2018 Benefits at a Glance
PLAN YEAR: January 15, 2014 – December 31, 2014
CONTENTS & CONTACT INFORMATION
Refer to this list when you need to contact one of your benefit vendors. For general information contact Human Resources.
BROKER
page 6
Provider Name Broker Contact
M.E. Wilson Company
Name
Provider Phone Number Provider Email Address
813-229-8021
name@mewilson.com
MEDICAL
page 6
Provider Name
UHC Group# xxxx 1-866-673-6293 www.myuhc.com
Provider Phone Number Provider Web Address
DENTAL
page 7
Provider Name
Principal Group# xxxx 1-877-238-6200 www.principal.com
Provider Phone Number Provider Web Address
VISION
page 7
Provider Name
Principal
Provider Phone Number Provider Web Address
1-866-425-2323 www.vsp.com
FLEX SPENDING & HEALTH SAVINGS ACCOUNT
page 8
Provider Name
Health Equity Through Florida Blue
Provider Phone Number Provider Web Address
1-877-223-5329
www.healthequity.com
LIFE AND AD&D AND VOLUNTARY LIFE AND AD&D
page 9
Provider Name
Cigna
Provider Phone Number Provider Web Address
1-800-733-1603 www.cigna.com
SHORT TERM AND LONG TERM DISABILITY
page 10
Provider Name
Cigna
Provider Phone Number Provider Web Address
1-800-733-1603 www.cigna.com
PAYROLL DEDUCTIONS
page 11
DISCLOSURE NOTICES
page 12-15
BENEFIT INFORMATION
Benefit
Who pays the cost?
YOUR BENEFITS PLAN Homes by West Bay offers a variety of benefits allowing you the opportunity to customize a benefits package that meets your personal needs. In the following pages, you’ll learn more about the benefits offered. You’ll also see how choosing the right combination of benefits can help protect you and your family’s health and finances – and your family’s future.
Homes by West Bay pays the majority of the employee portion of the Base plan and a significant amount of the Spouse & dependent portion
Medical Insurance
Dental Insurance
You pay entire cost
Vision
You pay entire cost
Life Insurance
Company pays entire cost
Voluntary Life Insurance
You pay entire cost
ELIGIBILITY
All Regular full-time employees are eligible to join the Homes by West Bay Benefits Plan on the 1st of the month following 60 days. “Regular Full-Time Employees” must be regularly scheduled and working at least 24 hours per week.
You may also enroll your dependents in the Benefits Plan when you enroll.
Eligible dependents include: • Your spouse, unless you are legally separated or divorced; • Your married or unmarried natural children, step-children living with you, legally adopted children and any other children for whom you have legal guardianship, who are: ► Under 26 years of age for medical; ► A dependent who is older than 26 years of age, but less than 30 years of age may be eligible for medical benefits. To be eligible, a Dependent must: • Be Unmarried and not have dependents of his or her own; AND • Be a Resident of Florida or a Student; AND • Not have coverage of their own, or covered under any other plan; AND • Not entitled to benefits under Medicare
WHEN CAN YOU ENROLL?
You can sign up for Benefits at any of the following times:
• After completing initial eligibility period; • During the annual open enrollment period; • Within 30 days of a qualified family-status change. If you do not enroll at one of the above times, you must wait for the next annual open enrollment period.
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BENEFIT INFORMATION
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CHOOSING YOUR BENEFITS You must actively choose any benefit that you pay for, or share in the cost with Homes by West Bay. Your part of the cost is automatically taken out of your paycheck. There are two ways that the money can be taken out:
WHY DO I PAY FOR BENEFITS WITH BEFORE-TAX MONEY? There is a definite advantage to paying for some benefits with before-tax money: Taking the money out before your taxes are calculated lowers the amount of your pay that is taxable. Therefore, you pay less in taxes.
