as his or her
social interaction skill such as the ability to maintain eye contact and initiate conversation. Therapy
may also involve developing the patient's speech, listening and conversational skills, and higher-level
cognitive skills such as understanding abstract thought, making decisions, sequencing, etc. Therapy
may be considered medically appropriate even for patients who do not have apparent speech problems,
but who do have deficits in higher-level language functioning as a result of trauma or identifiable
organic disease process.
Substance Abuse/Chemical Dependency
The physiological and psychological addiction to a controlled drug or substance, or to alcohol.
Dependence upon tobacco, nicotine, and caffeine are not included in this definition.
Substance Abuse Treatment Facility
An institution which provides a program for diagnosis, evaluation and effective treatment of
alcoholism, and/or drug use or abuse, provides detoxification services, infirmary level medical services
or arranges at a hospital in the area for any other medical services that may be required; is at all times
supervised by a staff of physicians; provides at all times skilled nursing care by licensed nurses who are
directed by a full-time registered nurse (RN); and prepares and maintains a written plan of treatment for
each patient based on medical, psychological and social needs which are supervised by a physician, and
meets licensing standards.
Surgical Procedure
   Lower Kuskokwim School District Employee HealthCare Plan                          page   54
                                                  DEFINITION OF TERMS (CONTINUED)
"Surgical Procedure" includes, but is not limited to, cutting, suturing, treating burns, reduction of
fractures, reducing dislocations, manipulating a joint under general anesthesia, electocauterizing,
paracentesis, applying plaster casts, administering pneumothorax, endoscopy, injecting sclerosing
solution, arthroscopic procedures or urethral dilation.
Temporomandibular Joint (TMJ) Disorder
Jaw joint disorders including conditions of structures linking the jaw bone, skull, the complex of
muscles, nerves and other tissues related to the Temporomandibular Joint. Treatment of TMJ is not
covered by this Plan.
Total Disability (Totally Disabled)
A physical state of a covered person resulting from an injury or illness which wholly prevents:
1. In the case of an employee, from engaging in any and all business or occupation and from
   performing any and all work for compensation or profit; or
2. In the case of a dependent, a COBRA Beneficiary or a retiree, from performing the normal activities
   of a person for that age and sex in good health.
Usual, Customary and Reasonable Fee (UCR)
The lesser of:
1. The usual fee - the charge most frequently made for the covered services or supplies by a physician,
   or hospital;
2. The customary fee - the charge made for covered services or supplies by those of similar
   professional standing in the same geographic area; or
3. The reasonable fee - the charge determined by considering the complexity involved, the degree of
   professional skill required and other pertinent factors, if (1) and (2) above cannot be easily
   determined.
Visit
Each session of treatment, consultation, therapy or related service given by a health care provider.
Waiting Period
The period of time which a full-time employee must satisfy before becoming eligible for coverage
under this Plan.




   Lower Kuskokwim School District Employee HealthCare Plan                         page   55
                                                                PRE-EXISTING CONDITIONS
Pre-Existing Conditions
A pre-existing condition is any injury, illness or related condition of a covered person for which the
covered person received medical care, advice, diagnosis or treatment or has taken prescribed drugs or
medicines within the six consecutive month period preceding the covered person's enrollment date.
The first $1,000 in benefit payment for a pre-existing condition is not limited by this Plan. Charges for
which the benefit payment will exceed $1,000 for pre-existing conditions are not payable unless
incurred 12 consecutive months after the person's enrollment date; this time may be offset if the person
has creditable coverage from a previous plan.
Genetic information is not a "condition" for the purpose of determining pre-existing conditions. The
pre-existing condition limitation does not apply to pregnancy, to a newborn child who is covered under
this Plan within 31 days of birth, or to a child who is adopted or placed for adoption before attaining
age 18 and who, as of the last day of the 31-day period beginning on the date of the adoption or
placement for adoption, is covered under this Plan. A pre-existing condition exclusion may apply to
coverage before the date of the adoption or placement for adoption.
The prohibition on pre-existing condition exclusion for newborn, adopted, or pre-adopted children does
not apply to an individual after the end of the first 63-day period during all of which the individual was
not covered under any creditable coverage.
Coverage Under a Qualifying Prior Plan (HIPAA)
Prior periods of coverage may shorten or eliminate the 12-month pre-existing condition waiting period.
Credit will be given for all days on which a covered person had qualifying health care coverage prior to
joining this Plan. Days of prior coverage are "credited" by reducing, day-for-day, the 12-month pre-
existing condition waiting period under this Plan. More specifically, the Plan's 12-month pre-existing
condition waiting period will be shortened one day for each day that a covered person had "creditable
coverage" under another health plan, provided that there is not a 63-day lapse (or longer) in coverage
immediately prior to the enrollment date on this Plan. Creditable coverage includes coverage under a
group health plan, individual health insurance coverage, a state health benefits risk pool, Medicare,
Medicaid, and certain other coverage. Coverage that a person had as a dependent (e.g., under a spouse's
plan) will count for this purpose.
In order for the 12-month pre-existing condition waiting period to be shortened as described, the
covered person must show that he or she had prior creditable coverage under another group health plan,
a health insurance policy, a state health benefits risk pool, Medicare, Medicaid, etc. To demonstrate that
he or she had creditable coverage, the covered person should provide a "Certificate of Creditable
Coverage" from the prior plan. Most group health plans, health insurers and HMOs are required to
provide these certificates upon request. The certificate will tell how long the person had coverage under
the prior plan, when it ended, and any waiting period satisfied.
See following page for an example.




   Lower Kuskokwim School District Employee HealthCare Plan                         page   56
                                                     PRE-EXISTING CONDITIONS (CONTINUED)

An Example
 Here's an example that shows how the pre-existing condition waiting period works: This
 Plan contains a 12-month pre-existing condition waiting period, but it also contains the
 crediting rule described previously. Assume that John terminated his employment with
 his employer (OLDCO) after being covered under OLDCO's group health plan for five
 months. Assume that John's OLDCO health coverage ceased immediately upon his
 termination, that he did not elect COBRA, and that he never had any other health
 coverage. Assume further that exactly 60 days later, John was hired by Lower
 Kuskokwim School District into a benefits-eligible job, and, after satisfying this Plan's
 eligibility waiting period, enrolled in the Plan.
 Applying the rules described previously, there are four key concepts to understand in this
 example: (1) John gets credit for his prior coverage because he did not have a 63-day
 lapse in coverage prior to his hire date, which is the first day of the waiting period for
 enrollment in this Plan (the waiting period to get into this Plan does not count as a lapse
 in coverage); (2) the 12-month pre-existing condition waiting period in this Plan is
 shortened to seven months because John gets credit for his prior five months of coverage;
 (3) the remaining seven-month pre-existing condition waiting period begins to run on his
 hire date, which is the first day of the waiting period for enrollment in the Plan, so when
 he becomes covered (after satisfying his eligibility waiting period), there's a shorter pre-
 existing condition waiting period left; and (4) the only coverage that can be excluded
 during the remaining pre-existing condition waiting period is coverage for benefits which
 exceed $1,000 for conditions (except for pregnancy) for which medical advice, diagnosis,
 care or treatment was received within the six-month period ending on his hire date, which
 is the first day of the waiting period for enrollment in this Plan.




  Lower Kuskokwim School District Employee HealthCare Plan                         page   57
                                                              ENROLLMENT AND ELIGIBILITY
Eligibility
Coverage provided under the Lower Kuskokwim School District Benefit Plan for employees and their
dependents shall be in accordance with the eligibility, effective date and termination provision as
stated.
Eligible Classes of Employees
To be eligible for coverage under this Plan an employee must meet the following criteria:
All full-time permanent employees of Lower Kuskokwim School District in the following six
divisions:
1. Classified employees in the Lower Kuskokwim Educational Support Personnel Association
    bargaining unit with a regularly assigned work week of 30 or more hours;
2. Certificated employees in the Lower Kuskokwim Education Association bargaining unit;
3. Certificated administrators in the Lower Kuskokwim Administrative bargaining unit;
4. Classified employees with a regularly assigned work week of 30 or more hours, who are not
    covered by any negotiated agreement;
5. Certificated administrators who are not covered by any negotiated agreement; and
6. Rehired employees who were previously retired must be provided same coverage eligibility as a
    new hire per the revised unified law of the State of Alaska, AS.14.20.135.
Eligibility Requirements for Employee Coverage
1. Classified employees in the Lower Kuskokwim Educational Support Personnel Association
    bargaining unit: The negotiated agreement entitles such employees to participate in this Plan,
    provided that their regularly assigned work week is 30 or more hours. Such employees are eligible
    to participate in the Plan on the first day of the first full monthly pay period after completion of the
    review period.
2. Certificated employees in the Lower Kuskokwim Education Association bargaining unit: These
    employees are generally the District's classroom teachers. Such employees are eligible to
    participate in the Plan on the first paid contract day on which the teacher has physically reported to
    work.
3. Certificated administrators in the Lower Kuskokwim Administrative bargaining unit: The
    negotiated agreement defines these employees as Site Administrators and Vice-Principals. The
    practice of the District is that such employees are eligible to participate in the Plan on the first paid
    contract day on which the employee has physically reported to work.
4. Classified employees with a regularly assigned work week of 30 or more hours, who are not
    covered by any negotiated agreement. This group of employees is generally managerial and
    supervisory. Such employees are eligible to participate in the Plan on the first day of the first full
    monthly pay period after completion of the review period.
5. Certificated administrators who are not covered by any negotiated agreement: This group of
    employees includes Directors, Assistant Superintendents, and the Superintendent. Such employees
    are eligible to participate in the Plan on the first paid contract day on which the employee has
    physically reported to work.
6. Rehired employees who were previously retired will be required to meet the eligibility
    requirements of their division stated above.
Enrollment Requirements
An employee has 31 days from the eligibility date to make application for enrollment to the Plan to be
eligible for coverage under the Plan. If the employee wishes to cover dependents, he or she must enroll
them at that time. If the employee does not have eligible dependents at the time of initial enrollment,

