Benefits At a Glance November 1, 2021 – October 31, 2022
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Contents & Contacts
BROKER Company Name
M.E. Wilson Company / Amanda Sands
Company Phone Number Company Email Address
813-229-8021 Ext. 139 asands@mewilson.com
MEDICAL
page 3
Company Name
Meritain
Company Phone Number Company Web Address
1-800-925-2272
www.mymeritain.com Aetna, Choice POS II
Network
PHARMACY Company Name
CVS/caremark 1-800-334-8134
Company Phone Number Company Email Address
RxHelp@rxbenefits.com
TELEMEDICINE Company Name
page 5
Teladoc
Company Phone Number Company Web Address
1-800-362-2667
www.mydrconsult.com
DENTAL
page 7
Company Name
Sunlife Financial 800-247-6875
Company Phone Number Company Web Address
www.sunlife.com/onlineadvantage
VISION
page 8
Company Name
Sunlife Financial 800-877-7195 www.vsp.com
Company Phone Number Company Web Address
LIFE INSURANCE Company Name
page 9
Hartford
Company Phone Number Company Web Address
1-800-523-2233 / 1-888-563-1124 (claims)
www.thehartford.com
SHORT TERM AND LONG TERM DISABILITY
page 10
Company Name
Hartford
Company Phone Number Company Web Address
1-800-523-2233 / 1-888-301-5615 (claims)
www.thehartford.com
NO COST PROGRAMS
page 11
SHARE FUND
page 12
Company Fax Number
508-382-1544
StaplesShareFund@staples.com www.staplessharefund.org
Company Web Address
VOLUNTARY PRODUCTS
page 13
Company Name
Hartford
Company Phone Number Company Web Address
1-800-523-2233
www.thehartford.com
ONLINE ENROLLMENT
page 14
Online Enrollment Company
ExponentHR
Customer Service
1-866-612-3200
Web Address
www.exponenthr.com
DISCLOSURE NOTICES
page 15
Your Benefits
Detwiler’s Farm Market offers a variety of benefits allowing you the opportunity to customize a benefits package that meets y our personal needs. In the following pages, you will learn more about the benefits offered. You will 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.
Medical
Detwiler’s FarmMarket pays the majority of the employee cost for the Meritain medical plans.
Detwiler’s Farm Market offers you the option to elect this voluntary benefit. You pay the full cost for coverage.
Dental
Detwiler’s Farm Market offers you the option to elect this voluntary benefit. You pay the full cost for coverage.
Vision
Basic Life
Detwiler’s FarmMarket pays the entire cost.
Short-Term and Long Term Disability
Detwiler’s Farm Market offers you the option to elect this voluntary benefit. You pay the full cost for coverage.
Detwiler’s Farm Market offers you the option to elect voluntary Critical Illness, Accident, Cancer and Gap Insurance. You pay the full cost for coverages.
Voluntary Benefits
Pre-tax benefits
?
You must actively choose any benefit that you pay for or share in the cost with through Detwiler’s Farm Market .
Why do I pay for benefits pre-tax?
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.
Your part of the cost is automatically deducted from your paycheck. Premiums for medical, dental, and vision are deducted pre-tax.
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Eligibility
Employees working 30 + hours/week are eligible for benefits the first of the month following 60 days. If you enroll in the benefits you may also cover your eligible dependents, these include:
➢ Your legal spouse, unless you are legally separated or divorced;
➢ Your married or unmarried natural children, step- children living with you, legally adopted children and any other children for whom you have legal guardianship, who are:
Under 26 years of age
•
When can you enroll?
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.
Examples of qualified family-status changes are as follows:
• Change in your work status that affects your benefits • Change in residence or work site that affects your eligibility for coverage
Your marriage
•
Your divorce or legal separation
•
Birth or adoption of an eligible child
•
• Death of your spouse or covered child
• Change in your child’s eligibility for benefits
• Change in your spouse’s work status that affects his or her 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 does coverage end?
Coverage will stop on the last day of the month in which your employment with the company ends.
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Medical
Detwiler’s Farm Market offers two medical plans through Meritain. The below chart provides an overview and comparison of these plans. To find a participating provider, visit www.aetna.com and select “find a doctor” . Detwiler’s Farm Market uses the Aetna Choice POS II network.
Option A CORE
Option B BUY-UP
IN-NETWORK
CALENDAR DEDUCTIBLE (the amount you are responsible for before Meritain shares in claims costs) Individual / Family $2,000 / $4,000 COINSURANCE (percent of claims costs you pay once you’ve met the deductible) 40% OUT OF POCKET MAXIMUM (the maximum you will pay for covered services in a calendar year) Individual / Family $5,000 / $10,000
$1,500 / $3,000
10%
$3,250 / $6,500
Maximum Includes
Deductible, Coinsurance, Copays & Prescriptions
PREVENTIVE CARE Wellness, Immunizations & Mammograms OFFICE VISITS PCP or Referral Required
Covered 100%
No
Office Visits (Illness / Injury)
$60 Copay
$60 Copay
Specialist Visits
40% after deductible
10% after deductible
HOSPITAL SERVICES
Inpatient Hospital
40% after deductible
10% after deductible
Outpatient Surgery
40% after deductible
10% after deductible
Emergency Room
40% after deductible 40% after deductible
10% after deductible 10% after deductible
Urgent Care
DIAGNOSTIC TESTING
Independent/Freestanding Lab
40% after deductible 40% after deductible
10% after deductible 10% after deductible
Complex Diagnostic
PRESCRIPTIONS
Generics: Covered 100% (Deductible waived) Brand copays (Deductible waived): Preferred: $75 Non-Preferred: $100 Specialty: $200
Generics: Covered 100% (Deductible waived) Brand copays apply after $500 Rx Deductible: Preferred: $30 Non-Preferred: $50 Specialty: $125 Generics: Covered 100% (Deductible waived) Brand copays apply after $500 Rx Deductible: Preferred: $75 Non-Preferred: $125
Retail (30 day supply)
Mail Order (90 day supply) Mandatory for all maintenance medications. Can be obtained at either a CVS retail store or through Caremark Mail-order service.