• BEFORE YOUR TAXES ARE CALCULATED – medical, dental, and vision
• AFTER YOUR TAXES ARE CALCULATED – voluntary life and accidental death & dismemberment, short term disability and long term disability
MAKING CHANGES
Generally, you can only change your benefit choices during the annual benefits enrollment period. However, you may be able to change your benefit choices at anytime if you have a change in status including: • Your marriage • Your divorce or legal separation • Birth or adoption of an eligible child • Death of your spouse or covered child • Change in your spouse’s work status that affects his or her benefits • Change in your work status that affects your benefits • Change in residence or work site that affects your eligibility for coverage • Change in your child’s eligibility for benefits • Receiving Qualified Medical Child Support Order (QMCSO)
If you do not notify Human Resources within 30 days of a family status change, you will have to wait until the next annual enrollment period to make benefit changes unless you have another family status change. WHEN COVERAGE ENDS Coverage will stop on the last day of the month in which employment with the company ends.
KEY BENEFIT TERMS
COBRA – A Federal law that allows workers and dependents who lose their medical, dental, or vision coverage to continue any of these coverages for a specified length of time by electing and paying for continuation benefits. Coinsurance – The percentage of the medical or dental charge that you pay after the deductible has been met. Copayment – A flat fee that you pay for medical services, regardless of the actual amount charged by your doctor or another provider. This generally applies to physicians’ office visits and prescription drugs. Deductible – The amount you pay toward medical and dental expenses each calendar year before the plan begins paying benefits. Out of Pocket Maximum – The maximum amount you will pay in coinsurance during the calendar year
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GETTING MORE FROM YOUR HEALTHCARE DOLLARS
PRESCRIPTION DRUG BENEFITS AT A REDUCED COST – Did you know you can obtain prescription drugs at local retailers at a reduced cost and sometimes even free? Publix offers a variety of generic Oral Antibiotic medications to you absolutely free. Bring in your prescription for an approved medication and receive it FREE, up to a 14-day supply. Publix recently approved a medication for diabetes. CVS, Target, Walgreens & WalMart also offer over 400 generic prescriptions for $4 and a 90 day supply for approx. $10. Remember DO NOT show your UHC ID card to receive these benefits, or you will be charged your UHC drug rate. In addition to the network of physicians, hospitals, emergency rooms, and urgent care clinics, you also have the option of going to the convenient care clinics located within some grocery and drug stores, for minor illness such as ear aches, colds, flu and so on. By selecting one of these providers, you pay only the regular office visit copay; a significant savings over the emergency room and urgent care copayments.
United Healthcare Extras There are some additional benefits that are available to you as a United Healthcare member. These products/services offer a variety of discounts at no additional cost to you and your dependents on the plan. Care24 United Healthcare Care24, staffed by nurses and master level counselors, can help with almost any personal, financial or legal problem, day or night. You can also access audio tapes and pamphlets on subjects ranging from diet and nutrition to sports injuries. CALL: 888-887-4114 Myuhc.com Myuhc.com is a one-stop employee self-services Web Site that provides convenient online services in which you can: • Complete a confidential health risk assessment • Participate in live, interactive discussions with leading medical experts • Order prescription drugs through the Online Pharmacy Care Coordination Through Care Coordination, United Healthcare offers programs for people with chronic diseases such as asthma, diabetes and high cholesterol. They work with primary physicians to help develop and support individualized treatment plans and then nurses provide education, answer questions about medications and help identify and facilitate lifestyle changes that reduce the risk of your illness. United Health Allies® Health Allies® is a value-added discount program available to all United Healthcare customers. When you see a complementary practitioner in the Health Allies® network, you'll receive a 20% discount on services. The network consists of acupuncture, massage therapy, naturopathic medicine, and dietary/nutritional counseling practitioners. Please note that this discount program is not insurance. • • • • Check the status of a claim View benefits and eligibility Find a physician Print a claim form
Please visit the various websites for locations, hours of operations and scope of services.