   Lower Kuskokwim School District Employee HealthCare Plan                            page   58
                                    ENROLLMENT AND ELIGIBILITY (CONTINUED)
but acquires eligible dependents at a later date, he or she must enroll them within 31 days of the date
he or she acquires them.
Waiver of Coverage
If the employee declines enrollment for self or dependents, he or she must sign a Waiver of Coverage.
The Waiver of Coverage states that coverage under another group health plan or other health insurance
is the reason for declining enrollment, and the employee is asked to identify that coverage. If the
Waiver of Coverage is not completed and signed, neither the employee nor his or her dependents will
be entitled to Special Enrollment Right #1 described below, but will still be entitled to Special
Enrollment Right #2.
Special Enrollment Rights
1. If the employee declines enrollment for self or dependents, (including spouse or same-sex partner
     as defined and documented by 2 AAC 38.010 – 2 AAC 38.100), because of other health coverage
     and that other health coverage ends, the employee may be allowed to enroll self or dependents in
     the Plan at that time, provided that enrollment is requested within 31 days after the other coverage
     ends.
2. If the employee acquires a new dependent as a result of marriage, birth, adoption, same-sex partner
     status as defined and documented by 2 AAC 38.010 – 2 AAC 38.100 or placement for adoption, he
     or she may be allowed to enroll self and dependents at that time, provided that enrollment is
     requested within 31 days after the marriage, birth, adoption, same-sex partner eligibility or
     placement for adoption.
If the employee waives coverage and eventually enrolls but does not meet the criteria described, he or
she will be treated as a "late enrollee.” As a consequence, he or she must wait until the next Open
Enrollment Period to enroll in the Plan, and the "enrollment date" for the purpose of determining pre-
existing conditions will be the first day that benefits are in effect.
Open Enrollment Period
An employee who fails to enroll within the time period allowed under the Plan, or who waives
coverage and does not qualify for the Special Enrollment Rights described previously must wait until
the next Open Enrollment Period in order to make application for enrollment in the Plan. The annual
Open Enrollment Period is December 1st through December 31st, for coverage beginning on January
1st.
Terminations/Changes in Enrollment
The Plan Sponsor must be notified within 31 days prior to a termination or a change in the employee
or dependent's coverage.
Dependent Enrollment
Eligible dependents may also be covered under the Plan. Eligible dependents include:
1. A covered employee's spouse or same-sex partner as defined and documented by 2 AAC 38.010 –
    2 AAC 38.100 and unmarried children, including children of same-sex partner (as defined and
    documented by 2 AAC 38.010 – 2 AAC 38.100), from birth to the limiting age of 26 years. When
    the child reaches limiting age, coverage will end on the child's birthday.
    The term "spouse" shall mean the person recognized as the covered employee's husband or wife
    under the laws of the state where the covered employee lives. The Plan Administrator may require
    documentation proving a legal marital relationship.
    The term "children" shall include natural children living in the same household as the employee,
    adopted children or children placed with a covered employee in anticipation of adoption or foster
    children. Stepchildren who reside in the employee's household may also be included, as long as a
    natural parent remains married or continues as a same-sex partner as defined and documented by 2
    AAC 38.010 – 2 AAC 38.100 to the employee and also resides in the employee's household.

   Lower Kuskokwim School District Employee HealthCare Plan                         page   59
                                     ENROLLMENT AND ELIGIBILITY (CONTINUED)
   If a covered employee is the legal guardian of an unmarried child or children, these children may
   be enrolled in this Plan as covered dependents.
   Any natural child of the employee's minor dependent, who resides with the employee and is
   primarily dependent upon the covered employee for support and maintenance may also be covered
   under this Plan.
   The phrase "child placed with a covered employee in anticipation of adoption" refers to a child
   whom the employee intends to adopt, whether or not the adoption has become final, who has not
   attained the age of 18 as of the date of such placement for adoption. The term "placed" means the
   assumption and retention by such employee of a legal obligation for total or partial support of the
   child in anticipation of adoption of the child. The child must be available for adoption and the legal
   process must have commenced.
   Any child of a Plan participant who is an alternate recipient under a Qualified Medical Child
   Support Order shall be considered as having a right to dependent coverage under this Plan.
   A participant of this Plan may obtain, without charge, a copy of the procedures governing qualified
   medical child support order (QMCSO) determinations from the Plan Administrator.
   The phrase "primarily dependent upon" shall mean dependent upon the covered employee for
   support and maintenance as defined by the Internal Revenue Code. The Plan Administrator may
   require documentation proving dependency, including birth certificates, tax records or initiation of
   legal proceedings severing parental rights.
2. A covered dependent child who reaches the limiting age and is totally disabled, incapable of self-
    sustaining employment by reason of mental or physical handicap, primarily dependent upon the
    covered employee for support and maintenance and unmarried. The Plan Administrator may
    require, at reasonable intervals during the two years following the dependent's reaching the
    limiting age, subsequent proof of the child's Total Disability and dependency.
    After such two-year period, the Plan Administrator may require subsequent proof not more than
    once each year. The Plan Administrator reserves the right to have such dependent examined by a
    physician of the Plan Administrator's choice, at the Plan's expense, to determine the existence of
    such incapacity.
These persons are excluded as dependents: other individuals living in the covered employee's home,
but who are not eligible as defined; the legally separated or divorced former spouse of the employee;
any person who is on active duty in any military service of any country.
If a person covered under this Plan changes status from employee to dependent or dependent to
employee, and the person is covered continuously under this Plan before, during and after the change
in status, credit will be given for deductibles and all amounts applied to maximums.
Dual Coverage
If both spouses, or same-sex partners as defined and documented by 2 AAC 38.010 – 2 AAC 38.100,
are eligible employees, dual coverage may be elected, but each spouse or same-sex partner will be
required to satisfy deductibles/copayments before benefits will be coordinated. If both mother and
father are employees, their children may be covered under both parents' Plans, but the children will be
required to satisfy deductibles/copayments before benefits will be coordinated.
In the event that dual coverage is elected, or dependent children are covered under both parents' Plans
through Lower Kuskokwim School District, if a Non-Preferred Provider facility is utilized, the benefits
payable under the secondary Plan will be no more than 60% of the balance due after the primary Plan's
benefit, less any applicable deductibles and copayments. In this instance, the covered person may have
significant out of pocket expenses, other than those listed in the Summary of Medical Benefits, and
Coordination of Benefits will not pay 100% on such Non-Preferred Provider expenses.
Eligibility Requirements for Dependent Coverage

   Lower Kuskokwim School District Employee HealthCare Plan                         page   60
                                  ENROLLMENT AND ELIGIBILITY (CONTINUED)
A family member of an employee will become eligible for dependent coverage on the first day that the
employee is eligible for employee coverage and the family member satisfies the requirements for
dependent coverage.
At any time, the Plan may require proof that a spouse, same-sex partner as defined and documented by
2 AAC 38.010 – 2 AAC 38.100, or a child, including children of same-sex partner (as defined and
documented by 2 AAC 38.010 – 2 AAC 38.100), qualifies or continues to qualify as a dependent as
defined by this Plan.


New Dependent Enrollment
If new dependents are acquired, the following rules apply:
New Spouse
A new spouse is eligible on the date of marriage, provided that application for enrollment is made
within 31 days of the marriage. If application for enrollment is made more than 31 days after the
marriage, the new spouse will be considered a late enrollee, and coverage will not begin until after the
next Open Enrollment Period.
Same-sex Partner
A same-sex partner as defined and documented by 2 AAC 38.010 – 2 AAC 38.100, including children
of same-sex partner (as defined and documented by 2 AAC 38.010 – 2 AAC 38.100), is eligible for
enrollment within 31 days of approval of the Same-sex Partner Affidavit.
Newborn Infant
A newborn child of a covered employee is not automatically enrolled in this Plan. Charges for covered
nursery care will be applied toward the Plan of the newborn child. If the newborn child is not enrolled
in this Plan on a timely basis, there will be no payment from the Plan and the parent(s) will be
responsible for all costs.
Charges for covered routine physician care will be applied toward the Plan of the newborn child. If the
newborn child is not enrolled in this Plan on a timely basis, there will be no payment from the Plan
and the parent(s) will be responsible for all costs.
If the newborn is not enrolled within 31 days of birth, the enrollment will be considered a late
enrollment, and coverage will not begin until after the next Open Enrollment Period.
Adopted Child(ren)
An adopted child is eligible on the date the adoption is finalized or the date that the child is placed in
the employee's home, whichever occurs first, provided that an application for enrollment is made
within 31 days of that date. If application for enrollment is made more than 31 days after the date of
adoption or the date that the child is placed in the employee's home, the adopted child will be
considered a late enrollee, and coverage will not begin until after the next Open Enrollment Period.
Rehire of a Laid-off or Terminated Employee
A terminated employee who is rehired within 12 months following an approved leave of absence for
sabbatical purposes will have coverage reinstated on the date he or she returns to work. A terminated
employee who is rehired within three months following a termination for any reason other than an
approved leave of absence for sabbatical purposes will have coverage reinstated on the date he or she
returns to work.
On the date the employee returns to work, coverage for the employee and eligible dependents will be
on the same basis as that provided for any other active employee and his or her dependents as of that
date. However, any restrictions on coverage that were in effect before such reinstatement will still
apply (e.g. any remaining pre-existing condition waiting period, etc.).
A terminated employee who does not meet the criteria described will be treated as a new hire and be
required to satisfy all eligibility and enrollment requirements, with the exception of an employee
returning to work directly from COBRA coverage. This employee does not have to satisfy the
   Lower Kuskokwim School District Employee HealthCare Plan                          page   61
                                     ENROLLMENT AND ELIGIBILITY (CONTINUED)
employment waiting period or any additional pre-existing conditions provision (other than that which
was still in effect under the COBRA coverage).
Employees on Sabbatical Leave
Employees on Sabbatical Leave will remain eligible for the same coverage they had in place as Active
Employees.
If benefits increase or decrease for Active Employees in the same class of employees, they will also
increase or decrease for employees on Sabbatical Leave.
Employees on Military Leave
Employees going into or returning from military service may elect to continue Plan coverage as
mandated by the Uniformed Services Employment and Reemployment Rights Act under the following
circumstances. These rights apply only to employees and their dependents covered under the Plan
before leaving for military service.
1. The maximum period of coverage of a person under such an election shall be the lesser of:
    (a) The 18 month period beginning on the date on which the person's absence begins; or
    (b) The day after the date on which the person was required to apply for or return to a position or
        employment and fails to do so.
2. A person who elects to continue the Plan coverage may be required to pay up to 102% of the full
    contribution under the Plan, except a person on active duty for 30 days or less cannot be required
    to pay more than the employee's share, if any, for the coverage.
3. An exclusion or Waiting Period may not be imposed in connection with the reinstatement of
    coverage upon reemployment if one would not have been imposed had coverage not been
    terminated because of service. However, an exclusion or Waiting Period may be imposed for
    coverage of any Illness or Injury determined by the Secretary of Veterans Affairs to have been
    incurred in, or aggravated during, the performance of uniformed service.
Loss of Employee Eligibility
If an employee is no longer eligible, his or her coverage and the coverage of all dependents will end
per the relevant Negotiated Agreement.
Loss of Dependent Eligibility
Coverage ends for the spouse of an employee on the day the marriage is legally dissolved (by divorce
or legal separation).
Coverage ends for the same-sex partner when loss of eligibility occurs as defined and documented by 2
AAC 38.010 – 2 AAC 38.100.
Coverage ends for a dependent child on the last day of the month in which the child no longer meets
the eligibility requirements of the Plan.
A covered person who loses coverage may be eligible for COBRA Continuation. Please see page 70 of
this document for information on COBRA Continuation of Coverage.
An eligible employee or dependent is required to notify the Plan Administrator within 60 days of any
Qualifying Event of which the Plan Administrator would not otherwise be aware such as divorce, legal
separation, or loss of eligible dependent status to be eligible for COBRA Continuation. Please see page
70 of this document for information on COBRA Continuation.
Employee and/or Dependents Covered in Error
Any employee and/or dependent who is enrolled in error under the Plan or who is enrolled in violation
of any of the terms of the Plan shall not be entitled to any benefits hereunder. The Plan shall make
proper adjustments to cover any contributions paid under such circumstances. The Plan shall have the
right to recover from any employee and/or dependent the cost of any benefits furnished while such an
employee and/or dependent was enrolled in error.
Family and Medical Leave Act (FMLA)
   Lower Kuskokwim School District Employee HealthCare Plan                       page   62
                                     ENROLLMENT AND ELIGIBILITY (CONTINUED)
The Family and Medical Leave Act (FMLA) applies only to groups that employ 50 or more employees
during each of 20 or more calendar work weeks in the current or preceding calendar year and that are
required by federal law to comply with FMLA provisions. Under this provision, eligible employees
may receive up to 12 weeks of leave during a 12-month period, as provided by FMLA, under the
following circumstances:
1. The birth of the employee's child;
2. The placement of a child with the employee for adoption or foster care;
3. Care for the employee's seriously ill spouse, parent or child; or
4. The employee's own serious physical or mental health condition.
Eligible employees and their covered dependents may continue coverage under this Plan during the
FMLA leave. The employee may contact the Human Resources Department at Lower Kuskokwim
School District for more detailed information on FMLA leaves.




