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2023-2024 Benefits Guide 1
HOW TO ENROLL You will be able to complete your enrollment by following the steps listed below. ENROLLMENT OPTIONS 2 01You can enroll independently through our online Enrollment Platform. Login instructions are included on the next page.02You can complete a paper election sheet to enroll or waive coverage. Please ask your employer for this form.
_________________________________EMPLOYEE BENEFITS: HOWTO LOGINTOBERNIE PORTALACCOUNTBelow are the instructions for how to login both with and without an email address:How to login with email:Go to: https://www.bernieportal.com/en/loginEmployee default logins:Username: email addressPassword: Selecttheforgotpasswordoption ifyou donotrememberorhavenotsetoneupbefore.ORHow to login without email:https://www.bernieportal.com/en/emplovercode/loginEmployee code logins:2-digit code: 2-digit birth month (Example:March=03)4-digit code: last 4 of socialEmployer code:____________KST Energy Services4a225f3
DeductibleFamily DeductibleCoinsuranceOut-Of-PocketOffice VisitSpecialty Doctor Office VisitInpatient Hospital ServicesPreventative Lab & X-RayAdvanced ImaginingUrgent CareEmergency RoomRXEmployee OnlyEmployee + SpouseEmployee + Child(ren)Employee + Family$146.82$269.29$266.86$449.35$146.82 $266.86Employees Weekly Rate$105.99$310.09$45 Copay$90 Copay$300 Copay + 90% After Ded.90% After Ded.In$6,250$12,50090%$8,500 ($17,000)$250 Copay 70% After Ded.$80 Copay$500 Copay + 90% After Ded.0/10/50/100/150/250No$75 Copay 70% After Ded.$300 Copay + 80% After Ded. As INN0/10/50/100/150/250 10/20/70/120/150/250$500 Copay + 80% After Ded. As INN0/10/50/100/150/250 10/20/70/120/150/250Unlimited$30 Copay 70% After Ded.$60 Copay 70% After Ded.$150 Copay + 80% After Ded. 70% After Ded.80% After Ded. 70% After Ded.S9M2CHCPPOIn OutG9L1CHCPPOIn OutS640ADTHMOYes$45 Copay 60% After Ded.60% After Ded.$90 Copay 60% After Ded.60% After Ded.$75 Copay$300 Copay + 80% After Ded. $350 Copay + 60% After Ded.$100 Copay + 80% After Ded. 60% After Ded.$200 Copay + 80% After Ded.$11,250 $22,50080% 60%$9,000($18,000) Unlimited$310.09$514.19No$3,750 $7,500Employees Weekly Rate$24.36 $84.38Employees Weekly Rate$2,000 $4,000$6,000 $8,00080% 70%$6,000 ($17,100)4 $300 Copay + 90% After Ded.
EN-2026 FOR EMPLOYEES (06-21) Unum | Dental InsuranceKST Energy Services LLCWhat else is included?Pregnancy benefitAn extra cleaning for expecting mothers in their 2nd or 3rd trimester.Wellness benefitsOral cancer screenings for patients 40 and older with high risk factors.Unumdentalcare.comUse unumdentalcare.com and the mobile app search for providers, manage your benefits and learn about good dental health. Features include easy access to ID Cards, claims history and coverage information.Carryover benefitsMembers who take care of their teeth, but use only part of their annual maximum benefit during a benefit period are rewarded with extra benefits in future years! Carryover benefits will be accrued and stored in the insured’s carryover account to be used in the next benefit year.The limits for this policy/certificate are:Passive PPOCarryover benefit $400Threshold limit $800Carryover account limit$1,500Unum Dental™ Dental Insurance can help you pay for dental exams, cleanings and other services.Why is this coverage so valuable?Routine dental care keeps your mouth and whole body healthy.Your plan is backed by Unum’s commitment to excellence in customer service.Personalized website and mobile app to manage your benefits including claims information, ID cards and more.There’s no waiting period for preventive and basic services.How does it work?Good dental care is critical to your overall well-being. With Unum Dental insurance, you can get the attention your teeth need — at a cost you can afford.Unum Dental allows you to see any dentist you choose. To get the most from your benefits and reduce out-of-pocket costs, choose an in-network provider by utilizing our large national network. These providers have agreed to file your claims and uphold the highest quality standards. You can find in-network providers at unumdentalcare.com.5