CVS Minute Clinic: www.cvs.com
Walgreen’s Take Care Clinic: www.walgreens.com
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FREQUENTLY ASKED QUESTIONS ABOUT YOUR MEDICAL PLAN What should I do if I have a problem getting a claim paid? A. Start by contacting the carrier’s member services number to determine the nature of the problem. If the issue is the way the doctor or other service provider has billed the claim, then contact your doctor or Claims Advocate at USI. If the insurance company has an eligibility issue, contact Human Resources for assistance. Q. What is the difference between brand formulary, brand non- formulary, and generic drugs? A. Brand formulary is a prescription drug that is listed on the formulary (i.e., a list of prescription drugs covered by the plan). These drugs are protected by a patent issued to the original innovator or marketer. Brand non-formulary drugs are patent protected but are not listed. A generic equivalent drug can become available when the patent protection runs out, and is deemed equal in therapeutic power to the brand name originals. Q. When should I go the Urgent Care vs. Emergency Room? A. For non-life threatening injury/illness after normal doctor’s office hours. Q.
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MEDICAL INSURANCE
Homes by West Bay offers 3 medical plans from UHC. To find participating providers go to www.myuhc.com and click on “Find a Physician”, choose the appropriate provider type. In Step 2: Insurance Plan Information choose Network name “Choice Plus” for all plans. Complete the remaining selection information and click Search.
The chart below provides a brief comparison of the plans. This chart is intended only to highlight the benefits available and should not be relied upon to fully determine your coverage. If the below illustration of benefits conflicts in any way with the Summary Plan Description (SPD), the SPD shall prevail. It is recommended that you review your exact description of services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.
5Q-N Rx 40
0F-8 Rx 40
5P-5 Rx 40
Plan Options:
Base
Mid
High
IN-NETWORK: Plan Year / Contract Year Basis Deductible (Individual / Family)
Calendar Year $2,000/ $4,000 $6,250/ $12,500
Calendar Year
Calendar Year
$1,000 per person
$0/$0
Maximum Out-of-Pocket (Individual/Family)
$3,000/ $6,000
$1,500/ $3,000
Out-of Pocket Max Includes Lifetime Major Medical Maximum
Deductible, Coinsurance, & Copays Deductible, Coinsurance, & Copays Coinsurance and Copays
Unlimited
Unlimited
Unlimited
Coinsurance
50%
100%
80%
Routine Preventive Services Wellness Immunizations Mammography/Colonoscopy CO-PAYS PCP Required / Open Access
Covered 100%
Covered 100%
Covered 100%
Open Access
Open Access
Open Access
Office Visits/Consultations for Illness/Injury
$30 Copay $60 Copay
$25 Copay $50 Copay
$15 copay $30 copay
Specialist Visits
Physician Services (Out of Office)
Covered 50% after deductible Covered 100% after deductible Covered 50% after deductible Covered 100% after deductible Covered 50% after deductible Covered 100% after deductible
Covered 80% Covered 80% Covered 80% $350 copay $100 copay Covered 100% Covered 100% Covered 80%
Inpatient Hospital Outpatient Surgery Emergency Room
$350 Copay $100 Copay
$200 Copay $100 Copay
Urgent Care
OUTPATIENT DIAGNOSTIC SERVICES Lab Services
Covered 100% Covered 100%
Covered 100% Covered 100%
X-Ray Services
Complex Diagnostic PRESCRIPTIONS Retail (30 day supply)
Covered 50% after deductible
Covered 90% after deductible
$10/ $35/ $60
$10 / $35/ $60
$10/ $35/ $60
Mail Order (90 day supply)
2.5 X retail
2.5 X retail
2.5 x retail
OUT-OF-NETWORK:
Deductible (Individual / Family)
$500/$1000 $3500/$7000
Maximum Out-of-Pocket (Individual/Family)
In-Network Only
In-Network Only
Lifetime Major Medical Maximum
Unlimited
Coinsurance
60%
Monthly Premium Base
Monthly Premium Mid
Monthly Premium High
Employee Only
$240.49 $514.65 $490.60 $735.90
$303.78 $650.09 $619.71 $929.57
$348.53 $745.85 $711.00 $1066.50
Employee + Spouse Employee + Child(ren)
Family
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DENTAL AND VISION INSURANCE
Homes by West Bay offers dental and vision through Principal. The dental PPO Plan allows you to use in-network or out-of-network benefits. If out-of-network dentists are used, you will be responsible to pay the difference between Principal’s allowed amount and what the dentist may charge. The vision plan provides coverage both in and out of network. The charts below provides a brief overview of the plans.
