Solico,Wesgarde, HMI Benefit Guide 2017

2017 Benefits at a Glance

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Plan Year: January 1, 2017 – December 31, 2017


Refer to this list when you need to contact one of your benefit vendors. For general information contact Human Resources. HUMAN RESOURCES HR Contact Yvonne Sheffield Provider Phone Number 800-275-7102 Ext. 270 Provider Email Address BROKER Provider Name M.E. Wilson Company Broker Contact Alison Leon Provider Phone Number 813-229-8021 Ext. 146 Provider Email Address MEDICAL page 3 Provider Name Continental Benefits Provider Phone Number 1-855-824-9457 Provider Web Address HEALTH SAVINGS ACCOUNT page 4 Provider Name HSA Bank Provider Phone Number 1-800-357-6246 Provider Web Address BALANCE BILL ASSISTANCE page 5 Provider Name AMPS/CDS Claims Delegate Services Provider Phone Number 800-425-9373 Provider Email Address DENTAL page 6 Provider Name Mutual Of Omaha Provider Phone Number 1-877-999-2330 Provider Web Address VISION page 7 Provider Name Superior Vision Provider Phone Number 1-800-507-3800 Provider Email Address BASIC AND VOLUNTARY LIFE page 8 Provider Name Mutual Of Omaha Provider Phone Number 1-800-877-5176 Provider Web Address SHORT TERM AND LONG TERM DISABILITY page 10 Provider Name Mutual Of Omaha Provider Phone Number 1-800-877-5176 Provider Web Address 401K page 11 Provider Name ADP 401k Provider Phone Number 866-695-7526 Provider Web Address


page 12-13


page 14-18



Who pays the cost?

The Company pays over 70 percent of the employee portion of the medical plan and over 60 percent of the spouse & dependent portion The Company pays greater than 65 percent of the employee portion of the dental plan and the cost for your covered dependents

YOUR BENEFITS PLAN The Company 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. In 2016, we rolled out smoking cessation plans for each state. As of 2017, we will implement tobacco user medical rates effective January 1 st . All employees will be required to complete the tobacco free affidavit form and submit it with their benefits application.

Medical Insurance

Dental Insurance

Vision Insurance

You pay entire cost

Life Insurance

The Company pays the entire cost

Voluntary Life

You pay entire cost

Short Term Disability

The Company pays the entire cost

Long Term Disability

You pay entire cost


All Regular full-time employees are eligible to join The Company 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 •

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


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. If you do not enroll at one of the above times, you must wait for the next annual open enrollment period.




CHOOSING YOUR BENEFITS You must actively choose any benefit that you pay for, or share in the cost with The Company. 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


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 and can produce supporting documentation to Human Resources. Below are examples of qualifying events: • 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 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. 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. 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.



The chart below provides a brief overview of the medical plan options available to you. 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.

The Company offers 2 medical plan options through Continental Group. To find participating providers for physician’s only go to and click on “Search for a Doctor”, check the box next to the “PHCS Practitioners Only” and enter your specific search criteria to find a doctor. If you have questions or concerns, please feel free to contact member services at 1-855- 824-9457

Base Copay Plan (Silver)

Buy-Up HSA Plan (Gold)

IN-NETWORK: Plan Year / Contract Year Basis Deductible (Individual / Family)

Calendar Year $3,000 / $6,000 $6,000 / $12,000

Calendar Year $2,000 / $4,000 $4,000 / $8,000

Maximum Out-of-Pocket (Individual/Family)

Out-of Pocket Max Includes

Deductible, Coinsurance, & Copays

Deductible & Coinsurance

Lifetime Major Medical Maximum






Routine Preventive Services Wellness Immunizations / Flu Shots Mammography/Colonoscopy CO-PAYS PCP Required / Open Access Office Visits for Illness/Injury

Covered 100%

Covered 100%

Open Access $30 Copay $50 Copay $40 Copay $30 Copay

Open Access

No Charge After Deductible No Charge After Deductible No Charge After Deductible No Charge After Deductible No Charge After Deductible No Charge After Deductible No Charge After Deductible No Charge After Deductible No Charge After Deductible No Charge After Deductible No Charge After Deductible 10% After the Deductible 10% After the Deductible 10% After the Deductible

Specialist Visits

Physical/Occupational/Speech Therapy Chiropractic Care (20 visits per calendar year for)

Inpatient Hospital Outpatient Surgery

Deductible & Coinsurance Deductible & Coinsurance

Emergency Room (subject to a 30% penalty non accident/non-life threatening)

