BENEF I TS AT A GLANCE January 1, 2020 December 31, 2020
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CONTENTS & CONTACT INFORMATION
Refer to this list when you need to contact one of your benefit vendors. For general information contact Human Resources.
BROKER Provider Name Broker Contact
M.E. Wilson Company
Amanda Sands
Provider Phone Number Provider Email Address
813-229-8021 Ext. 139 asands@mewilson.com
MEDICAL
page 3
Provider Name
Florida Blue
Provider Phone Number Provider Web Address
1-800-583-9072 www.bcbsfl.com
DENTAL
page 5
Provider Name
Guardian
Provider Phone Number Provider Web Address
800-541-7846
www.guardiananytime.com
VISION
page 6
Provider Name
Guardian
Provider Phone Number Provider Web Address
800-541-7846
www.guardiananytime.com
DISABILITY
page 7
Provider Name
Principal
Provider Phone Number Provider Web Address
1-800-247-4695
www.principal.com
VOLUNTARY LIFE
page 9
Provider Name
Principal
Provider Phone Number Provider Web Address
1-800-247-4695
www.principal.com
SUPPLEMENTAL BENEFITS
page 10
Provider Name
Colonial Life
Provider Phone Number Provider Web Address
1-800-325-4368
www.coloniallife.com
HOW TO ENROLL
page 11
DISCLOSURE NOTICES
page 14
BENEFIT INFORMATION
Benefit
Who pays the cost?
Your employer pays the majority of the employee portion of the medical plan. You may enroll your eligible dependents for an additional cost. You may elect dental coverage for yourself and your eligible dependents on a voluntary basis and you will be responsible for the cost. You may elect vision coverage for yourself and your eligible dependents on a voluntary basis and you will be responsible for the cost.
YOUR BENEFITS PLAN
Medical Insurance
Leader’s Casual Furniture 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.
Dental Insurance
Vision Insurance
Voluntary Benefits
The employee pays the entire cost.
ELIGIBILITY
All Regular full-time employees are eligible to join Leader’s Casual Furniture Benefits Plan on the 1st of the month following 60 days. “Regular Full- Time Employees” must be regularly scheduled and working at least 30 hours per week.
You may also enroll your dependents in the Benefits Plan when you enroll.
Eligible dependents include:
Your legal spouse & domestic partner.
•
• 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;
►
WHEN CAN YOU ENROLL?
► 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
You can sign up for Benefits at any of the following times:
• After completing your initial eligibility period; • During the annual open enrollment period; • Within 30 days of a qualified family-status change.
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
•
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 Leader’s Casual Furniture. 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 benefits
MAKING CHANGES
If you fail to notify Human Resources within 30 days of a family status change, you will be required to wait until the next annual enrollment period to make benefit changes unless you have another family status change.
Generally, you can only change your benefit choices during the annual benefits enrollment period. However, you may be able to change your benefit choices during the plan year 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
WHEN COVERAGE ENDS
• Change in your work status that affects your benefits
Coverage will stop on the last day of the month in which employment with the company ends.
• 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)
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. 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 year before the plan begins paying benefits. Out of Pocket Maximum – The maximum amount you will pay in deductibles and copayments during the year.
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MEDICAL INSURANCE
Leader’s Casual Furniture offers medical plan options through FloridaBlue. To find participating providers go to www.bcbsfl.com and click on “Find a Doctor”, choose the appropriate provider type. In Step 2: Network Name, choose “BlueCare or BlueOptions”. Complete the remaining information and click Search.
The chart below provides a brief overview of the medical 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.