Dental PPO Plan
In-Network
Out-of Network
Deductible Individual
$50
$50
$150
$150
Family
Annual Maximum
$1,000
Individual Diagnostic & Preventative Exams Cleanings Fluoride X-Rays Sealants Regular Restorative Services Extractions - Single Tooth Endodontics (Root Canal) Periodontics ( Gum Disease) Major Services Amalgam Fillings
100%
100%
Deductible Applies
80%
80%
Deductible Applies
Crowns Bridges Dentures
50%
50%
Vision VSP Network
In-Network
Out-of-Network
Lenses Single Bifocal Trifocal
$50 allowance $75 allowance $100 allowance $150 allowance $100 allowance $50 allowance
$50 allowance $75 allowance $100 allowance $150 allowance $100 allowance $50 allowance
Contact Lenses
Frames Exams
Frequency Exam
Once every 12 months Once every 12 months Once every 24 months
Lenses or contact lenses
Frame
20% retail discount on a second pair of eyeglasses on the day of exam or 20% from any VSP doctor within 12 months of last exam. Special discounts available through contracted LASIK and PRK surgery facilities
Additional Pairs
Laser Vision Correction
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FLEXIBLE SPENDING ACCOUNT (FSA) DEPENDENT CARE ACCOUNT
Homes by West Bay offers a both Health Care and Dependent Care Flexible Spending Account to all active employees working 24 or more hours per week. You may elect to have both types of accounts and contribute separate pretax dollar amounts to each. These accounts are kept completely separate; for instance, you could not be reimbursed for dependent care expenses from the health care account.
HEALTH CARE ACCOUNTS A health care FSA can reimburse you for eligible medical, dental and vision expenses, up to the amount you elect to contribute for the plan year. TYPICAL ELIGIBLE EXPENSES The following is a partial list of typical expanses eligible for health care FSA reimbursement. A complete list can be found at www.irs.gov . Deductible for group health and/or dental plan Copayments for group health and/or dental plan Many charges that are not covered by health/dental plan are also eligible for FSA reimbursement, such as: • Eye exams, eyeglasses, contact lenses; • Hearing exams, hearing aids, • Physical exams and mammograms in excess of one per year; • Medical expenses of a dependent not covered by a health plan • Orthodontia • Vision corrective surgery (such as Lasik) • Smoking cessation programs an related prescription drugs YOUR CONTRIBUTION Beginning in January 2014, the IRS limits the amount you may contribute to $2,500 per year. This amount will increase in future years to reflect cost-of-living increases.
DEPENDENT CARE ACCOUNTS A Dependent Care FSA is a great way to pay dependent care expenses and lower your taxable income. Dependent Care Spending Accounts are pre-tax, payroll deduction accounts established to reimburse employees for out-of-pocket dependent care expenses. To be considered eligible, dependent care expenses must be incurred by an employee who must arrange for care of an eligible dependent in order to work. For married employees, dependent care must be necessary so that both spouses can work. • A tax dependent of yours who is under age 13, or • Any other tax dependent of yours, such as an elderly parent, who is physically or mentally incapable of self- care and has the same principal residence as you • A spouse who is physically or mentally incapable of self-care and has the same principal residence as you YOUR CONTRIBUTION The Internal Revenue service limits the amount you can contribute to a dependent care FSA, up to: • $5,000 per year, if you are married and filing a joint return, or if you are a single parent • $2,500 per year, if married and filing separate federal tax returns Estimate what your daycare expenses will be for the year, and allocate enough from your pay, up to the allowable contribution, to cover those expenses. JUST REMEMBER THIS: FSA dollars are “use-it-or-lose-it” funds. Account balances cannot be carried over from year to year. If you have unused funds at the end of the plan year, or at the end of any applicable grace aperiod, those funds will be forfeited. That’s an IRS requirement. So estimate the amount you want to contribute to your FSA carefully. QUALIFYING DEPENDENT A qualifying dependent is:
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BASIC LIFE AND AD&D & VOLUNTARY LIFE INSURANCE
BASIC LIFE INSURANCE
Homes by West Bay provides life insurance to all active full time employees. The chart below provides an overview of the plan.