EN-2026 FOR EMPLOYEES (06-21) Unum | Dental InsuranceDental carryover benet and how it worksEach benefit year a member must have: • One cleaning, •One regular exam, and •Total dental claims for preventive, basic and major covered procedures paid during the year below the threshold limit. •If all three criteria above are met, a portion of the annual maximum will carry over to the next year.Other Specifications: •Each covered family member receives their own carryover benefit. •Group carryover benefit rider must be in effect for one benefit year before any members can utilize carryover benefits. •A member must be on the plan for a minimum of three months before accruing carryover benefits. •Carryover benefit may be used toward preventive, basic and major covered services only •A member’s carryover account will be eliminated, and the accrued carryover benefits lost if the insured has a break in coverage for any length of time or any reason.Dependent childrenDependent age guidelines vary by state. Please refer to your policy certificate or contact customer service at (888) 400-9304.Services not listedIf you expect to require a dental service not included on this brochure, it may still be covered. Please contact customer service at (888) 400-9304 to confirm your exact benefits.Alternate treatmentUnum covers the least expensive most commonly used and accepted American Dental Association treatments. Plan members may elect a more expensive treatment, but will be responsible for the cost difference resulting from the more expensive procedure.Coverage details and costsOverview Passive PPOBenefit Year Maximum*$2,000Deductible**$50 per benefit yearMaximum 3 per familyPlan Coinsurance In-network Non-networkClass A Preventive100% 100%Class B Basic80% 80%Class C Major50% 50%*Applies to Class A, B and C Services, if applicable **Waived for Class A (applies to Class B and C Services) Dental CoveragePassive PPOYouYou and your spouseYou and your childrenFamily†Rates guaranteed for 12 months from the effective date.Monthly cost†$30.42$59.52$79.95$118.206
EN-2026 FOR EMPLOYEES (06-21) Unum | Dental InsuranceCovered Procedures & Waiting PeriodsPassive PPOCLASS A PREVENTIVE SERVICESWaiting Period: None •Routine exams (2 per 12 months) •Prophylaxis (2 per 12 months) – (1 additional cleaning or periodontal maintenance per 12 months, if member is in 2nd or 3rd trimester of pregnancy) •Bitewing x-rays (maximum of 4 films; 1 per 12 months) •Fluoride treatment for children up to age 16 (1 per 12 months) •Sealants for children up to age 16 (permanent molars, 1 per 36 months) • Space MaintainersCLASS B BASIC SERVICESWaiting Period: None •Emergency Treatment (1 per 12 months) •Full mouth/panoramic x-rays (1 per 36 months) •Simple restorative services (fillings) – Posterior composite restorations •Simple extractionsCLASS C MAJOR SERVICESWaiting Period: 12 months •Oral Surgery (extractions and impacted teeth) •Anesthesia (subject to review, covered with complex oral surgery) • Repair of crown, denture or bridge •Inlays and onlays •Non-Surgical periodontics •Surgical periodontics (gum treatments) •Periodontal maintenance (2 per 12 month in combination with prophylaxis) •Endodontics (root canals) •Crowns, bridges, dentures and implantsRefer to your certificate of coverage for the services covered under your plan.7
Exclusions and LimitationsThe following dental services are not covered unless stated otherwise in the Certificate of Coverage:• any treatment which is elective or primarily cosmetic in nature and not generally recognized as a generally accepted dental practice by the American Dental Association, as well as any replacement of prior elective or cosmetic restorations;• replacement of a removable device or appliance that is lost, missing or stolen, and for the replacement of removable appliances that have been damaged due to abuse, misuse, or neglect. This may include but not be limited to removable partial dentures or dentures;• replacement of any permanent or removeable device or appliance unless the device or appliance is no longer functional and is older than the limitation in the Schedule of Covered Procedures. This may include but not be limited to bridges, dentures and crowns;• any appliance, service, or procedure performed for the purpose of splinting, to alter vertical dimension or to restore occlusion;• any appliance, service or procedure performed for the purpose of correcting attrition, abrasion, erosion, abfraction, bite registration, or bite analysis;• charges for implants (except noted above), removal of implants, precision or semi-precision attachments, denture duplication, or dentures and any associated surgery, or other customized services or