   Lower Kuskokwim School District Employee HealthCare Plan                     page   63
                                                                      COORDINATION OF BENEFITS
All health care benefits provided hereunder are subject to Coordination of Benefits as described below,
unless specifically stated otherwise. These coordination provisions apply separately to each Covered
Person, per Calendar Year. Coordination of Benefits applies to the medical, dental and vision benefits
included in This Plan.

                                                        DEFINITIONS

As used in this COB section, the following terms will be capitalized and will have the meanings
indicated:

Allowable Expense - Any necessary, reasonable and customary item of expense which is at least
partially covered by at least one Other Plan covering the person for whom a claim is made. When a
Plan provides benefits in the form of services rather than cash payments, the reasonable cash value of
each service rendered will be deemed to be both an Allowable Expense and a benefit paid.

Claim Determination Period - A period that commences each January 1st and ends at 12 o’clock
midnight on the next succeeding December 31st, or that portion of such period during which the
Claimant is covered under This Plan. The Claim Determination Period is the period during which This
Plan’s normal liability is determined. All claims must be submitted within This Plan’s timely filing
limits of 90-days not to exceed six months from date of service.

Other Plan - Any of the following that provides health care benefits or services:

       group, blanket, or franchise health insurance coverage;
       group service plan contract, group practice, group individual practice and other group
        prepayment coverages;
       group coverage under labor-management trusteed plans, union benefit organization plans,
        employer organization plans, employee benefit organization plans or self-insured employee
        benefit plans;
       Medicare. However this does not include Medicare when, by law, its benefits are secondary to
        those of any private insurance program or other non-governmental program.

NOTES: The term “Other Plan” refers separately to each agreement, policy, contract, or other
arrangement for services and benefits, and only to that portion of such agreement, policy, contract or
arrangement which reserves the right to take the services or benefits of Other Plans into consideration
in determining benefits.

An “Other Plan” includes benefits that are actually paid or payable or benefits that would have been
paid or payable if a claim had been properly made for them.

If an “Other Plan” has two parts and COB rules apply only to one of the two, each of the parts is
treated as a separate plan.

Primary Plan - The plan which will have its benefits determined first.

This Plan - The medical, dental, and vision benefits that are described in this Benefit Document.




   Lower Kuskokwim School District Employee HealthCare Plan                         page   64
                                                   COORDINATION OF BENEFITS (CONTINUED)

                                 EFFECT ON BENEFITS UNDER THIS PLAN

Whether This Plan is the Primary Plan or a Secondary Plan, coordination of benefits are
determined in accordance with the following rules:

   1. If This Plan is the Primary Plan, then benefits will be determined first without taking into
      account the benefits or services of any Other Plan.
   2. If This Plan is not the Primary Plan, then benefits may be reduced so that the benefits and
      services of all the plans do not exceed the Allowable Expense.
   3. The benefits of This Plan will never be greater than the sum of the benefits that would have
      been paid if the Covered Person were covered under This Plan only.

When an Other Plan Does Not Contain a COB Provision - If an Other Plan does not contain a
coordination of benefits provision that is consistent with the NAIC Model COB Contract Provisions,
then such Other Plan will be the Primary Plan and This Plan will pay its benefits AFTER such Other
Plan. This Plan’s liability will be the lesser of: (a) its normal liability, or (b) total Allowable Expenses
minus benefits paid or payable by the Other Plan.

When an Other Plan Contains a COB Provision - When an Other Plan also contains a coordination
of benefits provision similar to this one, This Plan will determine its benefits using the “Order of
Benefit Determination Rules” If, in accordance with those rules, This Plan is to pay benefits
BEFORE an Other Plan, This Plan will pay its normal liability without regard to the benefits of the
Other Plan. If This Plan, however, is to pay its benefits AFTER an Other Plan, it will pay the lesser of:
(1) its normal liability, or (2) total Allowable Expenses minus benefits paid or payable by the Other
Plan.

                             ORDER OF BENEFIT DETERMINATION RULES

Whether This Plan is the "primary" plan or a "secondary" plan is determined in accordance with the
following rules.
No COB Provision – If an Other Plan does not contain a coordination of benefit provision, then the
Other Plan will be primary and This Plan will be secondary.
Medicare as an "Other Plan" - Medicare will be the primary, secondary or last payer in accordance
with federal law. When Medicare is the primary payer, This Plan will determine its benefits based on
Medicare Part A, Part B and Part D benefits that would have been paid or payable, regardless of
whether or not the person was enrolled for such benefits.
NOTE: An active Employee (or spouse) age 65 or older who is eligible for Medicare and who chooses
to have Medicare as their primary carrier, may not also have coverage hereunder.
Non-Dependent vs. Dependent - The benefits of a plan that covers the Claimant other than as a
dependent will be determined before the benefits of a plan that covers such Claimant as a dependent.
However, if the Claimant is a Medicare beneficiary and, as a result of federal law, Medicare is
secondary to the plan covering the person as a dependent and primary to the plan covering the person
as other than a dependent (e.g., a retired employee), then the order of benefits between the two plans is
reversed so that the plan covering the person as an employee, member, subscriber or retiree is
secondary and the other plan is primary.
Child Covered Under More Than One Plan - When the Claimant is a dependent child, the primary
plan is the plan of the parent whose birthday is earlier in the year if: (1) the child's parents are married,
   Lower Kuskokwim School District Employee HealthCare Plan                            page   65
                                                   COORDINATION OF BENEFITS (CONTINUED)

(2) the parents are not separated, whether or not they have ever been married, or (3) a court decree
awards joint custody without specifying that one party has the responsibility to provide health care
coverage. If both parents have the same birthday, the plan that covered either of the parents longer is
primary.
When the Claimant is a dependent child and the specific terms of a court decree state that one of the
parents is responsible for the child's health care expenses or health care coverage and the plan of that
parent has actual knowledge of those terms, that plan is primary. This rule applies to Claim
Determination Periods or plan years commencing after the plan is given notice of the court decree.
When the Claimant is a dependent child whose father and mother are not married, are separated
(whether or not they have ever been married) or are divorced, the order of benefits is:

            the plan of the Custodial Parent;
            the plan of the spouse of the Custodial Parent;
            the plan of the noncustodial parent; and then
            the plan of the spouse of the noncustodial parent.
“Custodial Parent” means a parent awarded custody by a court decree. In the absence of a court
decree, it is the parent with whom the child resides for more than half the Calendar Year without
regard to any temporary visitation.
Active vs. Inactive Employee - The plan that covers the Claimant as an employee who is neither laid
off nor retired, is primary. The plan that covers a person as a dependent of an employee who is neither
laid off nor retired, is primary. If the Other Plan does not have this rule and if, as a result, the plans do
not agree on the order of benefits, this rule is ignored.
Continuation Coverage (COBRA) Enrollee - If a Claimant is a COBRA enrollee under This Plan, an
Other Plan covering the person as an employee, member, subscriber, or retiree (or as that person’s
dependent) is primary and This Plan is secondary. If the Other Plan does not have this rule and if, as a
result, the plans do not agree on the order of benefits, this rule is ignored.
Longer vs. Shorter Length of Coverage - If none of the above rules establish which plan is primary,
the benefits of the plan that has covered the Claimant for the longer period of time will be determined
before those of the plan that has covered that person for the shorter period of time.
NOTE: If the preceding rules do not determine the primary plan, the Allowable Expenses shall be
shared equally between This Plan and the Other Plan(s). However, This Plan will not pay more than it
would have paid had it been primary.


                OTHER INFORMATION ABOUT COORDINATION OF BENEFITS

Right to Receive and Release Necessary Information - For the purpose of enforcing or determining
the applicability of the terms of this COB section or any similar provision of any Other Plan, the
Contract Administrator may, without the consent of any person, release to or obtain from any
insurance company, organization or person any information with respect to any person it deems to be
necessary for such purposes. Any person claiming benefits under This Plan will furnish to the
Contract Administrator such information as may be necessary to enforce this provision.

This Plan is not responsible for coordination of benefits unless timely information has been provided
by the requesting party regarding the application of this provision.

   Lower Kuskokwim School District Employee HealthCare Plan                            page   66
                                                   COORDINATION OF BENEFITS (CONTINUED)


Reasonable Cash Value - If an Other Plan provides benefits in the form of services rather than cash
payment, the reasonable cash value of services provided will be considered the Allowable Expense.
The reasonable cash value of such service will be considered a benefit paid, and This Plan’s liability
will be reduced accordingly.

Facility of Payment - A payment made under an Other Plan may include an amount that should have
been paid under This Plan. If it does, the Contract Administrator may pay that amount to the
organization that made that payment. That amount will then be treated as though it were a benefit paid
under This Plan. The Plan will not have to pay that amount again.

Right of Recovery - If the amount of the payments made by This Plan is more than it should have paid
under this COB Section, This Plan may recover the excess from one or more of the persons it has paid
or for whom it has paid – or any other person or organization that may be responsible for the benefits
or services provided for the Claimant. The “amount of the payments made” includes the reasonable
cash value of any benefits provided in the form of services.

                   BENEFITS FOR MEDICARE-ELIGIBLE COVERED PERSONS

If a Claimant is entitled to Medicare, he will receive the full benefits of This Plan, except as follows:

       A Claimant receiving treatment for end-stage renal disease following the first 30 months is
        entitled to end-stage renal disease benefits under Medicare; or
       A Claimant is entitled to Medicare benefits as a disabled person, unless he has a current
        employment status as determined by Medicare rules through a group plan of 100 or more
        employees (according to federal OBRA legislation).