OPTION 1 BLUECARE 71
OPTION 2 BLUEOPTIONS 05905
OPTION 3 BLUECARE 54
OPTION 4 BLUECARE 52
IN-NETWORK: Plan Year or Calendar Year Basis Deductible (Individual / Family)
Calendar Year
Calendar Year
Calendar Year
Calendar Year
$5,000 / $10,000
$7,000 / $14,000
$5,000 / $10,000
$1,500 per person
Coinsurance
80% / 20%
70% / 30%
70% / 30%
70% / 30%
Maximum Out-of-Pocket (Individual/Family) Maximum Out-of-Pocket Includes Lifetime Major Medical Maximum
$7,900/ $15,800
$7,350 / $14,700
$6,350 / $12,700
$6,350 / $12,700
Deductible, Coinsurance & Copayments
Deductible, Coinsurance & Copayments
Deductible, Coinsurance & Copayments
Deductible, Coinsurance & Copayments
Unlimited
Unlimited
Unlimited
Unlimited
PREVENTIVE CARE:
Wellness Immunizations Mammography/Colonoscopy COPAYMENTS: Referral Required Office Visits/Consultations for Illness/Injury
Covered 100%
Covered 100%
Covered 100%
Covered 100%
No (PCP Required)
No
No (PCP Required)
No (PCP Required)
$10 Copayment
$50 Copayment
$40 Copayment
$40 Copayment
Specialist Visits
$100 Copayment
$75 Copayment
$65 Copayment
$65 Copayment
Inpatient Hospital
Deductible & Coinsurance Deductible & Coinsurance $250 copay + Deductible & Coinsurance
Deductible & Coinsurance Deductible & Coinsurance
Deductible & Coinsurance Deductible & Coinsurance
Deductible & Coinsurance Deductible & Coinsurance
Outpatient Surgery
Emergency Room
Deductible & Coinsurance
$300 Copay
$300 Copayment
Urgent Care
$75 Copayment
Deductible & Coinsurance
$85 Copay
$85 Copayment
OUTPATIENT DIAGNOSTIC SERVICES: Lab Services
Covered 100%
Covered 100%
Covered 100%
Covered 100%
X-Ray Services
Deductible & Coinsurance Deductible & Coinsurance
Deductible & Coinsurance Deductible & Coinsurance
$65 copay
$65 Copayment
Complex Diagnostic
$200 copay
$200 Copayment
PRESCRIPTIONS:
Retail (30 day supply)
$10 / $50 / $80
$10 / $50 / $80
$10 / $50 / $80
$10 / $50 / $80
Mail Order (90 day supply)
2.5 X retail
2.5 X retail
2.5 X retail
2.5 X retail
OUT-OF-NETWORK:
Deductible (Individual /
$14,000 / $28,000
Family)
Maximum Out-of-Pocket
$15,500 / $30,000
(Individual/Family)
In-Network Only
In-Network Only
In-Network Only
Unlimited
Lifetime Major Medical
Maximum
50% / 50%
Coinsurance
3
MEDICAL CONTRIBUTION SCHEDULE
Smoker Employee Pays (Per Pay Period)
Option 1 BlueCare 71
Non Smoker Employee Pays (Per Pay Period)
Total Monthly Cost
Employee Only
$ 530.77
$ 64.55
$ 87.62
Employee + Spouse
$1,263.22
$402.60
$425.68
Employee + Child(ren)
$ 976.61
$212.63
$235.70
Family
$1,655.98
$526.18
$549.26
Smoker Employee Pays (Per Pay Period)
Option 2 BlueOptions 5905
Non Smoker Employee Pays (Per Pay Period)
Total Monthly Cost
Employee Only
$ 586.59
$ 90.31
$113.39
Employee + Spouse
$1,396.09
$463.92
$487.00
Employee + Child(ren)
$ 1,079.32
$260.03
$283.11
Family
$1,830.16
$606.57
$629.65
Smoker Employee Pays (Per Pay Period)
Option 3 BlueCare 54
Non Smoker Employee Pays (Per Pay Period)
Total Monthly Cost
Employee Only
$ 579.14
$ 86.87
$109.95
Employee + Spouse
$1,378.35
$455.74
$478.81
Employee + Child(ren)
$1,065.61
$253.70
$276.78
Family
$1,806.91
$595.84
$618.92
Smoker Employee Pays (Per Pay Period)
Option 4 BlueCare 52
Non Smoker Employee Pays (Per Pay Period)
Total Monthly Cost
Employee Only
$ 585.28
$ 89.70
$112.78
Employee + Spouse
$1,392.95
$462.48
$485.55
Employee + Child(ren)
$1,076.90
$258.91
$281.99
Family
$1,826.05
$604.68
$627.75
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DENTAL INSURANCE
Leader's Casual Furniture offers dental coverage through Guardian. The Dental PPO Plans allow you to use in-network or out-of-network benefits. If out-of-network dentists are used, you will be responsible for paying the difference between Guardian’s allowed amount and what the dentist may charge, also known as “balance billing”. The charts below provides a brief overview of the plans.