$300 Copay $75 Copay

Urgent Care

OUTPATIENT DIAGNOSTIC SERVICES Lab Services (Freestanding Lab) X-Ray Services (Freestanding X-Ray)

Covered 100%

$50 Copay $300 Copay

Complex Diagnostic PRESCRIPTIONS Retail (30 day supply)

$10/ $50/ $75


50% up to $250 max Copay

Mail Order (90 day supply) OUT-OF-NETWORK: Deductible (Individual / Family)

2.5 X’s retail

$6,000/$12,000 $12,000/$24,000

$3,000/$6,000 $6,000/$12,000

Maximum Out-of-Pocket (Individual/Family)




Tobacco User Rate Silver Copay Plan

Tobacco User Rate Gold HSA Plan

Standard Rate Silver Copay Plan

Buy-Up Option

Employee Cost Per Pay Period

Gold HSA Plan

Employee Only Employee + Spouse Employee + Child(ren)

$ 51.29 $156.59 $120.97 $190.09

$ 61.29 $166.59 $130.97 $200.09

$ 66.69 $203.59 $156.95 $233.41

$ 76.69 $213.59 $166.95 $243.41




What is a Health Savings Account (HSA )? It is an interest bearing account created to help you pay medical expenses. The funds in your HSA can be used to help pay your deductible, coinsurance and any qualified medical expenses not covered by your health plan (including dental and vision expenses). All of the money you contribute is tax-deductible when used to pay for qualified medical expenses. An HSA is your account. It goes with you if you change jobs or when you retire. HSA Bank is our designated bank and employees are required to open a new account. Please contact Human Resources for the application. Your Total Annual Employee Election along with contributions from any other sources, including your employer, may not exceed the Annual Maximum Contribution amount set by the IRS. Contribution limits for the current tax year can be found below, at , or by visiting the IRS site at Additionally, investment accounts are not FDIC insured, may lose value and are not a deposit or other obligation of, or guarantee by the bank.

2017 IRS Annual Maximum HSA Contribution Limits

Employee Only

$3,400 $6,750


Catch-up Amount for employees 55 years or older

Additional $1,000 annually

Health Savings Account – Eligible Expenses (partial list) • Acupuncture • Alcohol and drug dependency treatment • Ambulance • Artificial limbs • Breast reconstruction surgery (mastectomy-related) • Dental expenses (exams, cleanings, X-rays, root canals bridges, etc.) • Diagnostic fees • Doctor fees (including Chiropractic services) • Drugs - prescription and over the counter (when ordered by physician) • Eyeglasses and exams, contact lenses & solutions, laser surgery • Fertility enhancements • Hearing aids and batteries • Hospital and Laboratory fees • Long-term care (medical expenses and premiums) • Nursing home • Physical and speech therapies • Psychiatric care • Smoking-cessation programs and products • Vasectomy • Weight-loss program (to treat a specific disease diagnosed by a physician)


AMPS/Claims Delegate Services BALANCE BILL SUPPORT

How The Process Works

1. You choose the facility. 2. AMPS/CDS applies the Permitted Payment Level as defined by your benefit plan and returns the claim to the administrator for payment. 3. After payment is made, you will receive an Explanation of Benefits (EOB), which tells you: • How much the hospital billed; • How much your Plan paid; • How much you owe. 4. Shortly after the EOB arrives, you should receive a bill from the provider. Locate your responsibility and make sure it matches your responsibility from the EOB. • If the amounts match, pay the billed amount in full or setup a payment plan. Be sure to make monthly good faith payments against the outstanding balance. Failure to address your balance in a reasonable time period can diminish your rights under the Fair Credit Billing Act (FCBA). • If the amounts do not match and you have received a balance bill then you should contact AMPS/CDS to get them involved in resolving your bill 800-425-9373  Approximately 30 days post payment, the Advocacy team at CDS will send you a Welcome letter.  Approximately 45 days post payment, the Advocacy team will make an introductory call.  Please contact AMPS / CDS as quickly as possible; ideally within 60 days of the post mark on the envelope, or the date on the hospital statement itself. This is the timeframe stipulated by the Fair Credit Billing Act and disputes made within this timeline offer you the maximum protection under the law.

