| Plan Options | LivingWell CDHP | LivingWell PPO | LivingWell Basic CDHP | LivingWell HDHP |
| In-Network | Out-of-Network | In-Network | Out-of-Network | In-Network | Out-of-Network | In-Network | Out-of-Network |
| Lifetime Maximum | Unlimited |
| HRA | Single 500; Family 1,000 | No HRA | Single 250; Family 500 | No HRA. Can use a non-KEHP HSA with this plan. |
| Annual Deductible | Single 1,500\nFamily 2,750 | Single 2,750\nFamily 5,250 | Single 1,000\nFamily 1,750 | Single 1,750\nFamily 3,250 | Single 2,000\nFamily 3,750 | Single 3,250\nFamily 6,250 | Single 2,000*\nFamily 4,000* | Single 4,000\nFamily 8,000 |
| Annual Maximum Out-of-Pocket | Applies to Medical and Pharmacy | Applies to Medical | Applies to Medical and Pharmacy | Applies to Medical and Pharmacy |
| Single 3,000\nFamily 5,750 | Single 5,750\nFamily 11,250 | Single 3,000\nFamily 5,750 | Single 5,750\nFamily 11,250 | Single 4,000\nFamily 7,750 | Single 7,750\nFamily 11,250 | Single 8,050\nFamily 16,100 | Single 16,100\nFamily 32,200 |
| Deductibles and Maximum Out-of-Pocket for In-Network and Out-of-Network providers accumulate separately and do not cross-apply |
| Co-Insurance | Plan: 80%\nMember: 20% | Plan: 50%\nMember: 50% | Plan: 75%\nMember: 25% | Plan: 50%\nMember: 50% | Plan: 70%\nMember: 30% | Plan: 50%\nMember: 50% | Plan: 70%\nMember: 30% | Plan: 50%\nMember: 50% |
| Doctor's Office Visit | Deductible, then 20% | Deductible, then 50% | Co-pay:\n25 PCP\n50 Specialist | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% |
| Annual Prescription Drug Maximum Out-of-Pocket | Combined with Medical | Single 2,500\nFamily 5,000 | Single 5,000\nFamily 10,000 | Combined with Medical | Combined with Medical |
| 30-Day Supply\nTier 1 - Generic\nTier 2 - Formulary | Deductible, then 20% | Deductible, then 50% | 20\n40 | 40\n80 | Deductible, then 30% | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% |
| 90-Day Supply\n(Retail or Mail Order) | Deductible, then 20% | Not Covered | 40\n80 | Not Covered | Deductible, then 30% | Not Covered | Deductible, then 30% | Not Covered |
| Covered Services |
| Preventive Care Office Visits |
| Well-baby, well-child visits, as recommended | 100% | Deductible, then 50% | 100% | Deductible, then 50% | 100% | Deductible, then 50% | 100% | Deductible, then 50% |
| Adult annual physical exam | 100% | Deductible, then 50% | 100% | Deductible, then 50% | 100% | Deductible, then 50% | 100% | Deductible, then 50% |
| Immunizations, as recommended | 100% | Deductible, then 50% | 100% | Deductible, then 50% | 100% | Deductible, then 50% | 100% | Deductible, then 50% |
| Screenings including Pap smears, and labs, as part of the preventive office visit | 100% | Deductible, then 50% | 100% | Deductible, then 50% | 100% | Deductible, then 50% | 100% | Deductible, then 50% |
| Outpatient Services |
| Primary Care and Specialist Office Visits | Deductible, then 20% | Deductible, then 50% | Co-pay\n25 PCP\n50 Specialist | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% |
| LiveHealth Online telehealth for Medical and Behavioral Health | 100% | N/A | 100% | N/A | 100% | N/A | N/A | N/A |
| Telehealth with provider other than LiveHealth Online | Deductible, then 20% | Deductible, then 50% | Co-pay\n25 PCP\n50 Specialist | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% |
===== PAGE 10 =====
## Benefits Grid
| Plan Options | LivingWell CDHP | LivingWell PPO | LivingWell Basic CDHP | LivingWell HDHP |
| In-Network | Out-of-Network | In-Network | Out-of-Network | In-Network | Out-of-Network | In-Network | Out-of-Network |
| Diagnostic tests in doctor's office | Deductible, then 20% | Deductible, then 50% | Office Visit Co-pay | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% |
| Surgery in Office Setting | Deductible, then 20% | Deductible, then 50% | Deductible, then 25% | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% |
| Behavioral Health and Substance Abuse Use | Deductible, then 20% | Deductible, then 50% | Deductible, then 25% | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% |
| Autism Services | Deductible, then 20% | Deductible, then 50% | Deductible, then 25% | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% |
| Allergy Injection without Office Visit | Deductible, then 20% | Deductible, then 50% | $15 Co-pay | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% |
| Allergy Serum | Deductible, then 20% | Deductible, then 50% | $15 Co-pay | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% |
| Chiropractic Care (manipulation therapy) (maximum of 26 visits per year, no more than one visit a day) | Deductible, then 20% | Deductible, then 50% | $25 Co-pay | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% |
| Therapy Services (per visit: physical, occupational, speech - maximum combined limit of 90 visits per year) | Deductible, then 20% | Deductible, then 50% | Deductible, then 25% | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% |
| Emergency Services |
| Urgent Care Center | Deductible, then 20% | $50 Co-pay | Deductible, then 30% | Deductible, then 30% |
| Emergency Room (emergency medical treatment only) | Deductible, then 20% | $150 Co-pay, then Deductible, then 25%. Co-pay waived if admitted. | Deductible, then 30% | Deductible, then 30% |
| Emergency Room Physician | Deductible, then 20% | Deductible, then 25% | Deductible, then 30% | Deductible, then 30% |
| Ambulance | Deductible, then 20% | Deductible, then 25% | Deductible, then 30% | Deductible, then 30% |
| Other Services |
| Inpatient Hospital (Semi-private room) | Deductible, then 20% | Deductible, then 50% | Deductible, then 25% | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% |
| Outpatient Hospital/Surgery | Deductible, then 20% | Deductible, then 50% | Deductible, then 25% | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% |