Basic Life Insurance
Principal
Employee Definition
Class 1 Class 2
Managers All Others
Benefit Outline
Class 1 Class 2
$50,000 $30,000
At age 65 reduce by 33% of original amount, at age 70 reduce by 33% of in force amount
Age Reduction Schedule
Accelerated Benefit Waiver of Premium
75% of life benefit to maximum of $250,000 Included to the earlier of age 70 or retirement
AD&D
Included - Equal to basic life
VOLUNTARY LIFE INSURANCE Homes by West Bay provides all active employees working 24 or more hours per week the option to purchase life insurance coverage through a group plan. The chart below provides an overview of the plan.
Voluntary Life Insurance Principal Employee Life
Increments of $10,000 up to $300,000. Minimum of $10,000
Guarantee Issue
$100,000
Increments of $5,000 up to lesser of 50% of employee's amount or $100,000. GI - $25,000 Birth to less than 19 years (25 if full time student) $1,000, $5,000 or $10,000 not to exceed 50% of employee amount
Spouse Life
Dependent Life
AD&D Optional - If elected equal to life amount Benefit Reduction Schedule At age 70, reduces by 33% of original amount, at age 75, reduces by 33% of in force amount. The reduced amounts will not be less than $20,000 Accelerated Death Benefit 75% of life benefit to maximum of $250,000 Waiver of Premium Benefit Included to the earlier of age 65, retirement or recovery Convertible Included Portable Enrollment Events Includes annual enrollment period
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SHORT AND LONG TERM DISABILITY INSURANCE
SHORT TERM DISABILITY Homes by West Bay provides short term disability insurance to all active full time employees. The chart below provides an overview of the plan.
Short Term Disability
Principal
Benefit Percentage
60%
Maximum Weekly Benefit
$1,500
8 th day Accident 8 th day Sickness
Elimination Period
Duration of Benefit
12 weeks
LONG TERM DISABILITY Homes by West Bay provides long term disability insurance to all active full time employees. The chart below provides an overview of the plan.
Long Term Disability
Principal
Benefit % of Monthly Covered Payroll
60%
Monthly Maximum
$9,000
Elimination Period
90 days
Own Occupation Period
End of Benefit Duration
Residual Disability
Zero day
Benefit Duration
Reducing Benefit Duration(to age 65)
Pre-Existing Conditions
3/12
Mental Illness Limitation
24 months
Substance Abuse Limitation
24 months
Work Incentive Benefit
Included
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PAYROLL DEDUCTIONS
The Charts below show the weekly and bi-weekly payroll deduction amounts for each of the benefits offered.
MEDICAL
Weekly Deductions
Employee Cost Base
Employee Cost Mid
Employee Cost High
Employee Only
$10.00 $78.54 $72.53 $91.99
$25.82 $112.40 $104.81 $116.20
$37.01 $136.34 $127.63 $133.31
Employee + Spouse Employee + Child(ren)
Family
Bi-Weekly Deductions Employee Only
Employee Cost Micro
Employee Cost Sportsman
Employee Cost Pro-Series
$20.00 $157.08 $145.06 $183.98
$51.65 $224.80 $209.61 $232.39
$74.02 $272.68 $255.26 $266.63
Employee + Spouse Employee + Child(ren)
Family
DENTAL
Employee Cost
Employee Cost
Weekly Deductions
Bi-Weekly Deductions
Employee Only
$5.08
Employee Only
$10.16 $22.04 $25.87 $39.63
Employee + Spouse Employee + Child(ren)
$11.02 $12.93 $19.81
Employee + Spouse Employee + Child(ren)
Family
Family
VISION
Employee Cost
Bi-Weekly Deductions
Employee Cost
Weekly Deductions
Employee Only
$0.87 $2.21 $2.05 $3.39
Employee Only
$1.74 $4.42 $4.10 $6.78
Employee + Spouse Employee + Child(ren)
Employee + Spouse Employee + Child(ren)
Family
Family
VOLUNTARY LIFE INSURANCE Rates vary based on age and amount of coverage. Please see the payroll deduction form for amounts.