AMPS/CDS Member Support Location: 420 Technology Pkwy #200. Norcross, GA 30092 Monday-Friday 8 am - 7 pm EST Phone: 800-425-9373 Email:

Continental Member Support Location: P.O. Box 3610 Brandon, FL 33509 Monday-Friday 8 am – 8 pm EST Phone: 855-824-9457




The Company offers dental through Mutual Of Omaha. 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 Mutual Of Omaha’s allowed amount and what the dentist may charge, also known as “balance billing”. Mutual Of Omaha uses several Dental Networks to provide you plenty of options. You can find a dentist by visiting www. or calling 877-999-2330 for more information. The chart below provides a brief overview of the plan. DENTAL INSURANCE

Dental PPO Plan


Out-of Network*

Calendar Year Deductible Individual






Annual Maximum

$1,000 Per Person

Diagnostic & Preventive Exams

Cleanings Fluoride X-Rays Sealants Regular Restorative Services Amalgam Fillings Extractions - Single Tooth Endodontics (Root Canal) Periodontics (Gum Disease) Major Services Crowns Bridges Dentures Orthodontia Dependents under 19 years old

Covered in full

Covered in full

Covered at 90% after deductible

Covered at 80% after deductible

Covered at 60% after deductible

Covered at 50% after deductible

50% ($1,000 lifetime maximum)

• Out of network claims are subject to reasonable and customary charges. • If you or your dependents do not enroll when first eligible, there is a 12 month waiting period for Basic, Major and Orthodontia coverage.

Employee Cost Per Pay Period

Employee Only

$ 5.15 $12.12 $12.85 $20.26

Employee + Spouse Employee + Child(ren)




The Company offers vision through Superior Vision, the 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. Additional discounts on Sunglasses and Laser Vision correction are also provided to members. You can find a provider list by visiting www. or calling 800-507-3800 for more information. The chart below provides a brief overview of the plan.

English Enrollment Video-Superior Vision Spanish Enrollment Video-Superior Vision

Vision Superior Vision Network



Routine Eye Exams

$10 Copayment

Reimbursed up to $33

Lenses Single Bifocal Trifocal Frames

$25 Copayment $25 Copayment $25 Copayment

Reimbursed up to $28 Reimbursed up to $40 Reimbursed up to $53 Reimbursed up to $65 Reimbursed up to $100

$140 allowance 20% off balance over $140

Contact Lenses

$135 allowance

Frequency Exam

Once every 12 months Once every 12 months Once every 24 months

Lenses or contact lenses


Employee Cost Per Pay Period

Employee Only

$3.19 $6.07 $6.39 $9.40

Employee + Spouse Employee + Child(ren)





The Company provides life insurance to all active full time employees, at no cost! The chart below provides an overview of the plan.

Basic Life Insurance

Mutual Of Omaha

Benefit Outline

Eligible Full Time Employees in their 1 st year


Eligible Full Time Employees after 1 year of service

1 ½ times your basic salary Included - Equal to basic life


• Please make sure your beneficiary information is up to date and on file with Human Resources. You may change your beneficiary at any time .

Hearing Discount Program Mutual Of Omaha has teamed up with Amplifon – the world’s largest distributor of hearing aids and services – to add affordable hearing care to every Mutual Of Omaha benefits package.

Amplifon’s hearing discount programs provides: • 40% off hearing exams at thousands of locations around the country

• Discounted, set pricing on thousands of hearing aids, including the latest technology to hit the market • Low price guarantee – if your employees find the same product at a lower price, Amplifon will beat it by 5%

• 60-day hearing aid trial period with no restocking fees • 1-year free follow-up care with unlimited appointments • Free batteries for 2 years with initial purchase • 3-year warranty and loss & damage coverage Call 1-888-534-1747 or visit to learn more.

ONLINE WILL PREPARATION & CLAIMANT SUPPORT SERVICES Included in your Life Insurance plan, Mutual Of Omaha offers access to online services through ComPsych Corporation. Will Preparation: • Step-by-step guidance and customization for your situation • Ability to name an executor and guardians to care for your child(ren) • Ability to create a living will (for an additional fee) Claimant Support Services: • 24/7 access to counseling, clinicians, attorneys, and financial experts • Support dealing with trauma and loss • Assistance with topics such as inheritance taxes, loss of income, creditors and probate



VOLUNTARY LIFE INSURANCE The Company provides all active employees working 30 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

Increments of $10,000 up to the lesser of 5x annual salary or $500,000. Minimum of $10,000

Employee Life

Guarantee Issue


Increments of $5,000 up to lesser of 100% of employee's amount or $100,000. Guarantee Issue - $30,000 Birth to less than 19 years (23 if full time student) 50% employee’s amount up to $10,000.