| Outpatient/Ambulatory Surgery Center | Deductible, then 20% | Deductible, then 50% | Deductible, then 25% | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% |
| Maternity Care | Deductible, then 20% | Deductible, then 50% | $25 Co-pay (office visit pregnancy diagnosed) Delivery Charge: Deductible, then 25% | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% |
| Durable Medical Equipment and Supplies | Deductible, then 20% | Deductible, then 20% | Deductible, then 25% | Deductible, then 25% | Deductible, then 30% | Deductible, then 30% | Deductible, then 30% | Deductible, then 30% |
| Home Health Care | Deductible, then 20% | Deductible, then 50% | Deductible, then 25% | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% |
| X-ray, Lab, and Diagnostics including MRI, CT, and PET scans | Deductible, then 20% | Deductible, then 50% | Deductible, then 25% | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% | Deductible, then 30% | Deductible, then 50% |
Notes: The boxed areas of the grid are components of each plan most often used by members when choosing a plan option, but are not all inclusive. You can refer to the Summary of Benefits and Coverage (SBC) for more information. KEHP has made every attempt to ensure the accuracy of the benefits outlined in this Benefits Grid. If an error has occurred, the benefits outlined in the 2025 Summary Plan Descriptions (SPDs) and Medical Benefit Booklets will determine how benefits are paid. Benefits are subject to the terms, conditions, limitations, and exclusions set forth in the SPDs.
• Co-pays do not accumulate toward the deductible, but they do accumulate toward the applicable maximum out-of-pocket. Once your maximum out-of-pocket is met, you do not have to pay any more co-pays.
- Certain drugs to treat diabetes, COPD, asthma, and hypertension are subject to reduced co-pays and co-insurance with no Deductibles. A 90-day supply of maintenance drugs may be subject to lower co-pays and co-insurance. Select preventive/maintenance drugs bypass the deductible on the CDHPs. Claims are processed based on provider billing type, which may include separate charges from a lab performing services outside of the doctor's office visit.
*The HDHP has a non-embedded deductible which means all family members share a deductible and out-of-pocket (OOP) maximum, regardless of the number of family members. The entire deductible must be met before any one family member receives benefits. The entire OOP must be met before the family has satisfied the OOP maximum.
===== PAGE 11 =====
## 2025 Monthly Premium Contributions for Non-Tobacco Users
| Bronze2 | Silver2 | Gold2 |
| Your Dental Plan at a Glance | In/Out-of-Network3 | In/Out-of-Network3 | In/Out-of-Network3 |
| Annual Benefit Maximum4 | 750 | 1,000 | 1,500 |
| Annual Deductible | 50 | 50 | 50 |
| Orthodontia\n(only for children through the age of 18) | Not covered | Not covered | 1,500 |
| Diagnostic and\nPreventive Services | 100%/100% of allowable amount3 | 100%/100% of allowable amount3 | 100%/100% of allowable amount3 |
| Basic Services | 50%/50% of allowable amount3 | 80%/80% of allowable amount3 | 80%/80% of allowable amount3 |
| Oral Surgery (Simple) | 50%/50% of allowable amount3 | 80%/80% of allowable amount3 | 80%/80% of allowable amount3 |
| Major Services5\n(including Complex Oral Surgery,\nPorcelain Crowns, and Implants) | Not covered | 50%/50% of allowable amount3 | 50%/50% of allowable amount3 |
| Annual Maximum Carryover | Not covered | Not covered | Covered |
No waiting periods for basic or major services. Up to 24-month waiting period missing tooth clause.5
| Bronze3 | Silver3 | Gold3 |
| Exam with dilation as necessary | 10 co-pay | 10 co-pay | 10 co-pay |
| Frames | 125 allowance and 20% off any remaining balance | 150 allowance and 20% off any remaining balance | 150 allowance and 20% off any remaining balance |
| Eyeglass lenses: single vision, bifocal, trifocal, lenticular | 25 co-pay | 10 co-pay | 10 co-pay |
| Standard progressive lens | Standard fixed price/discount | Standard fixed price/discount | 20 co-pay |
| Contact lenses |
| Conventional | 150 allowance, 15% off balance over 150 | 150 allowance, 15% off balance over 150 | 175 allowance, 15% off balance over 175 |
| Disposable | 150 allowance | 150 allowance | 175 allowance |
| Medically necessary | Covered in full | Covered in full | Covered in full |
| Frequency |
| Examination | Once every calendar year | Once every calendar year | Once every calendar year |
| Lenses or contact lenses | Once every calendar year | Once every calendar year | Once every calendar year |
| Frame | Once every two calendar years | Once every two calendar years | Once every calendar year |
| Partners and Programs | Phone Numbers | Websites |
| 24/7 NurseLine | 877-636-3720 | |
| Acupuncture @ UK Healthcare Integrative Medicine and Health | 859-323-HEAL (4325) | |
| Anthem - Health Insurance | 844-402-5347 | anthem.com/kehp |
| Behavioral Health Resource Center and Substance Use Disorder Resource Line | 855-873-4931 | |
| Building Healthy Families - Maternity Care | 844-402-5347 | anthem.com |
| Carrum | 888-855-7806 | carrum.me/kehp |
| Castlight | 800-681-6758 | mycastlight.com/mybenefits |
| COBRA | 888-678-4881 | healthequity.com |
| CVS | | |
| Caremark - Prescriptions | 866-601-6934 | caremark.com |
| Weight Management Program | 800-706-9317 | |
| Dental and Vision Insurance | 844-402-5347 | anthem.com |
| HealthEquity - FSA and HRA | 877-430-5519 | healthequity.com (when prompted, select WageWorks) |
| Hinge Health - Digital Alternative to Physical Therapy | 855-902-2777 | hingehealth.com/kehp |
| Judicial Retirement Plan | 502-564-5310 | |
| Kentucky Community & Technical College System | 859-256-3100 | |
| Kentucky Public Pension Authority | 800-928-4646 | kyret.ky.gov |
| 502-696-8800 |
| Kentucky Deferred Compensation | 800-542-2667 | kentuckydcp.ky.gov |
===== PAGE 34 =====