DMO
PPO
Calendar Year Deductible
In-Network
Out-of-Network
Individual
$0
$25
$50
Family
$0
$75
$150
Annual Maximum
Unlimited
$1,500
$1,500
Diagnostic & Preventative
Exams
Fee Schedule
100%, no deductible
100%, no deductible
Cleanings
Fee Schedule
100%, no deductible
100%, no deductible
Fluoride
Fee Schedule
100%, no deductible
100%, no deductible
X-Rays
Fee Schedule
100%, no deductible
100%, no deductible
Sealants
Fee Schedule
100%, no deductible
100%, no deductible
Regular Restorative Services
*12 Month Waiting Period for late applicants
Amalgam Fillings
Fee Schedule
90%, after deductible
80%, after deductible
Extractions – Single Tooth
Fee Schedule
90%, after deductible
80%, after deductible
Endodontics (Root Canal)
Fee Schedule
90%, after deductible
80%, after deductible
Periodontics (Gum Disease)
Fee Schedule
90%, after deductible
80%, after deductible
Major Services
*No Waiting Period
*12 Month Waiting Period for late applicants
Crowns
Fee Schedule
60%, after deductible
50%, after deductible
Bridges
Fee Schedule
60%, after deductible
50%, after deductible
Dentures
Fee Schedule
60%, after deductible
50%, after deductible
Orthodontia
Child
Fee Schedule
50%, no deductible
Adult
Fee Schedule
50%, no deductible
Lifetime Max
N/A
$1,500
DHMO Employee Cost Per Pay Period
PPO Employee Cost Per Pay Period
Employee Only
$ 6.99
$17.22
Employee + Spouse
$13.99
$36.41
Employee + Child(ren)
$15.74
$38.74
Family
$25.33
$61.68
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VISION INSURANCE
Leader's Casual Furniture offers vision coverage through Guardian. The Guardian vision network consists of optometrists, ophthalmologist opticians and optical retailers. You have the option of visiting any provider, however by choosing a participating provider, you receive the highest level of benefits.
Vision – (Davis Vision)
In-Network
Out-of-Network
Eye Exam (every 12 months)
$10 Copay
$50 allowance
Lenses** (every 12 months)
Single Vision
$10 Copay
$48 allowance
Bifocal Lenses
$10 Copay
$67 allowance
Trifocal Lenses
$10 Copay
$86 allowance
Frames (every 24 months)
$150 allowance + 20% discount
$48 retail allowance
Contact Lenses
Elective
$120 allowance + 15% discount
$105 allowance
Medically Necessary
Covered 100%
$210 allowance
• Covered lenses include single vision, bifocal, trifocal and lenticular.
• Lenses, Frames & Contacts are limited to either one pair of contacts or frames/lenses per calendar year.
Employee Cost Per Pay Period
Employee Only
$3.07
Employee + 1
$5.53
Family
$9.54
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SHORT TERM DISABILITY INSURANCE
SHORT TERM DISABILITY
Leader’s Casual Furniture provides all active employees working 30 or more hours per week the option to purchase short term disability insurance coverage through a group plan, at the employee’s cost.