Spouse Life

Dependent Life

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 Waiver of Premium Benefit Included to the earlier of age 65, retirement or recovery Convertible Included Portable Enrollment Events Includes annual enrollment period



SHORT TERM DISABILITY The Company provides short term disability insurance to all active full time employees, at no cost to you! The chart below provides an overview of the plan.

Short Term Disability

Mutual Of Omaha

Benefit Percentage

66 ⅔ %

Maximum Weekly Benefit


30 th day Accident 30 th day Sickness

Elimination Period

Duration of Benefit

22 weeks

VOLUNTARY LONG TERM DISABILITY The Company provides all active employees working 30 or more hours per week the option to purchase voluntary long term disability coverage through a group plan. The chart below provides an overview of the plan.

Long Term Disability

Mutual Of Omaha

Benefit % of Monthly Covered Payroll


Monthly Maximum


Elimination Period

180 days

Benefit Duration

Normal Social Security Retirement Age (to age 65)

VOLUNTARY LONG-TERM DISABILITY Rates per $100 of benefit




25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69

$0.08 $0.10 $0.16 $0.29 $0.44 $0.61 $0.71 $0.75 $0.79 $0.79

Monthly Pay

$__________ / 100.00 = $________

Rate per $100.00 (See Chart)

x _________

X 12______ / 26 _______

Bi-Weekly Premium




401k Information



Required Annual Employee Disclosure Notices

Life’s not always easy. Sometimes a personal or professional issue can get in the way of maintaining a healthy, productive life. Your Employee Assistance Program can be the answer for you and your family.

WE’RE HERE TO HELP Mutual of Omaha’s EAP assists employees and their eligible dependents with personal or job-related concerns, including:  Emotional well-being  Family and relationships  Legal and financial  Healthy lifestyles  Work and life transitions EAP BENEFITS  Unlimited telephone access to EAP professionals 24 hours a day, seven days a week  Telephone assistance and referral  Service for employees and eligible dependents  Legal assistance and financial services  Online will preparation  Legal library & online forms  Telephonic financial consultation  Resources for:  Financial tools and resources  Substance abuse and other addictions  Dependent and elder care assistance & referral services  Access to a library of educational articles, handouts and resources via WHAT TO EXPECT You can trust your EAP professional to assess your needs and handle your concerns in a confidential, respectful manner. Our goal is to collaborate with you and find solutions that are responsive to your needs. Your EAP benefits are provided through your employer. If additional services are needed, your EAP will help locate appropriate resources in your area. Don’t delay if you need help: Visit or call 800-316-2796 for confidential consultation and resource services.


Each year millions of Americans become victims of identity theft. Information that personally identifies you, such as your name, Social Security number or credit card numbers can be stolen and used to commit fraud or other crimes.

Identity Theft Assistance, provided by AXA Assistance, helps you and your dependents understand the risks of identity theft, learn how to prevent it, and most importantly, assist you if your information is compromised. ID Theft Assistance is available as part of your overall Travel Assistance package offered by your employer. Services include: AWARENESS AND EDUCATION We help you understand the growing threat of identity theft by:  Promoting awareness of identity theft  Answering your questions about identity theft and how to recognize if you’ve become a victim  Educating you on how to avoid having your identity stolen RECOVERY ASSISTANCE If your identity is compromised, the most important thing to do is respond quickly. We assist you by:

 Connecting you to the fraud departments at your bank(s) and credit card companies  Facilitating access to credit bureaus and obtaining a complimentary credit report  Guiding you in contacting federal government and local law enforcement agencies and filing reports and complaints



Required Annual Employee Disclosure Notices

Experiencing an emergency while traveling can be especially difficult. Knowing who to call for medical problems, currency exchange issues or lost luggage is critical. Take comfort in knowing that Travel Assistance* travels with you worldwide, offering access to a network of professionals who can help you with local medical referrals or provide other emergency assistance services in foreign locations.