attachments;• services provided for any type of temporomandibular joint (TMJ) dysfunction, muscular, skeletal deficiencies involving TMJ or related structures, myofascial pain.Limitations:• Multiple restorations on one surface are payable as one surface. Multiple surfaces on a single tooth will not be paid as separate restorations. On any given day, more than 8 periapical x-rays or a panoramic film in conjunction with bitewings will be paid as a full mouth radiograph. Pre-estimates are recommended for any treatment expected to exceed $300. A Network Access plan is available. THIS POLICY PROVIDES LIMITED BENEFITS This brochure is not intended to be a complete description of the insurance coverage available. The policies or their provisions may vary or be unavailable in some states. The policies have exclusions and limitations which may affect any benefits payable. For complete details of coverage and availability, please refer to Policy Form Series Dental 20-GDN or contact your Unum Dental representative. Underwriten by Starmount Life Insurance Company, Baton Rouge, LA.© 2021 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries. EN-2026 FOR EMPLOYEES (06-21)unum.com8
EN-376255 FOR EMPLOYEES (4-21) KST Energy Services LLCUnum Vision® Quality eye care meets convenienceHow much does it cost? You You and your spouse You and your children Family Plan features:• Our network offers members access to a large national network, including independent optometrists and retail stores like Walmart, Sam’s Club, Target Optical, America’s Best and many more.• Find an in-network provider at unumvisioncare.com• Manage benefits online with AlwaysAssist.com and on-the-go with the AlwaysAssist mobile app.Covered benefits:Exam: Each member is entitled to a comprehensive vision exam. An exam co-pay applies and is outlined in the grid at right.Materials: Each member has coverage for covered services and materials. Purchases are subject to benefit frequencies and co-pays. Plan features include:• Frame benefit: You may choose any frame within a provider’s collection, subject to the retail frame allowance listed at right. If the cost is greater than the plan’s benefits, you are responsible for the difference.• Eyeglass lens benefit: Standard plastic (CR-39 Plastic Material) single vision, bifocal, trifocal, and specialty lenses are generally covered after any applicable materials copay. If covered by plan allowance, you are responsible for any cost greater than the plan’s benefit.• Contact lens benefit: Members electing contact lenses instead of eye glass lenses may apply the contact lens allowance to any lenses in the provider’s collection. If the cost is greater than the plan’s benefits, you are responsible for the difference. Laser vision correction: Discounts are available with participating surgery providers across the country. (not an insured benefit)Unum Vision benefits:Vision Care ServicesIn-network ProvidersOut-of-network AllowancesExam (1 per 12 months)$10 co-pay Up to $35Materials$10 co-paySee allowances belowStandard Plastic Lenses (1 per 12 months)Single VisionCovered by co-payUp to $25BifocalCovered by co-payUp to $40TrifocalCovered by co-payUp to $50Lenticular$80 allowanceUp to $50Progressive $70 allowanceUp to $40Lens OptionsScratch Resistant CoatingCovered by co-pay (at Walmart only)Not coveredPolycarbonate Lenses for children to age 19Covered by co-payNot coveredFrames (1 per 24 months)Members choose from any frame available at provider locations.$150 allowance Up to $50Contact Lenses (1 per 12 months) In lieu of eyeglass lenses and frames (Includes fit*,follow-up and materials)$10 co-paySee allowances belowElective$150 allowance Up to $100Medically Necessary$210 allowance Up to $210*Some providers, such as Walmart, may charge for a contact lens fit and evaluation separately from your contact lens allowance, leaving the entire allowance for materials.Monthly premium$7.71$15.40$17.09$26.749