| Partners and Programs | Phone Numbers | Websites |
| Lark - Diabetes Prevention Program | 844-402-5347 | lark.com/anthem |
| Legislative Retirement Plan | 502-564-5310 | |
| LiveHealth Online Medical and Behavioral Health | 888-548-3432 | |
| LivingWell Health Clinics (employees only, no retirees, spouses, or dependents) | | |
| 300 Building, Frankfort | 502-564-3444 | |
| Capitol Annex, Frankfort | 502-564-3333 | |
| CHFS, Frankfort | 502-564-5555 | |
| Mayo-Underwood Building, Frankfort | 502-564-4444 | |
| Premise Health Wellness Center-Brownsboro, Louisville | 502-272-0330 | |
| MetLife Life Insurance | 800-638-6420 | |
| RethinkCare - Family support | 800-714-9285 | connect.rethinkcare.com/sponsor/kehp |
| SmartShopper - Transparency, shop for better pricing | 855-869-2133 | smartshopper.com |
| Teachers' Retirement System | 800-618-1687 | trs.ky.gov |
| 502-848-8500 | |
===== PAGE 35 =====
## Legal Notices
As a member of the Kentucky Employees' Health Plan (KEHP), you have certain legal rights. Several of those rights are summarized below. Please read these provisions carefully. To find out more information, you may contact the Department of Employee Insurance, Member Services Branch at (888) 581-8834 or (502) 564-6534 or visit kehp.ky.gov.
### A. NOTICE ABOUT SPECIAL ENROLLMENT RIGHTS
Under the Health Insurance Portability and Accountability Act (HIPAA), you have “special enrollment” rights
if you have a loss of other coverage or you gain a new dependent. In addition, you may qualify for a special
enrollment in KEHP under the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA).
If you decline enrollment for yourself or your eligible dependent(s) (including your spouse) because of other health insurance or group health plan coverage (regardless of whether the coverage was obtained inside or outside of a Marketplace), you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents' other coverage). However, you must request enrollment within 30 days after your or your dependents' other coverage ends (or after the employer stops contributing toward the other coverage).
unable to meet a standard to earn an incentive under the LivingWell wellness program, you may request a reasonable accommodation or an alternative standard. Contact the Department of Employee Insurance, Member Services Branch at (888) 581-8834 or (502) 564-6534 and we will work with you (and, if you wish, with your doctor) to find a wellness program with the same incentive that is right for you in light of your health status.
If you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your new dependent(s). However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.
### 3. CHIPRA Special Enrollment Provision – Premium Assistance Eligibility
If you or your children are eligible for Medicaid or the Children's Health Insurance Program (CHIP) and you're eligible for health coverage from your employer, Kentucky may have a premium assistance program that can help pay for coverage using funds from the state's Medicaid or CHIP programs. If you or your dependent(s) are eligible for premium assistance under Medicaid or CHIP, as well as eligible for health insurance coverage through KEEP, your employer must allow you to enroll in KEEP if you aren't already enrolled. This is called a "special enrollment" opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. In addition, you may enroll in KEEP if you or your dependent's Medicaid or CHIP coverage is terminated because of loss of eligibility. An employee must request this special enrollment within 60 days of the loss of coverage. You can find more information and the required CHIP notice at kehp.ky.gov (Resources/Docs, Forms, and Legal Notices link).
Protections from Disclosure of Medical Information: KEHP is required by law to maintain the privacy and security of your personally identifiable health information. KEHP does not collect or retain personal health or medical information through its LivingWell wellness program unless it is part of an audit, compliance, payment, operations, or customer service review; however, KEHP may receive and use aggregate information that does not identify any individual in order to design programs based on health risks
### B. WELLNESS PROGRAM DISCLOSURE AND NOTICE
that does not identify any individual in order to design programs based on health risks
the workplace and that are aimed at improving the health of KEHP members. KEHP will nev
disclose any of your personal information either publicly or to your employer, except as necessary to respond to a request from you for a reasonable accommodation needed to participate in the wellness program, or as expressly permitted by law. Medical information that personally identifies you that is provided in connection with the wellness program will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment.
LivingWell is KEHP's voluntary wellness program available to all persons who enroll in a KEHP health insurance plan and their enrolled spouse. The program is administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease. Those federal rules include the Americans with Disabilities Act of 1990, the Genetic Information Nondiscrimination Act of 2008, and the Health Insurance Portability and Accountability Act, as applicable, among others. If you choose to participate in the wellness program, you will be asked to complete a voluntary health assessment (or "HA") that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (e.g., cancer, diabetes, or heart disease). You are not required to complete the HA. However, employees who choose to participate in the LivingWell wellness program will receive an incentive in the form of discounted employee premium contributions for the employee's health insurance coverage. Although you are not required to complete the HA, only employees who do so will receive the discounted health insurance premiums.