Short Term Disability
Benefit Percentage
60% of basic earnings
Maximum Weekly Benefit
$1,000 per week
Benefits commence on the 8th day for an accident Benefits commence on the 8th day for a sickness
Elimination Period
Duration of Benefit
25 weeks
Definition of Earnings
Base Salary
Employee Rate Per $10 of Weekly Benefit
$.69
Voluntary STD Premium Calculation Worksheet
To calculate your approximate STD bi-weekly premium, follow these steps:
STEP 1 Enter your bi-weekly pay
1. _________
Multiply the number on line 1 by 26, then divide by 52. This is your weekly pay (this amount cannot exceed $1,667)
STEP 2
2. _________
STEP 3 Multiply the amount in Step 2 by 60%.
3. _________
STEP 4 Monthly rate:
4. __$.69____
STEP 5 Multiply the amount on Line 3 by the rate entered on Line 4.
5. _________
Divide the amount on Line 5 by 10 and enter the amount on Line 6 to get your monthly payroll deduction. Multiply the amount on Line 6 by 12, then Divide by 26 to get your approximate bi-weekly payroll deduction.
STEP 6
6. _________
STEP 7
7. _________
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LONG TERM DISABILITY INSURANCE
LONG TERM DISABILITY Leader’s Casual Furniture provides all active employees working 30 or more hours per week the option to purchase Long term disability insurance coverage through a group plan, at the employee’s cost.
Long Term Disability
Benefit % of Monthly Covered Payroll
50% of basic earnings
Monthly Maximum
$6,000 per month
Elimination Period
Benefits commence on the 180th day
Benefit Duration
Social Security Normal Retirement Age (SSNRA)
Definition of Earnings
Salary
VOLUNTARY LONG-TERM DISABILITY Monthly Rates per $100 of benefit
AGE
Rates per $100 of benefit
PREMIUM CALCULATION
< 24
$0.48
Annual Pay
1. $__________
25-29
$0.45
30-34
$0.51
Divide Annual Pay by 12
2. $__________
35-39
$0.69
Find rate on table below
3. $__________
Multiply the amount on line 2 by appropriate rate for your age entered on line 3.
4. $__________
40–44
$1.09
45-49
$1.16
Divide the amount on line 4 by 100 5. $__________ and enter the amount on line 5 to get your monthly payroll deduction. Multiply the amount on Line 5 by 12, 6. $__________ then divide by 26 to get your approximate bi-weekly payroll deduction
50–54
$1.82
55-59
$1.81
60-64
$1.87
65-69
$1.10
70+
$0.81
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VOLUNTARY LIFE INSURANCE
VOLUNTARY LIFE INSURANCE
Leader’s Casual Furniture provides all active employees working 30 or more hours per week the option to purchase life insurance coverage through a group plan, at the employee’s cost. The chart below provides an overview of the plan. Please note that anyone enrolling outside of their initial open enrollment period is considered a late entrant and will be subject to medical underwriting.
Voluntary Life Insurance
Employee Life
Increments of $10,000 up to $500,000
Under Age 70: $150,000 Age 70 and over” $10,000
Employee Guarantee Issue
Spouse Life
Increments of $5,000 up to 50% of the employee’s coverage (Maximum $200,000)
Under Age 70: $30,000 Age 70 and over” $10,000
Spouse Guarantee Issue
Dependent Life
$5,000 or $10,000, not to exceed 50% of employee amount
Accidental Death & Dismemberment (AD&D)
Included Equal to voluntary life amount
Age Employee Spouse Child
VOLUNTARY LIFE Monthly Life Rates per $1,000 of benefit Includes AD&D Cost
<29
$.107
$.107
$1.028/ $5000
30-34
$.115
$.115
$2.028/ $10,000
COST CALCULATION:
35-39
$.159
$.159
_____________________ Benefit Amount / 1,000 x____________________ Monthly Rate (from chart) = ____________________ x12 /26 =____________________ Approximate bi-weekly Cost
40-44
$.24
$.24
45-49
$.355
$.355
50-54
$.561
$.561
55-59
$.865
$.865
60-64
$1.189
$1.189
65-69
$2.171
$2.171
70+
$3.557
$3.557
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SUPPLEMENTAL BENEFITS
Voluntary Insurance Designed to Help Your Benefits Dollars Go Further!