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REQUIRED ANNUAL EMPLOYEE DISCLOSURE NOTICES
Required Annual Employee Disclosure Notices THE NEWBORNS’ AND MOTHERS’ HEALTH PROTECTION ACT OF 1996 The Newborns’ and Mothers’ Health Protection Act of 1996 prohibits group and individual health insurance policies from restricting benefits for any hospital length of stay for the mother or newborn child in connection with childbirth; (1) following a normal vaginal delivery, to less than 48 hours, and (2) following a cesarean section, to less then 96 hours. Health insurance policies may not require that a provider obtain authorization from the health insurance plan or the issuer for
WOMEN’S HEALTH AND CANCER RIGHTS ACT OF 1998 The Women’s Health and Cancer Rights Act of 1998 requires Homes by West Bay to notify you, as a participant or beneficiary of the Homes by West Bay Health and Welfare Plan, of your rights related to benefits provided through the plan in connection with a mastectomy. You, as a participant or beneficiary, have rights to coverage to be provided in a manner determined in consultation with your attending physician for: 1. All stages of reconstruction of the breast on which the mastectomy was performed; 2. Surgery and reconstruction of the other breast to produce a symmetrical appearance; and 3. Prostheses and treatment of physical compilations of the mastectomy, including lymphedema. These benefits are subject to the plan’s regular deductible and co-pay. For further details, refer to your Summary Plan Description. Keep this notice for your records and call Human Resources for more information. MICHELLE’S LAW The law allows for continued coverage for dependent children who are covered under your group health plan as a student if they lose their student status because of a medically necessary leave of absence from school. This law applies to medically necessary leaves of absence that begin on or after January 1, 2010 If your child is no longer a student, as defined in your Certificate of Coverage, because he or she is on a medically necessary leave of absence, your child may continue to be covered under the plan for up to one year from the beginning of the leave of absence. This continued coverage applies if your child was (1) covered under the plan and (2) enrolled as at student at a post-secondary educational institution (includes colleges, universities, some trade schools and certain other post-secondary institutions). Your employer will require a written certification from the child’s physician that states that the child is suffering from a serious illness or injury and that the leave of absence is medically necessary.
prescribing any such length of stay. Regardless of these standards an attending health care provider may, in consultation with the mother, discharge the mother or newborn child prior to the expiration of such minimum length of stay. Further, a health insurer or health maintenance organization may not: 1. Deny to the mother or newborn child eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the plan, solely to avoid providing such length of stay coverage; 2. Provide monetary payments or rebates to mothers to encourage such mothers to accept less than the minimum coverage; 3. Provide monetary incentives to an attending medical provider to induce such provider to provide care inconsistent with such length of stay coverage; 4. Require a mother to give birth in a hospital; or 5. Restrict benefits for any portion of a period within a hospital length of stay described in this notice. These benefits are subject to the plan’s regular deductible and co-pay. For further details, refer to your Summary Plan Description. Keep this notice for your records and call Human Resources for more information. Federal government to comply with Section 111 of the Medicare, Medicaid, and SCHIP Extensions of 2007’s new Medicare Secondary Payer regulations. The mandate is designed to assist in establishing financial liability of claims assignments. In other words, it will help establish who pays first. The mandate requires group health plans to collect additional information, more specifically Social Security numbers for all enrollees, including dependents 6 months of age or older. Please be prepared to provide this information on your benefits enrollment form when enrolling into benefits. SECTION 111 Effective January 1, 2009 group health plans are required by
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REQUIRED ANNUAL EMPLOYEE DISCLOSURE NOTICES continued
Required Annual Employee Disclosure Notices continued