If you or your children are eligible for Medicaid or the Children's Health Insurance Program (CHIP) and you're eligible for health coverage from your employer, Kentucky may have a premium assistance program that can help pay for coverage using funds from the state's Medicaid or CHIP programs. If you or your dependent(s) are eligible for premium assistance under Medicaid or CHIP, as well as eligible for health
Your health information will not be sold, exchanged, transferred, or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the wellness program. You will not be asked or required to waive the confidentiality of your health information as a condition of participating in the wellness program or receiving an incentive. Anyone who receives your information for purposes of providing you services as part of the wellness program will abide by the same confidentiality requirement. The only individuals who may receive your personally identifiable health information are persons employed by Castlight (KEHP's wellness administrator) and Anthem (KEHP's third-party medical administrator). This may include nurses in Anthem's disease management program or health coaches. Disclosure of your personally identifiable health information to these persons is necessary in order to provide you with
Additional incentives in the form of gift cards, consumer goods, and other prizes may be available for employees who participate in certain health-related activities such as walking challenges or quitting smoking. In addition, KEHP offers discounted, monthly employee premium contribution rates to non-tobacco users. Each KEHP member has at least one opportunity per Plan Year to qualify for the monthly premium contribution discount.
personally identifiable health information to these persons is necessary in order to provide you with services under the wellness program.
In addition, all medical information obtained through the wellness program will be maintained separate from your personnel records; information stored electronically will be encrypted; and no information you provide as part of the wellness program will be used in making any employment decision.
Appropriate precautions will be taken to avoid any data breach. In the event a data breach occurs involving information you provide in connection with the wellness program, we will notify you as soon as it is feasible after discovery of the breach.
You may not be discriminated against in employment because of the medical information you provide as part of participating in the LivingWell wellness program, nor may you be subjected to retaliation if you choose not to participate.
If you have questions or concerns regarding this notice, or about protections against discrimination and retaliation, please contact the Department of Employee Insurance, Member Services Branch at (888) 581-8834 or (502) 564-6534.
C. THE CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT OF 1986 (COBRA)
COBRA continuation coverage is a continuation of KEHP coverage when it would otherwise end because of a life event, also called a “qualifying event.” After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” Qualified beneficiaries may elect to continue their coverage under the plan for a prescribed period of time on a self-pay basis. Each qualified beneficiary has 60 days to choose whether or not to elect COBRA coverage, beginning from the later of the date the election notice is provided, or the date on which the qualified beneficiary would otherwise lose
KEHP is committed to helping you achieve your best health. Incentives for participating in KEH wellness program are available to all persons who enroll in a KEHP health insurance plan and spouse. If you are unable to participate in any of the health-related activities, or you think you
coverage under KEHP due to a qualifying event. The KEHP's third-party COBRA administrator is HealthEquity. To learn more about COBRA and your rights under COBRA, please refer to the Medical Booklet or go to kehp.ky.gov (Resources/Docs, Forms, and Legal Notices link).
D. THE WOMEN'S HEALTH AND CANCER RIGHTS ACT OF 1998 (WHCRA)
Your plan, as required by WHCRA, provides benefits for mastectomy-related services including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy, including lymphedema. For more information regarding this coverage, please refer to your Medical Benefit Booklet or go to kehp.ky.gov (Resources/Docs, Forms, and Legal Notices link)
===== PAGE 36 =====
### E. NEWBORNS' AND MOTHERS' HEALTH PROTECTION ACT OF 1996 (NEWBORNS' ACT)
Under federal law, group health plans generally may not restrict benefits for a hospital stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 (or 96, as applicable) hours. In any case, health insurance plans may not require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 (or 96) hours.
### F. HIPAA PRIVACY NOTICE
KEHP gathers and collects demographic information about its members such as name, address, and social security numbers. This information is referred to as individually identifiable health information and is protected by HIPAA and related privacy and security regulations. HIPAA requires KEHP to maintain the privacy of your protected health information (PHI) and notify you following a breach of unsecured PHI. In addition, KEHP is required to provide to its members a copy of its Notice of Privacy Practices (NPP) outlining how KEHP may use and disclose your PHI to carry out treatment, payment, or health care operations, or for any other purposes that are permitted or required by law. The NPP also informs members about their rights regarding their PHI and how to file a complaint if a member believes their rights have been violated. KEHP's Notice of Privacy Practices and associated forms may be obtained by visiting kehp.ky.gov (Resources/Docs, Forms, and Legal Notices link).
### G. KEHP PRESCRIPTION DRUG COVERAGE AND MEDICARE-NOTICE OF CREDITABLE COVERAGE
KEHP has determined that KEHP's prescription drug coverage is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.
### H. NOTICE OF AVAILABILITY OF SUMMARY OF BENEFITS AND COVERAGE (SBC)
As an employee or retiree, the health benefits available to you represent a significant component of your compensation/retirement package. Those benefits also provide important protection for you and your family in the case of illness or injury. KEHP offers a variety of health coverage options, and choosing the option that is right for you and your family is an important decision. To help you make an informed health coverage choice, KEHP publishes a Summary of Benefits and Coverage (SBC). For easier comparison, the SBC summarizes important information about your health coverage options in a standard format. The SBCs are only a summary. You should consult KEHP's Summary Plan Descriptions and Medical Benefit Booklets to determine the governing contractual provisions of the coverage. KEHP's SBCs are available on KEHP's website at kehp.ky.gov (Resources/Docs, Forms, and Legal Notices link). A paper copy is also available, free of charge, by contacting the Department of Employee Insurance, Member Services Branch at (888) 581-8834 or (502) 564-6534.