EN-376255 FOR EMPLOYEES (4-21) Vision InsuranceLaser Vision Correction Network Membership provides access to preferred pricing. Transactions are handled directly between members and providers. Refractive surgery is an elective procedure and may involve potential risks to patients. This is not an insured benefit. Unum cannot and does not guarantee the outcome of any refractive surgical procedure or a total elimination of the need for glasses or contacts. Providers may not be available in all metropolitan areas. Login to www.alwaysassist.com for a list of participating laser vision correction providers.Hearing Savings Plan Unum offers a Hearing Savings Plan at no additional cost, to all of its Unum Dental and Unum Vision members. Partnering with EPIC Hearing Healthcare, the Hearing Savings Plan provides:• 30-60% discounts off MSRP on name brand hearing instruments.• 40% savings on hearing aid batteries shipped directly to members’ homes.• On-call support for member questions, managed by professional hearing counselors.Other Unum Vision SpecificationsDependent children: Dependent age guidelines vary by state. Please refer to your policy certificate or contact customer service at 888-400-9304.Services not listed: If you expect to require a vision service not included on this brochure, it may still be covered. Please contact customer service at 888-400-9304, to confirm your exact benefits.This is a primary vision care benefit and is intended to cover only eye examinations and corrective eyewear. Medical or surgical treatment of eye disease or injury is not provided under this plan. Coverage may not exceed the lesser of actual cost of covered services and materials or the limits of the policy.Some providers at optical and/or retail chains, such as Walmart, may charge for a contact lens fit and evaluation separately and apart from your contact lens allowance, leaving the entire allowance for materials.Covered materials that are lost or broken will be replaced only at normal service intervals indicated in the Plan Design; however, these materials and any items not covered below may be purchased at Preferred Pricing from a Participating Provider. In addition, benefits are payable only for expenses incurred while the Group and individual Member coverage is in force.This plan will not cover:Orthoptics or vision training and any supplemental testing; Plano (non-prescription) lenses; or two pair of eyeglasses in lieu of bifocals or trifocals; Medical or surgical treatment of the eyes; An eye exam or corrective eye wear required by an employer as a condition of employment; Any injury or illness covered under Workers’ Compensation or similar law, or which is work related; Plain or prescription sunglasses or tinted lenses, and no-line bifocals and blended lenses (subject to allowance); Sub-normal vision aids; Services rendered or materials purchased outside the U.S. or Canada, unless: the insured resides in the U.S. or Canada, and the charges are incurred while on a business or pleasure trip; Charges in excess of Usual and Customary for services and materials; Experimental or non-conventional treatments or devices; Safety eyewear; Spectacle lens styles, materials, treatments or “add-ons” not shown in the Schedule of Benefits.A Network Access plan is available.THIS POLICY PROVIDES LIMITED BENEFITSThis brochure is not intended to be a complete description of the insurance coverage available. The policies or their provisions may vary or be unavailable in some states. The policies have exclusions and limitations which may affect any benefits payable. For complete details of coverage and availability, please refer to Policy Form Series VI-2002, VI-2007 and VI-2019 or contact your Unum Vision representative.Starmount Life Insurance Company8485 Goodwood Boulevard • Baton Rouge, LA 70806PH: (888) 400-9304Vision plans are marketed by Unum, administered and underwritten by Starmount Life Insurance Company, Baton Rouge, LA.© 2021 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries. 10
Enroll in the Emergent Plus plan today and protect you and your family against the nancial burden of massive out-of-pocket ambulance costs, all at an aordable group rate.Insurance companies may not cover all air and ground ambulance expenses which can result in excessive bills.