In cases where these exceptions apply, This Plan’s payment will be determined according to these
COB provisions and the following: This Plan will not provide benefits that duplicate any benefits to
which a Claimant would be entitled to under Medicare. This exclusion applies to all parts of Medicare
in which the Claimant can enroll without paying additional premium. If a Claimant is required to pay
additional premium for any part of Medicare, this exclusion will apply to that part of Medicare only if
the Claimant is enrolled in that part.

                WHEN “THIS PLAN” WILL PROVIDE EXCESS BENEFITS ONLY

Excess Benefits – If at the time of injury, sickness, disease or disability there is available, or
potentially available any Coverage (see Right of Subrogation and Refund, Page 69 of the Lower
Kuskokwim Employee HealthCare Plan Document), the benefits under This Plan shall apply only as
an excess over such other sources of Coverage. This Plan’s benefits shall be excess to:

       any responsible third party, its insurer, or any other source on behalf of that party;
       any first party insurance through medical payment coverage, personal injury protection, no-
        fault coverage, uninsured or underinsured motorist coverage;
       any policy of insurance from any insurance company or guarantor of a third party;
       workers’ compensation or other liability insurance company; or
       any other source, including but not limited to crime victim restitution funds, any medical,
        disability or other benefit payments, and school insurance coverage.



   Lower Kuskokwim School District Employee HealthCare Plan                           page   67
                                                   COORDINATION OF BENEFITS (CONTINUED)

Vehicle Limitation – When medical payments are available under any vehicle insurance, This Plan
shall pay excess benefits only, without reimbursement for vehicle plan and/or policy deductibles. This
Plan shall always be considered secondary to such plans and/or polices. This applies to all forms of
medical payments under vehicle plans and/or polices regardless of its name, title or classification.

The Coordination of Benefits provision applies to this Plan when the employee or covered dependents
have health care coverage under more than one plan, or are entitled to dual coverage per the relevant
Negotiated Agreement. This provision allows the Plan to coordinate its benefits with similar benefits
paid by other plans.
Dual Coverage
If both spouses are eligible employees, dual coverage may be elected, but each spouse will be required
to satisfy deductibles/copayments before benefits will be coordinated. If both mother and father are
employees, their children may be covered under both parents' Plans, but the children will be required
to satisfy deductibles/copayments before benefits will be coordinated.
In the event that dual coverage is elected, or dependent children are covered under both parents' Plans
through Lower Kuskokwim School District, if a Non-Preferred Provider facility is utilized, the benefits
payable under the secondary Plan will be no more than 60% of the balance due after the primary Plan's
benefit, less any applicable deductibles and copayments. In this instance, the covered person may have
significant out of pocket expenses, other than those listed in the Summary of Medical Benefits, and
Coordination of Benefits will not pay 100% on such Non-Preferred Provider expenses.
Medicare
An active employee age 65 or over and his or her dependent spouse age 65 or over who are covered
under this Plan are entitled to benefits under this Plan on the same basis as active employees and their
dependent spouses under the age of 65. This Plan will pay as the primary plan to the extent that an
employer-sponsored health plan is required by federal TEFRA (Tax Equity and Fiscal Responsibility
Act of 1982) and ADEA (Age Discrimination in Employment Act of 1967) laws.
This Plan also provides benefits primary over Medicare, to the extent that an employer-sponsored
health plan is required to by federal DEFRA (Deficit Reduction Act of 1984) laws, for covered persons
who are entitled to Medicare because of a disability, kidney transplants or renal dialysis or ESRD (End
Stage Renal Disease).
For all other covered persons entitled to Medicare, this Plan will be the secondary plan to Medicare.
Correction of Payments
If another plan makes payments that this Plan should have made under this coordination provision, this
Plan can reimburse the other plan directly. Any such reimbursement payment will be considered as
benefits paid under the Plan, and the Plan will be released from liability to the covered person
regarding them.
Right of Recovery
If the Plan makes payments that should have been made by another plan, the Plan will have the right to
recover payments from the person to or for whom such payments were made, or from insurance
companies or other organizations. The covered person involved must sign any documents that are
necessary to enforce the rights of the Plan under this provision.
Excess Coverage
This provision applies when a covered employee or dependent incurs medical or dental charges for
which the covered employee or dependent is eligible to receive medical, dental or disability
replacement benefits from a plan of liability insurance, property insurance, casualty insurance or
property/casualty insurance, including but not limited to a: motor vehicle plan, homeowner's plan,
renter's insurance plan, or boat owner's plan.


   Lower Kuskokwim School District Employee HealthCare Plan                        page   68
                                                   COORDINATION OF BENEFITS (CONTINUED)

When payments are available under another plan or policy, the Lower Kuskokwim School District
Employee HealthCare Plan shall pay excess benefits only. This Plan shall always be considered the
secondary carrier regardless of the individual's election under such policies.




   Lower Kuskokwim School District Employee HealthCare Plan                    page   69
                                                              THIRD PARTY RECOVERY PROVISION
Right of Subrogation and Refund
This provision applies when the covered person incurs medical or dental expenses resulting from injury
or illness that occurred by the act or omission of a third party. In such circumstances, the covered person
or beneficiary may have a claim against that third party, or insurer, for payment of the medical or dental
charges. Accepting benefits under the Plan for those incurred medical or dental expenses automatically
assigns to the Plan any rights the covered person or beneficiary may have to recover payments from any
third party or insurer. This subrogation right allows the Plan to pursue any claim which the covered
person or beneficiary has against any third party, or insurer, whether or not the covered person or
beneficiary chooses to pursue that claim. The Plan may make a claim directly against the third party or
insurer, but in any event, the Plan has a lien on any amount recovered by the covered person or
beneficiary whether or not designated as payment for medical expenses. This lien shall remain in effect
until the Plan is repaid in full.
The covered person:
1. Automatically assigns to the Plan his or her rights against any third party or insurer when this
    provision applies; and
2. Must repay to the Plan the benefits paid on his or her behalf out of the recovery made from the third
    party or insurer.
For any amount subject to subrogation or refund, the covered person or beneficiary agrees to recognize
the Plan's right to subrogation and reimbursement. These rights provide the Plan with a priority over any
funds paid by a third party to a covered person relative to the injury or illness, including a priority over
any claim for non-medical or dental charges, attorney fees, or other costs and expenses.
Notwithstanding its priority to funds, the Plan's subrogation and refund rights, as well as the rights
assigned to it, are limited to the extent to which the Plan has made, or will make, payment on medical or
dental expenses as well as any costs and fees associated with the enforcement of its rights under the
Plan.
When a right of recovery exists, the covered person or beneficiary will execute and deliver all required
instruments and papers as well as doing whatever else is needed to secure the Plan's right of subrogation
as a condition to having the Plan make payments. In addition, the covered person or beneficiary will do
nothing to prejudice the right of the Plan to subrogate.
Defined Terms
"Recovery" means moneys paid to the covered person or beneficiary by way of judgment, settlement, or
otherwise to compensate for all losses caused by the injuries or illness whether or not said losses reflect
medical or dental charges covered by the Plan. This right of refund also applies when a covered person
recovers under an uninsured or underinsured motorist plan, homeowner's plan, renter's plan, medical
malpractice plan or any liability plan.
"Subrogation" means the Plan's right to pursue the covered person's claims for medical or dental charges
against the other person.
"Refund" means repayment to the Plan for medical or dental benefits that it has paid toward care and
treatment of the injury or illness.
Assignment of Rights - As a condition to the Plan making payment for any medical or dental expenses,
the covered person must assign to the Plan his or her rights to any recovery arising out of or related to
any act or omission that caused or contributed to the injury or illness for which such benefits are to be
paid. The scope of this assignment is consistent with the amount subject to subrogation or refund set
forth above.




   Lower Kuskokwim School District Employee HealthCare Plan                          page   70
                                                              COBRA CONTINUATION OF COVERAGE
Under federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), certain
Employees and their families covered under Lower Kuskokwim School District Employee HealthCare
Plan (the Plan) will be entitled to the opportunity to elect a temporary extension of health coverage
(called "COBRA continuation coverage") where coverage under the Plan would otherwise end. This
notice is intended to inform Plan Participants and beneficiaries, in summary fashion, of their rights and
obligations under the continuation coverage provisions of COBRA, as amended and reflected in final
and proposed regulations published by the Department of the Treasury. This notice is intended to
reflect the law and does not grant or take away any rights under the law. The Plan Administrator is
Lower Kuskokwim School District, PO Box 305, Bethel, Alaska 99559, (907) 543-4820. The Plan
Administrator is responsible for administering COBRA continuation coverage. Complete instructions
on COBRA, as well as election forms and other information, will be provided by the Plan
Administrator or its designee to Plan Participants who become Qualified Beneficiaries under COBRA.

What is COBRA continuation coverage? COBRA continuation coverage is the temporary extension
of group health plan coverage that must be offered to certain Plan Participants and their eligible family
members (called "Qualified Beneficiaries") at group rates. The right to COBRA continuation coverage
is triggered by the occurrence of a life event that results in the loss of coverage under the terms of the
Plan (the "Qualifying Event"). The coverage must be identical to the Plan coverage that the Qualified
Beneficiary had immediately before the Qualifying Event, or if the coverage has been changed, the
coverage must be identical to the coverage provided to similarly situated active employees who have
not experienced a Qualifying Event (in other words, similarly situated non-COBRA beneficiaries).

Who can become a Qualified Beneficiary? In general, a Qualified Beneficiary can be:
  (1)    Any individual who, on the day before a Qualifying Event, is covered under a Plan by virtue
         of being on that day either a covered Employee, the Spouse of a covered Employee, the
         Same-sex Partner as defined and documented by 2 AAC 38.010 – 2 AAC 38.100 of a
         covered Employee, or a Dependent child of a covered Employee. If, however, an individual
         who otherwise qualifies as a Qualified Beneficiary is denied or not offered coverage under
         the Plan under circumstances in which the denial or failure to offer constitutes a violation of
         applicable law, then the individual will be considered to have had the Plan coverage and will
         be considered a Qualified Beneficiary if that individual experiences a Qualifying Event.
   (2)    Any child who is born to or placed for adoption with a covered Employee during a period
         of COBRA continuation coverage, and any individual who is covered by the Plan as an
         alternate recipient under a qualified medical support order. If, however, an individual who
         otherwise qualifies as a Qualified Beneficiary is denied or not offered coverage under the
         Plan under circumstances in which the denial or failure to offer constitutes a violation of
         applicable law, then the individual will be considered to have had the Plan coverage and will
         be considered a Qualified Beneficiary if that individual experiences a Qualifying Event.