### I. WAIVER HEALTH REIMBURSEMENT ARRANGEMENT (HRA)
If an employer participates in the Waiver Health Reimbursement Arrangement (HRA) program through KEHP, an employee may elect to waive KEHP health insurance coverage and choose a Waiver HRA that is funded by the employer, up to $2,100 a year. There are two Waiver HRA options: the Waiver General Purpose HRA and the Waiver Limited Purpose HRA. An employee is eligible for the Waiver General Purpose HRA only if the employee, and the employee's spouse and dependents, if applicable, have other group health plan coverage. An employee that elects a Waiver General Purpose HRA must attest that the employee and, if applicable, the employee's spouse and dependents are enrolled in another group health plan that provides minimum value. A "group health plan" refers to coverage provided by an employer, an employer organization, or a union. A "group health plan" does not include individual policies purchased through the Marketplace or governmental plans such as TRICARE, Veteran's Benefits, Medicare, or Medicaid. A group health plan that provides "minimum value" means the plan pays at least 60% of the total allowed cost of covered benefits/services and participants or members in the plan are required to pay no more than 40% of the total allowed cost of covered benefits/services. An employee that elects a Waiver General Purpose HRA and that ceases to be covered under another group health plan that provides minimum value is required to notify KEHP within 30 days of the date that the other group health plan coverage ceased. In this event, coverage under the Waiver General Purpose HRA will be terminated, and the employee may elect a KEHP health insurance plan option or the Waiver Limited Purpose HRA. Each employee is permitted to permanently opt out of and waive future reimbursements from the Waiver General Purpose HRA at least annually during open enrollment.
===== PAGE 37 =====
# KEHP Tobacco Use Declaration
The Commonwealth of Kentucky is committed to fostering and promoting wellness and health in the workforce. As part of KEHP's LivingWell wellness program, KEHP offers a monthly discount in health insurance premium contribution rates for non-tobacco users. You are eligible for the non-tobacco-user premium contribution rates provided you certify, during the health insurance enrollment process, that you or any other person over the age of 18 to be covered under your plan has not regularly used tobacco within the past six months. "Regularly" means tobacco has been used four or more times per week on average excluding religious or ceremonial uses. "Tobacco" means all tobacco products including, but not limited to, cigarettes, pipes, chewing tobacco, snuff, dip, cigars, and any other tobacco products regardless of the method of use. "KEHP Health Insurance Enrollment Application" refers to any method of enrolling in KEHP health insurance coverage including submitting a paper application, completing and submitting an application online, or enrolling in KEHP health insurance coverage through an online enrollment system such as KHRIS.
Whether you complete your KEHP health insurance enrollment online or submit a paper application, you are required to certify that all attestations regarding tobacco use are accurate. By completing the enrollment process, you certify the following:
1. I have truthfully answered all questions in my KEHP Health Insurance Enrollment Application regarding tobacco use by me, my spouse, and my dependents 18 years of age and over. My KEHP Health Insurance Enrollment Application accurately reflects the use of tobacco products in the past six months regarding myself and persons to be covered as a spouse or dependent under my insurance plan.
2. If I am completing my KEHP Health Insurance Enrollment Application during open enrollment, I understand that the tobacco-user premium contribution rates will apply beginning January 1, 2025, if I answered "Yes" to the tobacco use question.
3. If I am completing my KEHP Health Insurance Enrollment Application as a newly hired employee, I understand that the tobacco-user premium contribution rates will apply beginning on the first day of the second month after my hire date, if I answered "Yes" to the tobacco use question for non-commonwealth paid employees and up to the first day of hire for commonwealth paid employees.
4. I understand that it is my responsibility to notify KEHP of any changes in my tobacco use or that of my spouse or a dependent covered under my insurance plan, including notification to KEHP if all tobacco users become ineligible for coverage or are otherwise terminated during the Plan Year. Notification shall be made by completing a Tobacco Use Change Form.
5. I understand that if I or a spouse or dependent to be covered under my insurance plan currently use tobacco products and stop using tobacco products during the Plan year, I will be eligible for the discount non-tobacco premium contribution rates on the first day of the month following the signature date on the Tobacco Use Change Form certifying that neither I nor my spouse/dependent(s) regularly used tobacco products during the six months prior to completion of the Tobacco Use Change Form. Both cross-reference planholders must sign the Tobacco Use Change Form.
6. I understand that if I answered "No" to the tobacco use question, and either I or a spouse or dependent covered under my insurance plan becomes a regular tobacco user at any time, I must notify KEHP and my contribution rates will be adjusted to the tobacco-user premium contribution rates on the first day of the month following the signature date on the Tobacco Use Change Form.
7. I understand that the tobacco use question is a part of my KEHP application for health insurance coverage. Any person who knowingly, and with the intent to defraud, files an application for insurance containing any materially false information, or who conceals, for the purpose of misleading, information concerning any fact material to the application, commits a fraudulent insurance act which is a crime.
8. I understand that if I fail to answer the tobacco use questions truthfully, KEHP may adjust my contribution rates retroactively to apply the applicable higher tobacco-user premium contribution rates. Upon written notification, I will pay to KEHP the difference between the tobacco-user and the non-tobacco user premium contribution rates for the period for which I falsely certified eligibility for the non-tobacco user premium contribution rates.