ENJOY YOUR TRIP – WE’LL BE THERE IF YOU NEED US Travel Assistance can help you avoid unexpected bumps in the road anywhere in the world. For you, your spouse and dependent children on any single trip, up to 120 days in length, more than 100 miles from home. PRE-TRIP ASSISTANCE** Minimize travel hassles by calling us pre-departure for:  Information regarding passport, visa or other required documentation for foreign travel  Travel, health advisories and inoculation requirements for foreign countries  Domestic and international weather forecasts  Daily foreign currency exchange rates  Consulate and embassy locations IMMEDIATE ATTENTION FOR EMERGENCIES WHILE TRAVELING While traveling more than 100 miles from home you may access Travel Assistance services 24/7 by calling the toll-free number for immediate help from a travel assistance professional. EMERGENCY TRAVEL SUPPORT SERVICES  Telephonic translation and interpreter services – 24/7 access to telephone translation services  Locating legal services – referrals for local attorney or consular offices and help maintain business and family communications until legal counsel is retained (includes coordination of financial assistance for bonds/bail)  Baggage – assistance with lost, stolen or delayed baggage while traveling on a common carrier  Emergency payment and cash – assistance with advance of funds for medical expenses or other travel emergencies by coordinating with your credit card company, bank, employer, or other sources of credit; includes arrangements for emergency cash from a friend, family member, business or credit card  Emergency messages – assistance with recording and retrieving messages between you, your family and/or business associates at any time  Document replacement – coordination of credit card, airline ticket or other documentation replacement  Vehicle return – if evacuation or repatriation is necessary, return your unattended vehicle to the car rental company MEDICAL ASSISTANCE  Locating medical providers and referrals  Communication on your medical status with family, physicians, employer, travel company and consulate  Emergency evacuation if adequate medical facilities are not available, including payment of covered expenses  Transportation home for further treatment – in the event of death, assist in the return of mortal remains  Transportation arrangements for the visit of a family member or friend if your hospitalization is more than seven calendar days  Return home for dependent children if your hospitalization is more than seven calendar days  Assistance with lodging arrangements if convalescence is needed prior to, or after, medical treatment  Coordination with your health insurance carrier during a medical emergency  Assistance obtaining prescription drugs or other necessary personal medical items

IDENTITY THEFT Your Travel Assistance benefit automatically includes Identity Theft Assistance, coordinated at no additional cost. Whether at home or traveling, this benefit provides education, prevention and recovery information to help you protect your identity. EDUCATION AND PREVENTION  Comprehensive ID theft assistance guide  Tips to defend against ID theft RECOVERY INFORMATION  Information regarding the steps to recover from credit card and check fraud  Guidelines if your Social Security number is compromised  Instructions for lost or stolen passport  Contact list for financial institutions, credit bureaus and check companies ASSISTANCE If you need help with an ID theft issue, case managers are available 24 hours a day, seven days a week and can be reached by calling the same toll-free number used to contact AXA: 800-856- 9947. TRAVEL ASSISTANCE PLAN LIMITATIONS AXA will not pay emergency evacuation, medically necessary repatriation, repatriation of remains or other expenses incurred while traveling within 100 miles of participant’s place of residence, or for any one of the following reasons:  A single trip lasts more than 120 days in length  Traveling against the advice of a physician  Traveling for medical treatment  Pregnancy and childbirth (exception: complications of pregnancy) Expenses for emergency evacuation, medically necessary repatriation, repatriation of remains, return of dependent children, family or friend transportation arrangement and vehicle return are limited to $200,000 per person per event. All additional costs would be the responsibility of the member. This includes medical costs which are the responsibility of the person receiving medical services. Services must be authorized and arranged by AXA Assistance USA, Inc. designated personnel to be eligible for this program. No reimbursement claims for out-of-pocket expenses will be accepted.

*Brought to you by Mutual of Omaha. Services provided by AXA Assistance USA (AXA) **Available at any time, not subject to 100 mile travel radius



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


The Women’s Health and Cancer Rights Act of 1998 requires The Company to notify you, as a participant or beneficiary of the The Company 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



Required Annual Employee Disclosure Notices continued


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.

Employer Name: Sorenson Lighted Controls,, Inc. Employer Identification Number (EIN): 06-0774226 Employer Address:

2820 Drane Field Road, Lakeland, FL 33811 Contact Email: Employer Telephone Number: 863-644-7564 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 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. 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: Yvonne Sheffield, H.R. Manager; Phone: 863-644-7564; Email: The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area. 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.


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 Continental 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. Continental has determined that the prescription drug coverage offered by the Welfare Plan for Employees of The Company under the Continental 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 Continental 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 Continental 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 Continental 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 Continental 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 Continental 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 • 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, 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: 1/1/16 Name of Entity/Sender: Wes-Garde, Solico, HMI Contact--Position/Office: Yvonne Sheffield 2820 Drane Field Road

Lakeland, FL 33811 Ph • 863.644.7564

Phone Number:

Ph • 800-275-7102 X270



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.


GENERAL NOTICE OF COBRA RIGHTS *Continuation coverage rights under cobra**

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; • 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.

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.


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