The term "covered Employee" includes not only common-law employees (whether part-time or
full-time) but also any individual who is provided coverage under the Plan due to his or her
performance of services for the employer sponsoring the Plan (e.g., self-employed individuals,
independent contractor, or corporate director). However, this provision does not establish eligibility of
these individuals. Eligibility for Plan Coverage shall be determined in accordance with Plan Eligibility
provisions.
An individual is not a Qualified Beneficiary if the individual's status as a covered Employee is
attributable to a period in which the individual was a nonresident alien who received from the
individual's Employer no earned income that constituted income from sources within the United States.
   Lower Kuskokwim School District Employee HealthCare Plan                         page   71
                                                COBRA CONTINUATION OF COVERAGE (CONTINUED)

If, on account of the preceding reason, an individual is not a Qualified Beneficiary, then a Spouse,
same-sex partner as defined and documented by 2 AAC 38.010 – 2 AAC 38.100 or Dependent child of
the individual will also not be considered a Qualified Beneficiary by virtue of the relationship to the
individual.
Each Qualified Beneficiary (including a child who is born to or placed for adoption with a covered
Employee during a period of COBRA continuation coverage) must be offered the opportunity to make
an independent election to receive COBRA continuation coverage.

What is a Qualifying Event? A Qualifying Event is any of the following if the Plan provided that the
Plan participant would lose coverage (i.e.: cease to be covered under the same terms and conditions as
in effect immediately before the Qualifying Event) in the absence of COBRA continuation coverage:
      (1) The death of a covered Employee.
      (2) The termination (other than by reason of the Employee's gross misconduct), or reduction of
            hours, of a covered Employee's employment.
      (3) The divorce or legal separation of a covered Employee from the Employee's Spouse, or loss
            of eligibility of same-sex partner status as defined and documented by 2 AAC 38.010 – 2
            AAC 38.100. If the Employee reduces or eliminates the Employee's Spouse's Plan coverage
            in anticipation of a divorce or legal separation, and a divorce or legal separation later occurs,
            then the divorce or legal separation may be considered a Qualifying Event even though the
            Spouse's coverage was reduced or eliminated before the divorce or legal separation.
     (4) A covered Employee's enrollment in any part of the Medicare program.
     (5) A Dependent child's ceasing to satisfy the Plan's requirements for a Dependent child (for
            example, attainment of the maximum age for dependency under the Plan).
If the Qualifying Event causes the covered Employee, or the covered Spouse or a Dependent child of
the covered Employee, to cease to be covered under the Plan under the same terms and conditions as in
effect immediately before the Qualifying Event, the persons losing such coverage become Qualified
Beneficiaries under COBRA if all the other conditions of COBRA are also met. For example, any
increase in contribution that must be paid by a covered Employee, or the Spouse, or a Dependent child
of the covered Employee, for coverage under the Plan that results from the occurrence of one of the
events listed above is a loss of coverage.
The taking of leave under the Family and Medical Leave Act of 1993 ("FMLA") does not constitute a
Qualifying Event. A Qualifying Event will occur, however, if an Employee does not return to
employment at the end of the FMLA leave and all other COBRA continuation coverage conditions are
present. If a Qualifying Event occurs, it occurs on the last day of FMLA leave and the applicable
maximum coverage period is measured from this date (unless coverage is lost at a later date and the
Plan provides for the extension of the required periods, in which case the maximum coverage date is
measured from the date when the coverage is lost.) Note that the covered Employee and family
members will be entitled to COBRA continuation coverage even if they failed to pay the employee
portion of premiums for coverage under the Plan during the FMLA leave.

What factors should be considered when determining to elect COBRA continuation coverage?
You should take into account that a failure to continue your group health coverage will affect your
rights under federal law. First, you can lose the right to avoid having pre-existing condition exclusions
applied by other group health plans if there is more than a 63-day gap in health coverage and election of
COBRA continuation coverage may help you avoid such a gap. Second, if you do not elect COBRA
continuation coverage and pay the appropriate premiums for the maximum time available to you, you
will lose the right to convert to an individual health insurance policy, which does not impose such pre-
existing condition exclusions. Finally, you should take into account that you have special enrollment
   Lower Kuskokwim School District Employee HealthCare Plan                           page   72
                                                COBRA CONTINUATION OF COVERAGE (CONTINUED)

rights under federal law (HIPAA). You have the right to request special enrollment in another group
health plan for which you are otherwise eligible (such as a plan sponsored by your Spouse's, or same-
sex partner’s as defined and documented by 2 AAC 38.010 – 2 AAC 38.100, employer) within 30 days
after Plan coverage ends due to a Qualifying Event listed above. You will also have the same special
right at the end of COBRA continuation coverage if you get COBRA continuation coverage for the
maximum time available to you.

What is the procedure for obtaining COBRA continuation coverage? The Plan has conditioned the
availability of COBRA continuation coverage upon the timely election of such coverage. An election is
timely if it is made during the election period.

What is the election period and how long must it last? The election period is the time period within
which the Qualified Beneficiary must elect COBRA continuation coverage under the Plan. The election
period must begin not later than the date the Qualified Beneficiary would lose coverage on account of
the Qualifying Event and ends 60 days after the later of the date the Qualified Beneficiary would lose
coverage on account of the Qualifying Event or the date notice is provided to the Qualified Beneficiary
of her or his right to elect COBRA continuation coverage. If coverage is not elected within the 60 day
period, all rights to elect COBRA continuation coverage are forfeited.
Note: If a covered employee who has been terminated or experienced a reduction of hours qualifies for
a trade readjustment allowance or alternative trade adjustment assistance under a federal law called the
Trade Act of 2002, and the employee and his or her covered dependents have not elected COBRA
coverage within the normal election period, a second opportunity to elect COBRA coverage will be
made available for themselves and certain family members, but only within a limited period of 60 days
or less and only during the six months immediately after their group health plan coverage ended. Any
person who qualifies or thinks that he and/or his family members may qualify for assistance under this
special provision should contact the Plan Administrator for further information.
The Trade Act of 2002 also created a new tax credit for certain TAA-eligible individuals and for certain
retired employees who are receiving pension payments from the Pension Benefit Guaranty Corporation
(PBGC) (eligible individuals). Under the new tax provisions, eligible individuals can either take a tax
credit or get advance payment of 65% of premiums paid for qualified health insurance, including
continuation coverage. If you have questions about these new tax provisions, you may call the Health
Coverage Tax Credit Consumer Contact Center toll-free at 1-866-628-4282. TTD/TTY callers may call
toll-free at 1-866-626-4282. More information about the Trade Act is also available at
www.doleta.gov/tradeact.


Is a covered Employee or Qualified Beneficiary responsible for informing the Plan Administrator
of the occurrence of a Qualifying Event? The Plan will offer COBRA continuation coverage to
Qualified Beneficiaries only after the Plan Administrator or its designee has been timely notified that a
Qualifying Event has occurred. The employer (if the employer is not the Plan Administrator) will notify
the Plan Administrator of the Qualifying Event within 30 days following the date coverage ends when
the Qualifying Event is:
    (1)    the end of employment or reduction of hours of employment,
    (2)    death of the employee,
    (3)    commencement of a proceeding in bankruptcy with respect to the employer, or
    (4)    enrollment of the employee in any part of Medicare.



   Lower Kuskokwim School District Employee HealthCare Plan                        page   73
                                                    COBRA CONTINUATION OF COVERAGE (CONTINUED)

                                            IMPORTANT:
  For the other Qualifying Events (divorce or legal separation of the employee and spouse, or loss
  of eligibility of same-sex partner status as defined and documented by 2 AAC 38.010 – 2 AAC
  38.100, or a dependent child's losing eligibility for coverage as a dependent child), you or
  someone on your behalf must notify the Plan Administrator or its designee in writing within 60
  days after the Qualifying Event occurs, using the procedures specified below. If these procedures
  are not followed or if the notice is not provided in writing to the Plan Administrator or its
  designee during the 60-day notice period, any spouse, same-sex partner or dependent child who
  loses coverage will not be offered the option to elect continuation coverage. You must send this
  notice to the Plan Sponsor.
                                           NOTICE PROCEDURES:
   Any notice that you provide must be in writing. Oral notice, including notice by
   telephone, is not acceptable. You must mail, fax or hand-deliver your notice to the
   person, department or firm listed below, at the following address:
                             Lower Kuskokwim School District
                                         PO Box 305
                                       Bethel, AK 99559
   If mailed, your notice must be postmarked no later than the last day of the required
   notice period. Any notice you provide must state:

       the name of the plan or plans under which you lost or are losing coverage,
       the name and address of the employee covered under the plan,
       the name(s) and address(es) of the Qualified Beneficiary(ies), and
       the Qualifying Event and the date it happened.

   If the Qualifying Event is a divorce or legal separation, your notice must include a
   copy of the divorce decree or the legal separation agreement. If the Qualifying Event
   is a loss of eligibility of same-sex partner status the employee must inform the Plan
   Administrator, as defined and documented by 2 AAC 38.010 – 2 AAC 38.100.

   Be aware that there are other notice requirements in other contexts, for example, in order
   to qualify for a disability extension.

Is a waiver before the end of the election period effective to end a Qualified Beneficiary's election
rights? If, during the election period, a Qualified Beneficiary waives COBRA continuation coverage, the
waiver can be revoked at any time before the end of the election period. Revocation of the waiver is an
election of COBRA continuation coverage. However, if a waiver is later revoked, coverage need not be
provided retroactively (that is, from the date of the loss of coverage until the waiver is revoked). Waivers
and revocations of waivers are considered made on the date they are sent to the Plan Administrator or its
designee, as applicable.

Is COBRA coverage available if a Qualified Beneficiary has other group health plan coverage or
Medicare? Qualified beneficiaries who are entitled to elect COBRA continuation coverage may do so even
if they are covered under another group health plan or are entitled to Medicare benefits on or before the date
on which COBRA is elected. However, a Qualified Beneficiary's COBRA coverage will terminate
automatically if, after electing COBRA, he or she becomes entitled to Medicare or becomes covered under
other group health plan coverage (but only after any applicable preexisting condition exclusions of that other
plan have been exhausted or satisfied).

       Lower Kuskokwim School District Employee HealthCare Plan                       page   74
                                                  COBRA CONTINUATION OF COVERAGE (CONTINUED)


When may a Qualified Beneficiary's COBRA continuation coverage be terminated? During the
election period, a Qualified Beneficiary may waive COBRA continuation coverage. Except for an
interruption of coverage in connection with a waiver, COBRA continuation coverage that has been
elected for a Qualified Beneficiary must extend for at least the period beginning on the date of the
Qualifying Event and ending not before the earliest of the following dates:
      (1)     The last day of the applicable maximum coverage period.
      (2)     The first day for which Timely Payment is not made to the Plan with respect to the
              Qualified Beneficiary.
      (3)     The date upon which the Employer ceases to provide any group health plan (including a
              successor plan) to any employee.
      (4)     The date, after the date of the election, that the Qualified Beneficiary first becomes covered
              under any other Plan that does not contain any exclusion or limitation with respect to any
              pre-existing condition, other than such an exclusion or limitation that does not apply to, or is
              satisfied by, the Qualified Beneficiary.
      (5)     The date, after the date of the election, that the Qualified Beneficiary first enrolls in the
              Medicare program (either part A or part B, whichever occurs earlier).
      (6)     In the case of a Qualified Beneficiary entitled to a disability extension, the later of:
              (a)     29 months after the date of the Qualifying Event, or (ii) the first day of the month
                      that is more than 30 days after the date of a final determination under Title II or XVI
                      of the Social Security Act that the disabled Qualified Beneficiary whose disability
                      resulted in the Qualified Beneficiary's entitlement to the disability extension is no
                      longer disabled, whichever is earlier; or
              (b)     the end of the maximum coverage period that applies to the Qualified Beneficiary
                      without regard to the disability extension.
  The Plan can terminate for cause the coverage of a Qualified Beneficiary on the same basis that the
  Plan terminates for cause the coverage of similarly situated non-COBRA beneficiaries, for example, for
  the submission of a fraudulent claim.
  In the case of an individual who is not a Qualified Beneficiary and who is receiving coverage under the
  Plan solely because of the individual's relationship to a Qualified Beneficiary, if the Plan's obligation to
  make COBRA continuation coverage available to the Qualified Beneficiary ceases, the Plan is not
  obligated to make coverage available to the individual who is not a Qualified Beneficiary.