9. The KEHP offers monthly discounted premium contribution rates to non-tobacco users as a part of its LivingWell wellness program. Each KEHP member has at least one opportunity per Plan Year to qualify for the discount. KEHP is committed to helping you achieve your best health. Rewards for participating in a wellness program are available to all employees. If you think you might be unable to meet a standard for a reward under this wellness program, you might qualify for an opportunity to earn the same reward by different means. Contact the Department of Employee Insurance at (888) 581-8834 or (502) 564-6534 and we will work with you (and, if you wish, with your doctor) to find a wellness program with the same reward that is right for you in light of your health status.
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# Terms and Conditions
An Employee and Retiree (where applicable) may affix a signature to a paper copy of the KEHP Health Insurance Enrollment Application, the Group Life Insurance Application, the Group Dental or Vision Applications, or an electronic version of the applications. By typing your name on an electronic application or by logging in and using your unique KHRIS User ID and enrolling through the Employee Self-Service portal, you are agreeing to conduct enrollment in life, health, dental, and vision insurance coverage by electronic means, thereby creating a legal and binding contract, as well as consenting to receiving any and all records or disclosures in electronic form at the election of DEI or your employer as described in Section 4A below. By affixing your signature in either manner, you understand and agree that:
ald Retiree (Wiere applicable) may allx a sagiature to a paper copy of title KEHP Healtil
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#### A. PLAN YEAR. The 2025 Plan Year begins January 1, 2025 and ends at midnight on December 31, 2025
I. PRIORITY OF PAYMENTS. Any moneys submitted to DEI that you intend to be used to fund your FSA or pay for insurance premium contributions may first be used to pay other priority debts that may be due and owing, such as taxes and child support.
B. EFFECTIVE DATE OF ELECTIONS. If you are electing a health plan, dental plan, vision plan, or a Flexible Spending Account (FSA) during open enrollment, the coverage will be effective January 1 of the following Plan Year. If you are a new employee or a newly eligible employee, the coverage will be effective on an FSA outside of open enrollment, the FSA and your insurance coverage will be effective the first day of the second month after a new employee or newly eligible employee is eligible to enroll for non-common wealth paid employees and up to the first day of hire for common wealth paid employees. Employees enrolling in life insurance must be actively at work, full time, on the day the employee's insurance is scheduled to begin.
B. EFFECTIVE DATE OF ELECTIONS. If you are electing a health plan, dental plan, vision plan, or a Flexible Spending Account (FSA) during open enrollment, the coverage will be effective January 1 of the following Plan Year. If you are a new employee or a newly eligible employee electing insurance coverage or an FSA outside of open enrollment, the FSA and your insurance coverage will be effective the first day of the
seconda montn atter a new employee or newly eligible employee is eligible to enroll for non-commonwealth paid employees and up to the first day of hire for commonwealth paid employees. Employees are enrolling in life insurance must be actively at work, full time, on the day the employee's insurance is scheduled to begin.
C. PLAN INFORMATION. You have read and understood the 2025 Benefits Selection Guide (BSG). Plan rules and limitations are contained in the KEHP Summary Plan Descriptions (SPD) or Medical Benefit Booklets (MBB) and the Summary of Benefits and Coverage (SBC). Life, dental, and vision insurance rules and limitations are outlined in Certificates of Coverage (CoC). All benefits for your eligible dependents and you will be provided in accordance with the rules and limitations in the SPDs, MBBs, BSG, SBCs, and CoCs. You will abide by all terms and conditions governing participation, membership, and receipt of services from the plan(s) in which you have enrolled and as set forth in the SPD, MBB, and CoC. In the event of a conflict between the terms of coverage stated in the SPDs, the MBBs, the BSG, the SBCs, and the CoCs, the terms of coverage stated in the SPDs or MBBs and CoCs will govern.
J. CHILD AND ADULT DAYCARE FSA ELECTION AND CARRYOVER. If you choose a Child and Adult Daycare FSA, you are eligible to seek reimbursement, as authorized by 26 U.S.C. Sections 21 and 129, for dependent care expenses. You may elect to contribute up to $2,500 (or $5,000 in the case of an Employee who is married and filing jointly) into a Child and Adult Daycare FSA for Plan Year 2025. The Child and Adult Daycare FSA may only reimburse eligible dependent care expenses that are incurred during the applicable coverage period. Funds in your Child and Adult Daycare FSA may only be used to reimburse eligible child and adult daycare expenses and may not be refunded upon termination of the FSA for any reason. Funds contributed into a Child and Adult Daycare FSA will not carryover to the next plan year.
L. HEALTHEQUITY HEALTHCARE CARD. HealthEquity will administer FSAs and HRAs for the 2025 Plan Year and will issue a HealthEquity Healthcare Card to you for the payment of eligible Healthcare FSA and HRAA expenses. Your HealthEquity Healthcare Card will be suspended if requested claim verification is not sent to HealthEquity within ninety (90) days after the card swipe. You agree to follow all rules and guidelines established by the Plan concerning the HealthEquity Healthcare Card. The Plan reserves the right to deny access to the card, require repayment, deduct/withhold from your paycheck, and offset your Healthcare FSA or HRA if you fail to verify a claim.