I. No access to protected health information (PHI) except for summary health information for limited purpose and enrollment / dis-enrollment information. Neither the group health plan nor the plan sponsor (or any member of the plan sponsor’s workforce) shall create or receive protected health information (PHI) as defined in 45 C.F.R. §160.103 except for (1) summary health information for purpose of (a) obtaining premium bids or (b) modifying, amending, or terminating the group health plan, and (2) enrollment and dis-enrollment information. II. Insurer for group health plan will provide privacy notice The insurer for the group health plan will provide the group health plan’s notice of privacy practices and will satisfy the other requirements under HIPAA related to the group health plan’s PHI. The notice of privacy practices will notify participants of the potential disclosure of summary health information and enrollment / dis-enrollment information to the group health plan and the plan sponsor. III. No intimidating or retaliatory acts The group health plan shall not intimidate, threaten, coerce, discriminate against, or take other retaliatory action against individuals for exercising their rights , filing a complaint, participating in an investigation, or opposing any improper practice under HIPAAA. requirements of 45 C.F.R. §164.530 (k) so that the group health plan is not subject to most of HIPAA’s privacy requirements. IV. No Waiver The group health plan shall not require an individual to waive his or her privacy rights under HIPAA as a condition of treatment, payment, enrollment or eligibility. If such an action should occur by one of the plan sponsor’s employees, the action shall not be attributed to the group health plan. HIPAA PRIVACY POLICY FOR FULLY- INSURED PLANS WITH NO ACCESS TO PHI The group health plan is a fully-insured group health plan sponsored by the “Plan Sponsor”. The group health plan and the plan sponsor intend to comply with the
PATIENT PROTECTION: If the Group Health Plan generally requires the designation of a primary care provider who participates in the network and who is available to accept you or your family members. For children, your may designate a pediatrician as the primary care provider. You do not need prior authorization from the carrier or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology. The health care professionals, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, or for information on how to select a primary care provider, and for a list of the participating primary care providers, contact the Plan Administrator or refer to the carrier website. It is your responsibility to ensure that the information provided on your application is accurate and complete. Any omissions or incorrect statements made by you on your application may invalidate your coverage. The carrier has the right to rescind coverage on the basis of fraud or misrepresentation. CHILDREN’S HEALTH INSURANCE PROGRAM REAUTHORIZATION ACT (CHIPRA) OF 2009 Effective April 1, 2009, a special enrollment period provision is added to comply with the requirements of the Children’s Health Insurance Program Reauthorization Act (CHIPRA) of 2009. If you or a dependent is covered under a Medicaid or CHIP plan and coverage is terminated as a result of the loss of eligibility for Medicaid or CHIP coverage, you may be able to enroll yourself and/or your dependent(s). However, you must enroll within 60 days after the date eligibility is lost. If you or a dependent becomes eligible for premium assistance under an applicable State Medicaid or CHIP plan to purchase coverage under the group health plan, you may be able to enroll yourself and/or your dependent(s). However, you must enroll within 60 days after you or your dependent is determined to be eligible for State premium assistance. Please note that premium assistance is not available in all states.
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Required Annual Employee Disclosure Notices - Continued REQUIRED ANNUAL EMPLOYEE DISCLOSURE NOTICES continued
MEDICARE PART D This notice applies to employees and covered dependents who are eligible for Medicare Part D. Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with UHC and about your options under Medicare’s prescription drug Plan. If you are considering joining, you should compare your current coverage including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare through Medicare prescription drug plans and Medicare Advantage Plan (like an HMO or PPO) that offer prescription drug coverage. All Medicare prescription drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. UHC has determined that the prescription drug coverage offered by the Welfare Plan for Employees of Homes by West Bay under the UHC option are, on average for all plan participants, expected to pay out as much as the standard Medicare prescription drug coverage pays 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. You should also know that if you drop or lose your coverage with UHC and don’t enroll in Medicare prescription drug coverage after your current coverage ends, you may pay more (a penalty) to enroll in Medicare prescription drug coverage later. _______________________________________________________ When can you join a Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15 th to December 7 th . However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What happens to your current coverage if you decide to join a Medicare Drug Plan? If you decide to join a Medicare drug plan, your current UHC coverage will not be affected. You can keep this coverage if you elect part D and this plan will coordinate with Part D coverage. If you decide to join a Medicare drug plan and drop your current UHC coverage, be aware that you and your dependents will be able to get this coverage back.