One thing people can count on in life is change. We often fail to consider how these changes affect our current and long- term financial plans. To ensure you are up-to-date with your personal benefits needs, consider this question:
“Do I have the financial resources to help my family maintain their standard of living if I were to become seriously ill, injured or die?”
If you answered “I don’t know”, Colonial insurance could be the answer. As a benefit eligible employee of Leader’s Casual Furniture you can choose from the following insurances that protect you and your family against these financial concerns that are caused from accidents, illnesses and death.
➢ Accident Insurance - Do your children play sports? Are you accident prone? This plan pays an emergency room benefit along with a follow up doctor visit. It covers you and your family 24/7 and also includes income for each day you are hospitalized, AD&D and catastrophic benefits with lump sum payments for specific injuries.
➢ Cancer Insurance – 62% of cancer related expenses are out-of-pocket costs that major medical plans are not designed to cover such as deductibles, coinsurance, loss of wages, travel expenses, treatment and medications. In addition, there is an annual wellness benefit of $100 for cancer screening tests for each person covered by the policy.
➢ Hospital Confinement Insurance - Pays an admission benefit in addition to a daily confinement benefit. This plan can help you budget for any out-of-pocket expenses (deductible and/or coinsurance) that occur when you or a family member is hospitalized.
➢ Critical Illness Insurance - Can help fill the gaps created by loss of income or high medical bills. This plan complements your other benefits by adding additional income when needed most. This coverage pays a lump sum benefit, upon diagnosis of a covered critical illness (i.e. stroke, heart attack, organ transplant, and end stage renal failure).
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HOW TO LOGIN TO MAXWELL HEALTH
1
Go to your Internet browser (internet Explorer, Google, Chrome, FireFox) and enter in the following URL: https://app.maxwellhealth.com/member/login
2
Click “I don’t have an email address”.
The next time you go to login you will use the email entered as your username and click “ Forgot my password ’.
3
Enter in your first name, last name and SSN. Confirm Privacy Policy Terms of Service by clicking "Accept Maxwell Health's Privacy Policy & Terms of Service."
4
Once you’ve logged in you should see the below screen, hit “
Most of your personal information will be populated on this page. Please enter any empty fields and review the information for accuracy. (*=required) As you continue you will be asked to enter/review your dependent’s information. 5
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ENROLLING IN BENEFITS
6
After verifying you and any dependent’s information you’ll jump right into the process of shopping and electing benefits.
You can compare benefits and costs side by side by clicking “Compare”. Please note, The costs shown will be the monthly cost.
You’ll have the option to waive coverages or indicate your intent to elect by adding them to your shopping cart. At this time you can indicate the coverage level you wish.
You can review your cart at anytime and see the total monthly cost for all benefits elected.
7
Once you’ve completed your elections and/or waivers please review your cart, edit if needed, then “Submit Enrollment”.
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ENROLLING IN BENEFITS CONTINUED
Once benefits have been submitted you may be prompted to complete forms. These forms are required based on the benefits elected. By clicking “View” you may access the forms online to complete via electronic signature. 8
If you experience a qualifying event throughout the year and need to change your benefits you may do so by logging into Maxwell Health and clicking “Change My Benefits”. You’ll need to select the reason for the change as well as the date the change occurred. Keep in mind you must submit the request and provide necessary documentation to HR within 30 days from the date of the change.
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REQUIRED ANNUAL EMPLOYEE DISCLOSURE NOTICES
THE NEWBORNS’ AND MOTHERS’ HEALTH PROTECTION ACT OF 1996
WOMEN’S HEALTH AND CANCER RIGHTS ACT OF 1998 The Women’s Health and Cancer Rights Act of 1998 requires Leader's Casual Furniture to notify you, as a participant or beneficiary of the Leader's Casual Furniture 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. 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. MICHELLE’S LAW
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 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. 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; 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. Further, a health insurer or health maintenance organization may not: 4. Require a mother to give birth in a hospital; or
SECTION 111
Effective January 1, 2009 group health plans are required by 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.