K. HEALTHCARE FSA ELECTION AND CARRYOVER. You may elect to contribute up to $3,200 into a Healthcare FSA for Plan Year 2025 to pay for eligible health care expenses not paid for by your health insurance plan. Unused amounts of at least $50 and up to a maximum of $640 remaining in your Healthcare FSA at the end of the Plan Year will carry over to the next Plan Year and may be used to
E. CROSS-REFERENCE. The cross-reference payment option for health insurance may be available to spouses who are both eligible to participate in KEHP and have at least one dependent. If your spouse and you are eligible and elect the cross-reference payment option for health insurance, you are planholders with family coverage. Upon a loss of eligibility by either spouse, the remaining planholder will default to a parent-plus coverage level. The cross-reference payment option ceases upon loss of eligibility or employment by either spouse/planholder. NOTE: Effective 1/1/2025, there will not be new cross-reference plans offered for newly eligible enrollees. Planholders with existing eligibility for cross-reference plans ma
employment by either spouse/planholder. NOTE: Effective 1/1/2025, there will not be new cross-reference plans offered for newly eligible enrollees. Planholders with existing eligibility for cross-reference plans may have such eligibility extended past 1/1/2025.
reimburse you for eligible expenses that are incurred during the subsequent Plan Year. You may use the Healthcare FSA carry over amounts whether or not you elect a Healthcare FSA for the subsequent Plan Year. Amounts over $640 remaining in your Healthcare FSA at the end of the Plan Year are forfeited. All funds remaining in a Healthcare FSA account where there have been no new contribution elections for two consecutive Plan Years will be forfeited.
F. DEPENDENT ELIGIBILITY. You certify that each enrolled dependent meets the dependent eligibility requirements as set forth in the SPDs, MBBs, and CoCs. DEI will require supporting documentation to verify the eligibility of any dependent enrolled or requesting to be enrolled in benefits. Spouses and step-children may be subject to periodic re-verification upon notice to you. Your failure to properly document dependent eligibility will result in the termination of the unverified dependent from your insurance plan(s).
D. THIRD PARTY ADMINISTRATORS. DEL uses third parties, including Anthem, CVS/Caremark, HealthEquity, Castlight, SmartShopper, and Metropolitan Life Insurance Company (MetLife) to provide certain administrative functions. DEI may communicate with you directly or through these third parties about your insurance coverage, your benefits, or health-related products or services provided by or included in the Commonwealth's group health, dental, vision, or life insurance plans.
M. WAIVING HEALTH INSURANCE COVERAGE. If you elect to waive KEHP health insurance coverage, with a without a Waiver Health Reimbursement Arrangement (HRA), you are doing so voluntarily. If your employer participates in the Waiver HRA program, there are two options available: the Waiver General Purpose HRA and the Waiver Limited Purpose HRA. You understand that you will be eligible for the Waiver General Purpose HRA only if you have other group health plan coverage. You further understand that your spouse and eligible dependents, if applicable, cannot be covered under the Waiver General Purpose HRA unless your spouse and dependents also have other group health plan coverage.
H. DEDUCTION FROM EARNINGS. When you enroll in insurance coverage (health, dental, vision, or life) or an FSA, you authorize your employer to deduct from your earnings the amount required to cover your employee contribution to the FSA and insurance coverage you elected, including any arrears you may owe. Deductions for FSA and the employee contributions to health, dental, and vision insurance are made on a pre-tax basis unless you sign a Post-Tax Request Form. Deductions for life insurance premiums are made on a post-tax basis.
N. WAIVER GENERAL PURPOSE HRA RULES. If you elect a Waiver General Purpose HRA, you declare that you and your spouse and dependents, if applicable, are enrolled in another group health plan that provides minimum value. A "group health plan" refers to coverage provided by an employer, an employer organization, or a union. A "group health plan" does not include individual policies purchased through the
... group mean plan" does not include individual policies purchased through the
mental plans such as TRICARE, Veteran's Benefits, Medicare, or Medicaid. A group
vides "minimum value" means the plan has at least one cost of
.arketplace or governmental plans such as TRICARE, Veteran's Benefits, Medicare, or Medicaid. A group health plan that provides “minimum value” means the plan pays at least 60% of the total allowed cost of covered benefits/services and participants or members in the plan are required to pay no more than 40% of the total allowed cost of covered benefits/services. If you elect a Waiver General Purpose HRA and cease to be covered under another group health plan that provides minimum value, you agree to notify KEHP within 30 days of the date that the other group health plan coverage ceased. In this event, coverage under the Waiver General Purpose HRA will be terminated and you may elect a KEHP health insurance plan option
to be covered under another group health plan that provides minimum value, you agree to notify KEHP within 30 days of the date that the other group health plan coverage ceased. In this event, coverage under the Waiver General Purpose HRA will be terminated and you may elect a KEHP health insurance plan option or the Waiver Limited Purpose HRA. Unused funds remaining in the Waiver General Purpose HRA upon termination are forfeited. You are permitted to permanently opt out of and waive future reimbursements
; Waiver General Purpose HRA at least annually at open enrollment.
O. HRA CARRYOVER. Waiver HRAs: Unused amounts up to and including $2,100 remaining in your Waiver HRA at the end of the Plan Year may be carried over to the next Plan Year provided you are eligible to elect an HRA. CDHP Integrated HRAs: Unused amounts up to and including $7,500 remaining in your CDHP Integrated HRA at the end of the Plan Year may be carried over to the next Plan Year. You must elect the same type of HRA in a subsequent Plan Year for the funds to carry over.
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# Terms and Conditions
P. WAIVER HRA/FSA FUNDS AFTER TERMINATION. You may use funds remaining in a Waiver HRA or FSA after termination to reimburse you for eligible expenses incurred during the coverage period and prior to termination of the HRA or FSA. Upon termination of employment, including retirement, the remaining amounts in a Waiver HRA and FSA are forfeited, except that you may be reimbursed for any eligible expenses incurred prior to the last day of the last pay period worked, provided that you file a claim by March 31 following the close of the Plan Year in which the expense was incurred.