$5,000$60,000are sent to the emergency room through ground or air ambulance every year.DID YOU KNOW?MILLIONPEOPLE25The information provided in this product sheet is for informational purposes only. The benets listed, and the descriptions thereof, do not represent the full terms and conditions applicable for usage and may only be oered in some memberships. Premiums vary depending on the benets selected. Commercial Air and Worldwide coverage are not available in all territories. For a complete list of benets, premiums, and full terms and conditions please refer to the applicable member service agreement for your territory. MASA MTS products and services are not available where prohibited. For Florida residents, Medical Air Services Association of Florida, Inc. is doing business as MASA MTS and is a prepaid limited health service organization licensed under Chapter 636, Florida Statutes, license number: 65-0265219 operating in Florida at 1250 S. Pine Island Road, Suite 500, Plantation, FL 33324. MASA Global, MASA MTS and MASA TRS are registered trade names of Medical Air Services Association, Inc., an Oklahoma corporation.SOURCE: Welch, Shari. “Emergency Department Usage Trend Data Can Help Physicians Prepare for Patients.” ACEP Now http://bit.ly/3qBvNrcEmergent Air TransportationIn the event of a serious medical emergency, Members have access to emergency air transportation into a medical facility or between medical facilities.Emergent Ground TransportationIn the event of a serious medical emergency, Members have access to emergency ground transportation into a medical facility or between medical facilities.Non-Emergency Inter-Facility TransportationIn the event that a member is in stable condition in a medical facility but requires a heightened level of care that is not available at their current medical facility, Members have access to non-emergency air or ground transportation between medical facilities.Repatriation/RecuperationSuppose you or a family member is hospitalized more than 100-miles from your home. In that case, you have benet coverage for air or ground medical transportation into a medical facility closer to your home for recuperation.EMERGENT PLUS MEMBERSHIP BENEFITSContact Your MASA MTS Representative,to learn more about membership plan options.$14 /MONTHA MASA MTS Membership provides the ultimate peace of mind at an aordable rate for emergency ground and air transportation service within the United States and Canada, regardless of whether the provider is in or out of a given group healthcare benets network. After the group health plan pays its portion, MASA MTS works with providers to deliver our members $0 in out-of-pocket costs for emergency transport.VER: EPPSLAVS1.05052111 Keith Loefflerkloeffler@masamts.com713-817-3178
DID YOU KNOW?are sent to the emergency room through ground or air ambulance every year.Insurance companies may not cover all air and ground ambulance expenses which can result in excessive bills.$5,000$60,000PLATINUM MEMBERSHIP BENEFITSA Platinum Membership provides the ultimate peace of mind at an aordable rate when it comes to protecting you and your family from massive out-of-pocket ambulance charges.MILLIONPEOPLE2512
$39 /MONTHA MASA MTS Membership provides the ultimate peace of mind at an aordable rate for emergency ground and air transportation service within the United States and Canada, regardless of whether the provider is in or out of a given group healthcare benets network. After the group health plan pays its portion, MASA MTS works with providers to deliver our members’ $0 in out-of-pocket costs for emergency transport.Emergent Air TransportationIn the event of a serious medical emergency, Members have access to emergency air transportation into a medical facility or between medical facilities.Emergent Ground TransportationIn the event of a serious medical emergency, Members have access to emergency ground transportation into a medical facility or between medical facilities.Non-Emergency Inter-Facility TransportationIn the event that a member is in stable condition in a medical facility but requires a heightened level of care that is not available at their current medical facility, Members have access to non-emergency air or ground transportation between medical facilities.Repatriation/RecuperationSuppose you or a family member is hospitalized more than 100-miles from your home. In that case, you have benet coverage for air or ground medical transportation into a medical facility closer to your home for recuperation.Escort TransportationIf you or a family member requires medical transportation, you may elect to have a family member or friend accompany you during the medical transport. This benet is limited to space availability within the vehicle, giving due priority to medical personnel and equipment.Visitor TransportationIf you or a family member is hospitalized more than 100-miles away from home for more than 7-days (consecutively), you may elect to have a family member or friend transported (by commercial airline) to be