When will you pay a higher premium (penalty) to join a Medicare drug Plan? You should also know that if you drop or lose your current coverage with UHC and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For more information about this notice or your current prescription drug coverage… Contact our office for further information (see contact information below). NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through UHC changes. You also may request a copy of this notice at any time. For more information about your options under Medicare prescription drug coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: • Visit www.medicare.gov • Call your State Health Insurance Assistance Program (see your copy of the Medicare & You handbook for their telephone number) for personalized help, • Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778). Remember: Keep this notice. If you enroll in one of the new plans approved by Medicare which offer prescription drug coverage, you may be required to provide a copy of this notice when you join to show that you are not required to pay a higher premium amount. Date: 1/1/14 Name of Entity/Sender: Homes by West Bay Contact--Position/Office: Jean Treimanis 9010 Palm River Rd Tampa, FL 33619 Phone Number: 813-689-9932
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HEALTHCARE REFORM AND YOU
The Patient Protection and Affordable Care Act & The Health Care and Education Affordability Reconciliation Act of 2010, together, create the most comprehensive health insurance reform ever under taken in recent history by our Country. Many of the new law’s required changes have already been incorporated into company health plans across the country since the effective date in September of 2010. However, there will be many more changes taking place in the months to come, as more guidance is issued by the government to employers, insurance carriers and individuals. One of the key requirements of the new law beginning in 2014, is the mandate that all U.S. citizens & legal residents either carry health insurance or pay an income tax penalty. While the tax penalty is not too severe in the first year, it becomes progressively more costly each year thereafter. Penalties for failing to buy coverage Tax penalties for failing to buy coverage are phased in according to the following schedule: In 2014, the greater of $95 or 1% of taxable income; In 2015, the greater of $325 or 2% of taxable income; In 2016, the greater of $695 or 2.5% of taxable income; and After 2016, the penalty is indexed for inflation. However, there are two ways to avoid the tax penalty: You can buy coverage for you and your family through your place of employment, if your employer offers such coverage. That coverage must meet certain standards set by the law in order for you and the employer to escape respective tax penalties. The coverage must meet certain minimum coverage standards (Generally pays at least 60% of your covered medical expenses) and must be considered “affordable” (Employer cannot charge you a premium for single or employee only coverage greater than 9.5% of your W-2 earnings for the year). The 9.5% would apply to annual salaries of up to about $45,000. Or, you can provide coverage for you and your family through a Federally run Insurance Exchange that is supposed to be up and running by 1/1/2014. Essentially, an Exchange is an interactive site where an individual can go to research, evaluate and buy health plans. The State of Florida chose not to set up a state run exchange, so the Federal government will take over that responsibility.
If you obtain coverage through an Exchange: The Exchange will eventually sell insurance policies at certain levels of coverage: • Bronze level – a medical plan designed to pay 60% of covered medical benefits; • Silver level – a medical plan designed to pay 70% of covered medical benefits; • Gold level – a medical plan designed to pay 80% of covered medical benefits; • Platinum level – a medical plan designed to pay 90% of covered medical benefits; • Catastrophic – available to young adults up to age 30 or those exempt from the individual mandate (additional requirements may apply) If you satisfy certain low income thresholds and do not have medical coverage through an employer, or have employer- provided coverage that is considered “unaffordable” or pays benefits that are below the “Bronze” plan discussed above, there are tax credits available to help you pay the premiums for coverage purchased through the Exchange. The credits also help pay for expenses like deductibles and co pays. More information on these credits will be provided to you later. If you and your family are below 133% of the Federal Poverty Level in 2014, you may qualify for Medicaid. Other changes to take effect in 2014 are: The health plan may no longer exclude coverage of a pre- existing condition; The health plan may not impose more than a 90-day waiting period for coverage; Your plan may no longer place an annual limit on key benefits in the plan; Your health plan must allow dependent children up to age 26 to enroll in coverage, regardless of the availability of employer-sponsored coverage where they work. You may only obtain coverage through an Exchange if you are not participating in your employer’s plan.
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The information in this Benefits Summary is presented for illustrative purposes and is based on information provided by the employer. The text contained in this Summary was taken from various summary plan descriptions and benefit information. While every effort was taken to accurately report your benefits, discrepancies or errors are always possible. In case of discrepancy between the Benefits Summary and the actual plan documents, the actual plan documents will prevail. All information is confidential, pursuant to the Health Insurance Portability and Accountability Act of 1996. If you have any questions about this summary, contact Human Resources.
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