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REQUIRED ANNUAL EMPLOYEE DISCLOSURE NOTICES continued
HIPAA PRIVACY POLICY FOR FULLY-INSURED PLANS WITH NO ACCESS TO PHI
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, you 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.
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. 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 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.
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.
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.
15
REQUIRED ANNUAL EMPLOYEE DISCLOSURE NOTICES continued
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 FloridaBlue 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 FloridaBlue 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: • 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). • Visit www.medicare.gov
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 FloridaBlue 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. FloridaBlue has determined that the prescription drug coverage offered by the Welfare Plan for Employees of Leader's Casual Furniture under the FloridaBlue 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 FloridaBlue 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. _______________________________________________________ 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 FloridaBlue 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 FloridaBlue coverage, be aware that you and your dependents will be able to get this coverage back. When can you join a Medicare Drug Plan?
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:
1/1/20
Name of Entity/Sender: Contact--Position/Office:
Leader's Casual Furniture Barbara Walters 6303 126 th Avenue North Largo, Florida 33773
Phone Number:
727-254-5567
16
GENERAL NOTICE OF COBRA RIGHTS *Continuation coverage rights under cobra**
Introduction You’re getting this notice because you recently gained coverage under a group health plan (the Plan). This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator. You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of- pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees. What is COBRA continuation coverage? COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries may elect COBRA continuation coverage, but they may be required to pay for the coverage. If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • Your hours of employment are reduced, or • Your employment ends for any reason other than your gross misconduct.
• Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or • You become divorced or legally separated from your spouse. Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events: • The parent-employee dies; • The parent-employee’s hours of employment are reduced; • The parent-employee’s employment ends for any reason other than his or her gross misconduct; • The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); • The parents become divorced or legally separated; or • The child stops being eligible for coverage under the Plan as a “dependent child.” When is COBRA continuation coverage available? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events: • The end of employment or reduction of hours of employment; • Death of the employee; • The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both). For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. You must provide this notice to the employer sponsoring the Plan.
If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • Your spouse dies; • Your spouse’s hours of employment are reduced; • Your spouse’s employment ends for any reason other than his or her gross misconduct;
17
GENERAL NOTICE OF COBRA RIGHTS Continued
How is COBRA continuation coverage provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage. Disability extension of 18-month period of COBRA continuation coverage: If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage. Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. There are also ways in which this 18-month period of COBRA continuation coverage can be extended:
health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov. If you have questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.HealthCare.gov. Keep your Plan informed of address changes To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator.
Are there other coverage options besides COBRA Continuation Coverage? Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group
18
New Health Insurance Marketplace Coverage Options and Your Health Coverage
Form Approved OMB No. 1210-0149 (expires 5-31-2020)
PART A: General Information When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance : the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace and employment-based health coverage offered by your employer. What is the Health Insurance Marketplace? The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014.
Can I Save Money on my Health Insurance Premiums in the Marketplace? You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your household income.
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.5% of your household income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit. 1 Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis.
How Can I Get More Information? For more information about your coverage offered by your employer, please check your summary plan description or contact:
Barbara Walters 727-254-5567
The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area.
PART B: Information About Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to complete an application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace application.
3. Employer Name
4. Employer Identification Number (EIN)
Leader’s Casual Furniture
59-2640693
5. Employer Address
6. Employer Phone Number
6303 126 th Ave North
727-254-5567
7. City
8. State
9. Zip Code
Largo
FL
33773
10. Who can we contact about employee health coverage at this job?
Barbara Walters
11. Phone Number (if different from above)
12. E-mail address
727-254-5567
barbara.walters@leadersfurniture.com
1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs
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