present while you recover.Return TransportationIn the event a Member is hospitalized more than 100-miles away from home for more than 24-hours, Member has access to return transportation, upon their release, to the commercial airport nearest their home.Mortal Remains TransportationIf you or a family member dies more than 100-miles from home, MASA shall pay (on behalf of the Member’s estate) the airway bill associated with the return of the Member’s mortal remains.Minor ReturnSuppose you require the use of one or more of the transportation benets and, as a result of your need, a minor child (who is in your custody) is left unattended. Even if this occurs, the minor child will be covered for return transportation (by commercial airline) to the commercial airport nearest the child’s home.Organ Retrieval/Organ TransportationIn the event of an organ transplant procedure, MASA will arrange for the transportation of you or the transplant organ to the transplant site.Vehicle ReturnSuppose you use one or more of the member transportation benets. As a result of using the benet, you may elect to have MASA transport your ground vehicle to your home or rental return location.Pet ReturnIf you use one or more of the member transportation benets while with your pet, you may elect to have MASA MTS transport your pet home.Worldwide CoverageContingent on a 10-day prior notice to MASA MTS of your travel plans, you have coverage for worldwide non-emergent air transportation, repatriation/recuperation, return transportation, escort transportation, visitor transportation, and mortal remains transportation. Coverage is limited to 90 days or less of travel.PLATINUM MEMBERSHIP BENEFITSThe information provided in this product sheet is for informational purposes only. The benets listed, and the descriptions thereof, do not represent the full terms and conditions applicable for usage and may only be oered in some memberships. Premiums vary depending on the benets selected. Commercial Air and Worldwide coverage are not available in all territories. For a complete list of benets, premiums, and full terms and conditions please refer to the applicable member service agreement for your territory. MASA MTS products and services are not available where prohibited. For Florida residents, Medical Air Services Association of Florida, Inc. is doing business as MASA MTS and is a prepaid limited health service organization licensed under Chapter 636, Florida Statutes, license number: 65-0265219 operating in Florida at 1250 S. Pine Island Road, Suite 500, Plantation, FL 33324. MASA Global, MASA MTS and MASA TRS are registered trade names of Medical Air Services Association, Inc., an Oklahoma corporation.SOURCE: Welch, Shari. “Emergency Department Usage Trend Data Can Help Physicians Prepare for Patients.” ACEP Now http://bit.ly/3qBvNrcContact Your MASA MTS Representative,to learn more about membership plan options.VER: PMPSLAVS1.05052113 Keith Loefflerkloeffler@masamts.com713-817-3178
Name: Gender:Date of Birth: Phone:Address: Email:Weekly √ Weekly √$3.23 $9.00 Weekly √SS#Medical: Dental: Vision:Weekly √SS#Medical: Dental: Vision:Weekly √$7.02 $13.74 SS#$18.45 $27.28 Medical: Dental: Vision:Weekly √$1.78 $3.55 SS#$3.94 $6.17 Medical: Dental: Vision:√Date:Employee/FamilyEmployee/ChildrenEmployee/FamilyEmployee/ChildrenEmployee/FamilyEmployee/FamilyEmployee OnlyEmployee/SpouseEmployee/ChildrenPCP: ____________________________________________Relationship:Name: DOB:Relationship:Date of Hire:Name: DOB:Dependents to be CoveredName: DOB:Relationship:Name: DOB:Relationship:Zip Code:Emergent PlusPlatinumMASAI am covered by Tri-CareI am covered by an Individual PlanI am covered by MedicaidI have no other coverage but do not want thisI am covered by spouses's employer's planI am covered by MedicareEmployee OnlyEmployee/SpouseEmployee/ChildrenI am on COBRA coverage from Prior EmployerVisionEmployee OnlyEmployee/SpouseDentalEmployee OnlyEmployee/SpouseEmployee/ChildrenEmployee/FamilyBlue Choice Silber PPO - S9M2 CHCKST Energy Services Election SheetSignature:Blue Choice Silber PPO - G9L1 CHCI Elect to Waive all Medical Insurance due to:Dependents to be CoveredDependents to be CoveredDependents to be Covered( You may be required to show proof of coverage)Social Security: Number:Employee OnlyEmployee/SpouseBlue Advantage Silver HMO - S640 ADT$24.36$146.82$146.82$269.29$84.38$266.86$266.86$449.35$105.99$310.09$310.09$514.19