Page 14 - KIPP NYC 2022 Benfits Summary

Vision Plan Benefits
KIPP NYC offers vision coverage to you and your eligible dependents, through VSP (Vision Service Plan). The vision plan offers in-network and out-of-network benefits utilizing the VSP Signature network.
Choice
You have the option of seeing any provider within the VSP Signature network. Claim forms are not required when utilizing in-network providers.
If you choose an out-of-network provider, the plan will reimburse you according to the Out-of-Network reimbursement schedule outlined in the below benefits summary. Visit www.vsp.com and click on the “Benefits & Claims” section to submit a claim. You’ll have the opportunity to upload receipts or submit them by fax or mail. Submit your itemized receipt(s) along with the out-of-network reimbursement form. VSP will reimburse you the allotted amount based on the out-of-network reimbursement schedule. For more detailed benefits information or to search for a provider, visit www.vsp.com.
VSP Plan Summary
VISION PLAN PROVISIONS
Exam
Materials
Frequency of Services
Vision Exam
Lenses
Frames
Contact Lenses
Must Choose Lenses/Frames or Contacts
Single Bifocal Trifocal
Conventional
Disposable Medically Necessary
ID Cards
Member ID cards are not issued and are not required for you to access vision care. Simply call a VSP network doctor to schedule an appointment and tell them you are a VSP member. The doctor and VSP handle the rest!
How to Enroll
Visit the Benefits tab on UKG during your benefit enrollment window.
IN-NETWORK
OUT-OF-NETWORK
Copayment
$10 copay See below
12 months 12 months 12 months 12 months
$0 copay $0 copay $0 copay
$150 allowance
$150 allowance
Up to $60 copay for fitting $150 allowance
Up to $60 copay for fitting Covered in full
Yes
Up to $50 reimbursement See below
12 months 12 months 12 months 12 months
Up to $50 reimbursement
Up to $75 reimbursement Up to $100 reimbursement
Up to $70 reimbursement
Up to $105 reimbursement
Up to $105 reimbursement Up to $105 reimbursement
Basic Lenses
Frames
Contacts
14 KIPP NYC PUBLIC SCHOOLS