Q. HRA AND FSA EXPENSE REIMBURSEMENT. An HRA and/or Healthcare FSA may only reimburse you for medical expenses, as authorized by 26 U.S.C. Sections 105(b) and 213(d), that are incurred during the applicable coverage period. Federal law now permits you to use your HealthEquity card to pay for over-the-counter (OTC) medications, drugs, menstrual care products, and certain personal protective equipment such as face masks, hand sanitizer, and sanitizing wipes. The Waiver Limited Purpose HRA may only reimburse you for eligible dental and vision expenses. If you have an FSA and an HRA, funds for eligible expenses will be reimbursed from your FSA first before being reimbursed from your HRA.
R. HRA AND FSA RUN-OUT PERIOD. You have a 90-day run-out period (until March 31) for reimbursement of eligible FSA and HRA expenses incurred during the period of coverage.
S. MINIMUM ESSENTIAL COVERAGE. KEHP provides plan options that, under the Affordable Care Act, constitute minimum essential coverage that is affordable and provides a minimum value. As such, by receiving an offer of coverage through your employer, neither you, your spouse, nor your dependent(s) are eligible for a health insurance premium tax credit if purchasing insurance through the Marketplace.
T. COORDINATION OF KEHP HEALTH PLANS AND MEDICARE COVERAGE. In general, the three KEHP plan options and the Waiver General Purpose HRA must pay primary to Medicare. The Waiver Limited Purpose HRA pays secondary to Medicare.
U. LIVINGWELL PROMISE. Federal law allows KEHP to reward members who participate in the KEHP's LivingWell wellness program. In 2025, all four KEHP health plans are a part of the KEHP's LivingWell wellness program and require completion of the LivingWell Promise in order to receive premium discounts in Plan Year 2026.
If you fulfilled your LivingWell Promise in 2024, you will receive a monthly premium discount of up to $40.00 in 2025. If you did not fulfill your LivingWell Promise, you will not receive a monthly premium discount in 2025.
If you elect a KEHP health plan in 2025, you must complete a Health Assessment provided by Castlight between January 1, 2025, and July 1, 2025, to receive a premium discount in 2026. If you are a new employee with a hire date after January 1, 2025 and you choose a LivingWell plan option outside of open enrollment, you will not be required to complete the LivingWell Promise to receive the premium discount in 2026.
V. INSURANCE DEPENDENT ELECTIONS AND PREMIUM REFUND. It is your responsibility to timely notify DEI that either your dependent or your spouse is no longer eligible for life insurance coverage. (See the eligibility provisions CoC for more information on eligibility). “Timely” notice means that you advised DEI that a dependent or spouse is no longer eligible for insurance coverage within 90 days of the loss of eligibility. Upon notice that a dependent or spouse is no longer eligible for insurance coverage, DEI will refund your premium back to the date that eligibility ceased, up to a maximum of 90 days.
W. HIPAA. You have rights under HIPAA regarding the protection of your health information. KEHP will comply with the HIPAA Privacy and Security rules, and uses and disclosures of your protected health information will be in accordance with federal law. KEHP may use and disclose such information to business associates or other third parties only in accordance with KEHP's Notice of Privacy Practices available at kehp.ky.gov (Resources/Docs, Forms, and Legal Notices link).
X. FRAUD WARNING. Any person who knowingly, and with the intent to defraud, files an application for insurance containing any materially false information
Y. ACKNOWLEDGEMENT. You have fully read these Terms and Conditions, the KEHP Legal Notices, and the KEHP Tobacco Use Declaration. Your signature on the KEHP Health Insurance Enrollment Application, the Group Dental or Vision Applications, the Group Life Insurance Application, or your electronic signature used for online enrollment certifies that all information provided during this enrollment opportunity is correct to the best of your knowledge.
(including a forged signature or incorrect signature date), or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act which is a crime. You can be held responsible for any fraudulent act that you could have prevented while acting within your duties related to obtaining employer-sponsored health, dental, vision, and life insurance, and it may be used to reduce or deny a claim or to terminate your coverage. Information contained in your life insurance benefit elections, if incorrect or misleading, may void the policy effective as of the date of issuance.
Z. EXCEPTIONS MAY APPLY. Exceptions may apply to employees of certain employers participating in KEHP's health plan and the Commonwealth's group dental, vision, and life insurance benefits. Exceptions may also apply to TRS, KPPA, KCTCS, LRP, and JRP retirees. Please refer to the participation rules of your employer or retirement system for further information.
AA. CONSENT TO ELECTRONIC DISCLOSURES. You consent to receiving any and all communications, including records, disclosures, or coverage information (or any portion of the same) in electronic form, including by email or through KHRIS, at the election of DEI, the Insurance Coordinator/Human Resource Generalist communicating on DEI's behalf, or a vendor utilized by DEI or your employer for the administration of your insurance benefits. You may still receive paper documents from time to time, or may be required to complete and sign paper documents. You also acknowledge that you may print or save any electronic communication or agreement for your records and later review. You must have access to a computer and web browser that is sufficiently up to date to access the KEHP/KHRIS website and access to an email that accepts external email. You may request a paper copy of any electronic record or disclosure by contacting your employer's insurance coordinator. A fee may be charged for each paper copy. You may withdraw consent to obtain electronic records and notices by contacting your employer's insurance coordinator with the request and filling out any necessary form.
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Kentucky Employees' Health Plan
Help me do it1
Do it myself
Do it for me2