 What are the maximum coverage periods for COBRA continuation coverage? The maximum
 coverage periods are based on the type of the Qualifying Event and the status of the Qualified
 Beneficiary, as shown below:
    (1)     In the case of a Qualifying Event that is a termination of employment or reduction of hours
            of employment, the maximum coverage period ends 18 months after the Qualifying Event if
            there is not a disability extension and 29 months after the Qualifying Event if there is a
            disability extension.
    (2)     In the case of a covered Employee's enrollment in the Medicare program before
            experiencing a Qualifying Event that is a termination of employment or reduction of hours
            of employment, the maximum coverage period for Qualified Beneficiaries other than the
            covered Employee ends on the later of:
            (a)     36 months after the date the covered Employee becomes enrolled in the Medicare
                    program; or

     Lower Kuskokwim School District Employee HealthCare Plan                          page   75
                                                COBRA CONTINUATION OF COVERAGE (CONTINUED)

             (b)     18 months (or 29 months, if there is a disability extension) after the date of the
                     covered Employee's termination of employment or reduction of hours of
                     employment.
   (3)       In the case of a Qualified Beneficiary who is a child born to or placed for adoption with a
             covered Employee during a period of COBRA continuation coverage, the maximum
             coverage period is the maximum coverage period applicable to the Qualifying Event giving
             rise to the period of COBRA continuation coverage during which the child was born or
             placed for adoption.
   (4)       In the case of any other Qualifying Event than that described above, the maximum coverage
             period ends 36 months after the Qualifying Event.

Under what circumstances can the maximum coverage period be expanded? If a Qualifying Event
that gives rise to an 18-month or 29-month maximum coverage period is followed, within that 18- or
29-month period, by a second Qualifying Event that gives rise to a 36-months maximum coverage
period, the original period is expanded to 36 months, but only for individuals who are Qualified
Beneficiaries at the time of and with respect to both Qualifying Events. In no circumstance can the
COBRA maximum coverage period be expanded to more than 36 months after the date of the first
Qualifying Event. The Plan Administrator must be notified of the second Qualifying Event within 60
days of the second Qualifying Event. This notice must be sent to in accordance with the procedures
above.

How does a Qualified Beneficiary become entitled to a disability extension? A disability extension
will be granted if an individual (whether or not the covered Employee) who is a Qualified Beneficiary
in connection with the Qualifying Event that is a termination or reduction of hours of a covered
Employee's employment, is determined under Title II or XVI of the Social Security Act to have been
disabled at any time during the first 60 days of COBRA continuation coverage. To qualify for the
disability extension, the Qualified Beneficiary must also provide the Plan Administrator with notice of
the disability determination on a date that is both within 60 days after the date of the determination and
before the end of the original 18-month maximum coverage. This notice should be sent to the Plan
Sponsor in accordance with the procedures above.

Does the Plan require payment for COBRA continuation coverage? For any period of COBRA
continuation coverage under the Plan, qualified beneficiaries who elect COBRA continuation coverage
must pay for COBRA continuation coverage. Qualified beneficiaries will pay up to 102% of the
applicable premium and up to 150% of the applicable premium for any expanded period of COBRA
continuation coverage covering a disabled Qualified Beneficiary due to a disability extension. The Plan
will terminate a Qualified Beneficiary's COBRA continuation coverage as of the first day of any period
for which timely payment is not made.

Must the Plan allow payment for COBRA continuation coverage to be made in monthly
installments? Yes. The Plan is also permitted to allow for payment at other intervals.

What is Timely Payment for payment for COBRA continuation coverage? Timely Payment means
a payment made no later than 30 days after the first day of the coverage period. Payment that is made to
the Plan by a later date is also considered Timely Payment if either under the terms of the Plan, covered
employees or Qualified Beneficiaries are allowed until that later date to pay for their coverage for the
period or under the terms of an arrangement between the Employer and the entity that provides Plan


   Lower Kuskokwim School District Employee HealthCare Plan                         page   76
                                                COBRA CONTINUATION OF COVERAGE (CONTINUED)

benefits on the Employer's behalf, the Employer is allowed until that later date to pay for coverage of
similarly situated non-COBRA beneficiaries for the period.
Notwithstanding the above paragraph, the Plan does not require payment for any period of COBRA
continuation coverage for a Qualified Beneficiary earlier than 45 days after the date on which the
election of COBRA continuation coverage is made for that Qualified Beneficiary. Payment is
considered made on the date on which it is postmarked to the Plan.
If Timely Payment is made to the Plan in an amount that is not significantly less than the amount the
Plan requires to be paid for a period of coverage, then the amount paid will be deemed to satisfy the
Plan's requirement for the amount to be paid, unless the Plan notifies the Qualified Beneficiary of the
amount of the deficiency and grants a reasonable period of time for payment of the deficiency to be
made. A "reasonable period of time" is 30 days after the notice is provided. A shortfall in a Timely
Payment is not significant if it is no greater than the lesser of $50 or 10% of the required amount.

Must a qualified beneficiary be given the right to enroll in a conversion health plan at the end of
the maximum coverage period for COBRA continuation coverage? If a Qualified Beneficiary's
COBRA continuation coverage under a group health plan ends as a result of the expiration of the
applicable maximum coverage period, the Plan will, during the 180-day period that ends on that
expiration date, provide the Qualified Beneficiary with the option of enrolling under a conversion
health plan if such an option is otherwise generally available to similarly situated non-COBRA
beneficiaries under the Plan. If such a conversion option is not otherwise generally available, it need
not be made available to Qualified Beneficiaries.

IF YOU HAVE QUESTIONS
If you have questions about your COBRA continuation coverage, you should contact. For more
information about your rights under COBRA, the Health Insurance Portability and Accountability Act
(HIPAA), and other laws affecting group health plans, contact the nearest Regional or District Office of
the U.S. Department of Labor's Employee Benefits Security Administration (EBSA). Addresses and
phone numbers of Regional and District EBSA Offices are available through EBSA's website at
www.dol.gov/ebsa.

KEEP YOUR PLAN ADMINISTRATOR INFORMED OF ADDRESS CHANGES
In order to protect your family's rights, you should keep the Plan Administrator informed of any
changes in the addresses of family members. You should also keep a copy, for your records, of any
notices you send to the Plan Administrator.




   Lower Kuskokwim School District Employee HealthCare Plan                       page   77
                                                                 GENERAL PLAN PROVISIONS
Entire Plan
The Plan, including amendments and attached papers, if any, constitutes the entire contract of coverage.
No change in this Plan shall be valid unless approved by an executive officer of the Plan Sponsor and
unless such approval is amended or attached to the Plan. The Plan Administrator has the sole authority
to amend this Plan. No other individual has the authority to change the Plan or waive any of its
provisions.
Representations Not Warranties
All statements made by the employee, the Plan or covered persons shall be considered representations
and not warranties. All such statements will be made in good faith without any intention of fraud.
Transfer of Benefits
A covered person transferring to this Plan from other policies shall be subject to the provisions of the
Plan upon transfer. Benefits received under the previous plan are included in determining the benefits
available under this Plan and not to increase the benefits available.
Special Rights Upon Childbirth
This Plan under Lower Kuskokwim School District may not restrict benefits for any hospital length of
stay in connection with childbirth for the mother or newborn child following a normal vaginal delivery
to less than 48 hours, or restrict benefits for any hospital length of stay in connection with childbirth for
the mother or newborn child following a cesarean section to less than 96 hours, or require that a
provider obtain authorization from the Plan for prescribing any length of stay. The minimum stays do
not apply if the decision to discharge the mother or newborn is one made by the mother and her
physician.
Women's Health and Cancer Rights
Under Federal law, group health plans and health insurance issuers offering group insurance coverage
that provides medical and surgical benefits with respect to a mastectomy are now generally subject to
the following requirements. If a participant or beneficiary who is receiving benefits in connection with
a mastectomy chooses to have a breast reconstruction with that mastectomy, the group health plan or
health insurance issuer must also provide coverage for: (1) reconstruction of the breast on which the
mastectomy was performed; (2) surgery and reconstruction of the unaffected breast to make it
symmetrical with the breast reconstructed following mastectomy; and (3) prosthesis and physical
complications of all stages of the mastectomy including lymphedemas. These services must be provided
in a manner determined in consultation between the attending physician and the patient. Such coverage
may be subject to annual deductibles, coinsurance and other provisions as deemed appropriate by the
health plan and as are consistent with those established for other benefits under the plan.
Federal law also states that a group health plan, and a health insurance issuer offering group health
insurance coverage in connection with a group health plan, may not:
1. Deny a patient eligibility, or continued eligibility to enroll or to renew coverage under the terms of
    the plan solely in order to avoid the requirements of this section; or
2. Penalize the patient or physician, otherwise reduce or limit the reimbursement of an attending
    provider, or provide incentives (monetary or otherwise) to an attending physician to induce him or
    her to provide care to an individual participant or beneficiary in a manner inconsistent with this
    section.
Written notice of the availability of such coverage shall be delivered to each participant upon
enrollment and annually thereafter. This Plan complies with all of these requirements.




   Lower Kuskokwim School District Employee HealthCare Plan                           page   78
                                                     GENERAL PLAN PROVISIONS (CONTINUED)

Right to Examine Records
It is specifically understood and agreed that each covered person, by enrolling in the Plan, grants the
Plan the right to examine all medical, dental and other records pertaining to any cases for which the
benefits of the Plan are claimed.
Legal Action to Enforce the Plan
No legal procedure to enforce any of the provisions of the Plan may be instituted by the employee or
family members during a period of 60 days after the due and proper notice of intent to do so. No legal
procedure shall be brought against the Plan Sponsor and/or the Contract Administrator after the
expiration of three years from the original date of illness or injury.
Fraudulent Claims
If a covered person claims benefits for which no care, service or supply is received, the claims will be
denied. If benefits are paid in error under this Plan, the Plan will be entitled to recover such amounts.
(See " Recovery of Benefits Paid in Error".) It is a federal crime to "knowingly and willfully engage in
a scheme or artifice to defraud or obtain money by false pretense for a health care program". A 10-year
federal prison term and a fine of $250,000 can be imposed for each violation.
Recovery of Benefits Paid in Error
If the Plan mistakenly makes a payment for a person to which that person is not entitled, or if the Plan
pays a person who is not eligible for payment at all, the Plan has the right to recover the payment from
the person or anyone else who benefited from it, including a provider of service.
Any person who is enrolled in error under the Plan or who is enrolled in violation of any of the terms
and conditions of the Plan shall not be entitled to any Plan benefits, but the Plan shall make proper
adjustment to cover any dues paid under such circumstances. The Plan shall have the right to recover
from any person the cost of any benefits furnished while such person was enrolled in error.
Venue
All suits or legal proceedings brought against the employer by the employee or anyone claiming any
right under this Plan must be filed:
1. Within 12 months of the date the Contract Administrator denied, in writing, the rights or benefits
    claimed under this Plan; and
2. In the State of Alaska.
All suits or legal proceedings brought by Lower Kuskokwim School District will be filed within the
appropriate statutory period of limitation, and venue may lie, at our option, in the State of Alaska.
Integrity Administrators, Inc. and/or Lower Kuskokwim School District are not Liable for
Quality of Medical Care
A covered person has the sole right to choose their health care provider. Integrity Administrators, Inc.
and/or the Plan is not responsible for the quality of medical care a person receives, since all those who
provide care do so as independent contractors. Integrity Administrators, Inc. and/or the Plan cannot be
held liable for any claim or damages connected with injuries suffered by a covered person while
receiving medical services or supplies.
Right to Receive and Release Necessary Information
Certain facts are needed to apply provisions of the Plan. The Plan has the right to determine which facts
it needs. The Plan may obtain necessary facts from or give them to any other organization or person.
The Plan need not inform or obtain consent of any person to do this. Each person claiming benefits
under this Plan must give the Plan any facts it needs to process the claim.
Funding
The procedure and method for funding the Plan is for the Plan Sponsor to pay benefits and
administration fees from its general assets, after a payroll deduction from employees, where required.
To the extent that the annual aggregate contribution made by the Plan Sponsor from its own funds

   Lower Kuskokwim School District Employee HealthCare Plan                        page   79
                                                     GENERAL PLAN PROVISIONS (CONTINUED)

exceeds the annual cost of the Plan, such excess contributions will be retained by the Plan Sponsor, as
permitted by law, in its own assets and shall not become an asset of the Plan.
Contract Administrator
The Contract Administrator shall provide services in connection with the operation of the Plan
including such functions as specified in writing in the Administration Agreement. The Contract
Administrator is Integrity Administrators, Inc..
Administrative Functions
The Plan Administrator shall adopt such rules for the administration of the Plan as he/she considers
desirable, provided they do not conflict with the Plan, and may construe the Plan, correct defects,
supply omissions, and reconcile inconsistencies to the extent necessary to effectuate the Plan.




   Lower Kuskokwim School District Employee HealthCare Plan                      page   80
                                                                                 ADMINISTRATION
Delegation of Fiduciary Responsibility
The Plan Administrator shall be responsible for the administration of the Plan. However, the Plan
Administrator may delegate to any person or entity any of his/her powers or duties under the Plan. Such
delegation shall be in writing and, to the extent of any such delegation, the delegate shall become the
named fiduciary responsible for the administration of the Plan. A named fiduciary can appoint others to
carry out fiduciary responsibilities (other than a trustee) under the Plan. These other persons become
fiduciaries themselves and are responsible for their acts under the Plan. To the extent that the named
fiduciary allocates its responsibility to other persons, the named fiduciary shall not be liable for any act
or omission of such person unless either: 1) the named fiduciary has violated its stated duties in
appointing the fiduciary, establishing the procedures to appoint the fiduciary or continuing either the
appointment of the procedure; or 2) the named fiduciary breached its fiduciary responsibility. A
Contract Administrator is not a fiduciary under the Plan by virtue of paying claims in accordance with
the Plan's rules as established by the Plan Administrator.
Records and Reports
The Plan Administrator shall keep a record of all proceedings and actions insofar as they relate to the
Plan and shall maintain all such books of account, records, and other data as shall be necessary to
administer the Plan properly with the Internal Revenue Service Code. The Plan Administrator shall
maintain records which shall contain all relevant data pertaining to covered employees or dependents
and their rights under the Plan. Such records as may pertain solely to a particular covered employee or
dependent shall be made available for examination by such covered employee or dependent. The Plan
Administrator shall make a copy of the Plan available to each covered employee or dependent, upon
such covered employee or dependent request.
Contracts for Necessary Services
The Plan Administrator may contract for legal, advisory, accounting, clerical and other services to carry
out the Plan. The costs of such services and other administrative expenses shall be approved and paid by
the Plan.
Non-Discrimination in Administration
All rules, decisions and designations by the Plan Administrator under the Plan shall be made in a non-
discriminatory manner and persons similarly situated shall be treated alike.
Liability of the Plan
Neither the Plan, nor any of the officers, employees or their delegates shall be liable for any loss due to
their errors or omissions in the administration of the Plan unless the loss is due to the gross negligence or
willful misconduct of the party to be charged to exercise a fiduciary responsibility. Such responsibility
must be exercised with the care, skill, prudence and diligence under the circumstances then prevailing
that a prudent person, acting in a like capacity and familiar with such matters, would use in the conduct
of an enterprise of a like character and with like aims.
Amendment and Termination
The Plan shall be subject to amendment at any time hereafter by the Plan Administrator with the
approval of the Plan Sponsor in the event the Plan Administrator and Plan Sponsor are not one in the
same.
The Plan may be terminated at any time hereafter by action of the board of the Plan Sponsor, which
action shall be communicated in writing to the Plan Administrator in the event the Plan Administrator
and Plan Sponsor are not one in the same.
The amendment, termination or discontinuance of the Plan shall not adversely affect any right of any
covered employee or dependent to benefits under the provisions of the Plan arising prior to such
amendment or termination.
Indemnification
   Lower Kuskokwim School District Employee HealthCare Plan                          page   81
                                                              ADMINISTRATION (CONTINUED)

The Plan shall indemnify any employee to whom it has delegated fiduciary duties against any and all
claims, losses, damages, expenses and liabilities arising from responsibilities in connection with the
Plan, unless the same is determined to be due to gross negligence or willful misconduct.
Right to Terminate Employment
The establishment and maintenance of the Plan shall not confer upon any employee the right to continue
in the employ of the Plan Sponsor and the Plan Sponsor expressly reserves the right to terminate the
employment of any employee, whenever the interest of the Plan Sponsor in their sole judgment, may so
require.
Law Governing Construction
All questions pertaining to the interpretation, administration, validity and effect of the provisions of the
Plan shall be determined in accordance with the laws of the State of Alaska (except for such laws as
pertain to the doctrine of the conflict of laws) to the extent they are not pre-empted by federal law.
Cancellation of the Plan
If the Plan is canceled, coverage ends for all members on the date the Plan ends.
Amendments
In the event that any amendment or rider shall be affixed to the Plan that alters, increases, decreases, or
in any way changes the benefits specified in the Plan, such amendment or rider shall be subject to all
other terms and conditions of the Plan except as specifically provided in such amendment or rider. No
consent of any participant or any other person referred to in the Plan shall be required.
Miscellaneous
To the full extent permitted by law, all rights and benefits occurring under the Plan shall be exempt from
execution, attachment, garnishment or other legal or equitable process, for the debts or liabilities of any
employee.
The Plan is not in lieu of and does not affect any requirement for coverage by Workers' Compensation
insurance.
No failure to enforce any provision of the Plan shall affect the right thereafter to enforce such provision,
nor shall failure affect its right to enforce any other provision of the Plan.




   Lower Kuskokwim School District Employee HealthCare Plan                          page   82
                                                                        PLAN PARTICIPANTS' RIGHTS
Plan Description
This document is the Summary Plan Description.
Name of Plan:                                             Lower Kuskokwim School District
                                                          Employee HealthCare Plan

Employer Tax ID Number:                                   92-0056756

Group Number:                                             1180

Type of Plan:                                             Medical, Dental, Vision, and Hearing

Type of Administration:                                   Contracted administration by:
                                                          Integrity Administrators, Inc.
                                                          P.O. Box 13128
                                                          Sacramento, CA 95813-3128

                                                          (800) 562-9383

Plan Administrator:                                       Lower Kuskokwim School District
                                                          Business Manager
                                                          PO Box 305
                                                          Bethel, AK 99559

                                                          (907) 543-4820

Plan Sponsor and Fiduciary:                               Lower Kuskokwim School District
                                                          Business Manager
                                                          PO Box 305
                                                          Bethel, AK 99559

                                                          (907) 543-4820

Agent for Legal Services:                                 Lower Kuskokwim School District
                                                          Business Manager
                                                          PO Box 305
                                                          Bethel, AK 99559

                                                          (907) 543-4820

Sources of Contributions to the Plan:                     Employer

Plan's Fiscal Year Ends:                                  June 30




   Lower Kuskokwim School District Employee HealthCare Plan                                 page   83
                                                    PLAN PARTICIPANTS’ RIGHTS (CONTINUED)

Participants in this Plan shall be entitled to:
   Examine, without charge, at the Plan Administrator's office, all Plan documents and copies of all
    documents governing the Plan.
   Obtain copies of all Plan documents and other Plan information upon written request to the Plan
    Administrator. The Plan Administrator may make a reasonable charge for the copies.
   Continue health care coverage for a Plan participant, spouse, or other dependents if there is a loss
    of coverage under the Plan as a result of a qualifying event. Employees or dependents may have to
    pay for such coverage.
   Review this summary plan description and the documents governing the Plan on the rules
    governing COBRA continuation coverage rights.
   Reduction or elimination of exclusionary periods of coverage for Pre-Existing Conditions under
    this group health Plan, if the covered person has creditable coverage from another plan. The
    employee or dependent should be provided a Certificate of Creditable Coverage, free of charge,
    from the group health plan or health insurance issuer when coverage is lost under the Plan, when a
    person becomes entitled to elect COBRA continuation coverage, when COBRA continuation
    coverage ceases, if a person requests it before losing coverage, or if a person requests it up to 24
    months after losing coverage. Without evidence of creditable coverage, a Plan participant may be
    subject to a Pre-Existing Conditions exclusion for six months after the enrollment date of coverage.
If a Plan participant's claim for a benefit is denied or ignored, in whole or in part, the participant has a
right to know why this was done, to obtain copies of documents relating to the decision without
charge, and to appeal any denial, all within certain time schedules.
If a Plan participant requests a copy of Plan documents or the latest annual report from the Plan and
does not receive them within 30 days, he or she may file suit in a federal court. In such a case, the
court may require the Plan Administrator to provide the materials and to pay the Plan participant up to
$110 a day until he or she receives the materials, unless the materials were not sent because of reasons
beyond the control of the Plan Administrator. If the Plan participant has a claim for benefits which is
denied or ignored, in whole or in part, the participant may file suit in state or federal court.
In addition, if a Plan participant disagrees with the Plan's decision or lack thereof concerning the
qualified status of a medical child support order, he or she may file suit in federal court.
The individuals who operate the Plan, called "fiduciaries" of the Plan, have a duty to do so prudently
and in the interest of the Plan participants and their beneficiaries. No one, including the employer or
any other person, may fire a Plan participant or otherwise discriminate against a Plan participant in any
way to prevent the Plan participant from obtaining benefits under the Plan.
If it should happen that the Plan fiduciaries misuse the Plan's money, or if a Plan participant is
discriminated against for asserting his or her rights, he or she may seek assistance from the U.S.
Department of Labor, or may file suit in a federal court. The court will decide who should pay court
costs and legal fees. If the Plan participant is successful, the court may order the person sued to pay
these costs and fees. If the Plan participant loses, the court may order him or her to pay these costs and
fees, for example, if it finds the claim or suit to be frivolous.
If the Plan participant has any questions about the Plan, he or she should contact the Plan
Administrator. If the Plan participant has any questions about the Health Insurance Portability and
Accountability Act (HIPAA), that Plan participant should contact either the nearest area office of the
Pension and Welfare Benefits Administration, U.S. Department of Labor listed in the telephone
directory or the Division of Technical Assistance and Inquiries, Pension and Welfare Benefits
Administration, at 200 Constitution Avenue, N.W., Washington, DC 20210.



    Lower Kuskokwim School District Employee HealthCare Plan                          page   84
                                                                                     HIPAA PRIVACY

COMPLIANCE WITH HIPAA PRIVACY STANDARDS. Certain members of the Employer’s
workforce perform services in connection with administration of the Plan. In order to perform these
services, it is necessary for these employees from time to time to have access to Protected Health
Information (defined below).

Under the Standards for Privacy of Individually Identifiable Health Information (45 CFR Part 164, the
“Privacy Standards”), these employees are permitted to have such access only if the Plan is in
accordance with the Privacy Standards.

(1)       General. The Plan shall not disclose Protected Health Information to any member of the
          Employer’s workforce unless each of the conditions set out in this HIPAA Privacy section is
          met. “Protected Health Information” shall have the same definition as set out in the Privacy
          Standards but generally shall mean individually identifiable health information about the past,
          present or future physical or mental health or condition of an individual, including information
          about treatment of payment for treatment.
(2)       Permitted Uses and Disclosures. Protected Health Information disclosed to members of the
          Employer’s workforce shall be used or disclosed by them only for purposes of Plan
          administrative functions. The Plan’s administrative functions shall include all Plan payment and
          health care operations. The terms “payment” and “health care operations” shall have the same
          definitions as set out in the Privacy Standards, but the term “payment” generally shall mean
          activities taken with respect to payment of premiums or contributions, or to determine of fulfill
          Plan responsibilities with respect to coverage, provision of benefits, or reimbursement for health
          care. “Health care operations” generally shall mean activities on behalf of the Plan that are
          related to quality assessment; evaluation, training or accreditation of health care providers;
          underwriting, premium rating and other functions related to obtaining or renewing an insurance
          contract, including stop-loss insurance; medical review; legal services or auditing functions; or
          business planning, management and general administrative activities.
(3)       Authorized Employees. The Plan shall disclose Protected Health Information only to members
          of the Employer’s workforce who are designated and are authorized to receive such Protected
          Health Information, and only to the extent and in the minimum amount necessary for these
          persons to perform duties with respect to the Plan. For purposes of this HIPAA Privacy section,
          “members of the Employer’s workforce” shall refer to all employees and other persons under the
          control of the Employer.
          (a)     Updates Required. The Employer shall amend the Plan promptly with respect to any
                  changes in the members of its workforce who are authorized to receive Protected Health
                  Information.
          (b)     Use and Disclosure Restricted. An authorized member of the Employer’s workforce who
                  receives Protected Health Information shall use or disclose the Protected Health
                  Information only to the extent necessary to perform his or her duties with respect to the
                  Plan.
          (c)     Resolution of Issues of Noncompliance. In the event that any member of the Employer’s
                  workforce uses or discloses Protected Health Information other than as permitted by the
                  Privacy Standards, the incident shall be reported to the privacy official. The privacy
                  official shall take appropriate action, including:
                        (i) Investigation of the incident to determine whether the breach occurred
                            inadvertently, through negligence, or deliberately; whether there is a pattern of
                            breaches; and the degree of harm caused by the breach;

      Lower Kuskokwim School District Employee HealthCare Plan                         page   85
                                                                 HIPAA PRIVACY (CONTINUED)

                       (ii) Applying appropriate sanctions against the persons causing the breach, which,
                            depending upon the nature of the breach, may include, oral or written reprimand,
                            additional training, or termination of employment;
                       (iii)Mitigating any harm caused by the breach, to the extent practicable; and
                       (iv) Documentation of the incident and all actions taken to resolve the issue and
                            mitigate any damages.
(4)       Certification of Employer. The Employer must provide certification to the Plan that it agrees
          to:
          (a)    Not use or further disclose the Protected Health Information other than as permitted or
                 required by the Plan documents or as required by law;
          (b)    Ensure that any agent or subcontractor, to whom it provides Protected Health Information
                 received from the Plan, agrees to the same restrictions and conditions that apply to the
                 Employer with respect to such information;
          (c)    Not use or disclose Protected Health Information for employment-related actions and
                 decisions or in connection with any other benefit or employee benefit plan of the
                 Employer;
          (d)    Report to the Plan any use or disclosure or the Protected Health Information of which it
                 becomes aware that is inconsistent with the uses or disclosures permitted by this
                 document, or required by law;
          (e)    Make available Protected Health Information to individual Plan members in accordance
                 with Section 164.524 of the Privacy Standards;
          (f)    Make available Protected Health Information for amendment by individual Plan members
                 and incorporate any amendments to Protected Health Information in accordance with
                 Section 164.526 of the Privacy Standards;
          (g)    Make available Protected Health Information required to provide any accounting of
                 disclosures to individual Plan members in accordance with Section 164.528 of the Privacy
                 Standards;
          (h)    Make its internal practices, books and records relating to the use and disclosure of
                 Protected Health Information received from the Plan available to the Department of
                 Health and Human Services for purposes of determining compliance with the Privacy
                 Standards;
          (i)    If feasible, return or destroy all Protected Health Information received from the Plan that
                 the Employer still maintains in any form, and retain no copies of such information when
                 no longer needed for the purpose of which disclosure was made, except that, if such return
                 or destruction is not feasible, limit further uses and disclosures to those purposes that
                 make the return or destruction of the information unfeasible; and
          (j)    Ensure the adequate separation between the Plan and member of the Employer’s
                 workforce, as required by Section 164.504(f)(2)(iii) of the Privacy Standards.




      Lower Kuskokwim School District Employee HealthCare Plan                        page   86
                                                                               HIPAA SECURITY

COMPLIANCE WITH HIPAA ELECTRONIC SECURITY STANDARDS. Under the Security
Standards for the Protection of Electronic Protected Health Information (45 CFR Part 164.300 et. seq.,
the “Security Standards”), the Plan documents must reflect certain obligations required of the Employer.
 (1) The Employer agrees to implement reasonable and appropriate administrative, physical and
       technical safeguards to protect the confidentiality, integrity and availability of Electronic
       Protected Health Information that the Employer creates, maintains or transmits on behalf of the
       Plan. “Electronic Protected Health Information” shall have the same definition as set out in the
       Security Standards, but generally shall mean Protected Health Information that is transmitted by
       or maintained in electronic media.
 (2) The Employer shall ensure that any agent or subcontractor to whom it provides Electronic
       Protected Health Information shall agree, in writing, to implement reasonable and appropriate
       security measures to protect the Electronic Protected Health Information.
 (3) The Employer shall ensure that reasonable and appropriate security measures are implemented to
       comply with the conditions and requirements set forth in compliance with HIPAA Privacy
       Standards provisions (3) Authorized Employees and (4) Certification of Employers.




   Lower Kuskokwim School District Employee HealthCare Plan                      page   87
                                                              HEALTH CARE REFORM NOTICES

                                              Model Statement of Belief
                                                Grandfather Status

The LOWER KUSKOKWIM SCHOOL DISTRICT EMPLOYEE HEALTHCARE PLAN believes this coverage
is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (the Affordable
Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain
basic health coverage that was already in effect when that law was enacted. Being a grandfathered
health plan means that your Plan may not include certain consumer protections of the Affordable Care
Act that apply to other plans, for example, the requirement for the provision of preventive health
services without any cost sharing. However, grand-fathered health plans must comply with certain other
consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on
benefits.
Questions regarding which protections apply and which protections do not apply to a grandfathered
health plan and what might cause a plan to change from grandfathered health plan status can be directed
to the Plan Administrator at (907) 543-4820. You may also contact the U.S. Department of Health and
Human Services at www.healthreform.gov.




   Lower Kuskokwim School District Employee HealthCare Plan                      page   88
                 LOWER KUSKOKWIM SCHOOL DISTRICT
           AIR TRAVEL PRE-AUTHORIZATION SUPPLEMENT FORM
                        THIS FORM MAY BE PHOTOCOPIED AS NEEDED


The Lower Kuskokwim School District Employee HealthCare Plan provided, under special
circumstances and with certain restrictions, benefits for air transportation for you and your dependents.
Please read the description of this benefit in the Description of Medical Benefits in the Summary Plan
Description. In order to consider such expenses, the Plan must have the information requested below.
Please have the attending physician complete the Medical Information section, and mail or fax the
completed form to:
                                      Integrity Administrators, Inc.
                                               P.O. Box 13128
                                        Sacramento, CA 95813-3128
                                            Fax: (916) 921-3383
It is the covered person's responsibility to submit a copy of the airfare ticket for consideration. This may
be submitted to the address or fax number listed above.
Employee's Name: __________________________________________________________
Address: __________________________________________________________________
__________________________________________________________________________
Social Security Number:_____________________________________________________
Patient's Name: ____________________________________________________________
               MEDICAL INFORMATION (to be completed by attending physician)
Physician's Name: __________________________________________________________
Address: __________________________________________________________________
__________________________________________________________________________
Diagnosis of Patient: ________________________________________________________
Treatment Recommended: ___________________________________________________
Will surgery be required? _____________________________________________________
Surgical procedure: __________________________________________________________
If service is not available locally, what is the nearest facility equipped to perform medically necessary
procedure? _________________________________________________________________
Where is the facility located? __________________________________________________
When will the procedure be performed? __________________________________________
Is travel requested for diagnostic testing? _________________________________________
Is travel requested for second opinion evaluation? __________________________________
Physician's Name (printed): __________________________________________________
Physician's Signature: ______________________________________________________
Date: _____________________________________________________________________
Physician's Phone Number: __________________________________________________

								
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