Generics: Covered 100% (Deductible waived) Brand copays (Deductible waived):
Preferred: $187.50 Non-Preferred: $250
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.
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Medical
Option A CORE
Option B BUY-UP
OUT-OF-NETWORK 1
Deductible
$3,000 / $6,000
$4,000/$8,000 $12,700/$25,400 60%
Maximum Out-of-Pocket
$6,000 / $12,000
Coinsurance
30%
PERSONAL HEALTH FUND
$500/ Single (after $1,500 deductible) $1,000/ Family (after $3,000 Deductible) Rx costs are excluded
$500/ Single (after $1,000 Deductible) $1,000/ Family (after $2,000 Deductible) Rx costs are excluded
Cost for coverage (per paycheck)
Option A CORE $ 61.11 $249.99 $226.30 $382.69
Option B BUY-UP $114.10 $333.32 $300.39 $502.79
Employee only
Employee + Spouse
Employee + Child(ren)
Employee + Family
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.
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Telemedicine
THERE IS NO CHARGE FOR THIS BENEFIT – NO COPAY!
Teladoc is the on-demand healthcare solution that gives you the medical care you need, when you need it. You can talk to a doctor anytime, anywhere about non-emergency medical conditions.
With Teladoc, you can talk to a doctor 24/7/365 by phone, online video or mobile app. Use Teladoc for medical advice and care when: • Your primary care doctor is not open • You are at home, traveling or do not want to take time off work to see a doctor • You need a prescription or refills. ( Please note, there is no guarantee you will be prescribed medication ).
Common conditions treated (but not limited to):
• Eye/ear infections • Bronchitis • Sinus infections
• Headaches/migraines • Rash/skin infections • Allergies
• Cold/Flu • Stomachache/diarrhea • Urinary tract infections
Teladoc is available only to employees who are enrolled in one of the Detwiler’s Farm Market medical plans
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Know Where to Go
Telemedicine
Convenience Care
Doctor’s office
Urgent care
ER
Access telehealth services to treat minor medical conditions. Connect with a board-certified doctor via video or phone when where and how it works best for you.
Treats minor medical concerns. Staffed by nurse practitioners and physician assistants. Located in retail stores and pharmacies. Often open nights and weekends. › Colds and flu › Rashes or skin conditions › Sore throats, earaches, sinus pain
The best place to go for routine or preventive care, to keep track of medications, or for a referral to see a specialist.
For conditions that aren’t life threatening. Staffed by nurses and doctors and usually have extended hours.
For immediate treatment of critical injuries or illness. Open 24/7. If a situation seems life-threatening, call 911 or go to the nearest emergency room. › Chest Pain › Shortness of Breath › Life Threatening Illness or Injuries › Critical Conditions
› Colds and flu › Rashes › Sore throats › Headaches › Stomachaches › Fever › Allergies
› General health issues › Preventive care
› Muscle Sprains or Strains › Back Pain
› Routine checkups › Immunizations and screenings
› Skin Infections › Broken Bones
› Minor cuts or burns › Pregnancy testing › Vaccines
Terms to Know
When you enroll in coverage you become a UnitedHealthcare. A UnitedHealthcare member gets access to their network of providers (doctors and facilities) – these are in-network providers. UHC members receive Discounted Rates with these in-network providers. Discounted Rate
Copays
Copays are set dollar amounts you pay for specific services. These cost are typically collected at the time of service. For example, under the BQ67 plan you have a $40 copay for a visit to your primary care physician.
Services not subject to a copay are subject to your deductible. You pay first dollar costs for claims subject to your deductible and you receive the Discounted Rate for all covered claims with an in-network provider. Deductible
Coinsurance
Coinsurance is a cost share. Once you meet the deductible UHC will share in the cost of your claims. The percent of the cost for the claim you are responsible for. The amounts you pay in coinsurance apply to your out of pocket maximum.
Out-of-Pocket
This amount is the maximum amount you will pay towards covered services on the plan for the calendar year. This amount includes the amounts you pay in deductible, coinsurance, copays, and prescription copays.
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Dental
Detwiler’s Farm Market offers 2 dental plan options through Sunlife Financial. The PPO Dental 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 Sunlife’s allowed amount and what the dentist may charge, also known as “balance billing” . The chart below provides a brief overview of the plans.
LOW PPO Dental Plan
HIGH PPO Dental Plan
IN-NETWORK
CALENDAR YEAR DEDUCTIBLE (applies to basic and major services only)
$50
$50
Individual
$150
$150
Family
ANNUAL MAXIMUM (maximum Sunlife will pay towards claims per year)
Per covered person
$1,250
$1,250
DIAGNOSTIC & PREVENTIVE
Exams, Cleanings (2 in 12 months), X-Rays, Sealants, etc.
Covered in full
Covered in full
BASIC SERVICES
Amalgam Fillings, Extractions - Single Tooth, Endodontics (Root Canal) & Periodontics (Gum Disease)
20% after deductible
Covered in full after deductible
MAJOR SERVICES
50% after deductible
40% after deductible
Crowns, Bridges & Dentures
OUT-OF-NETWORK* CALENDAR YEAR DEDUCTIBLE
$100 / $300
$100 / $300
ANNUAL MAXIMUM
$1,250
$1,250
SERVICES Diagnostic & Preventive Basic Major
You pay 0% after deductible 50% after deductible 75% after deductible
You pay 0% after deductible 20% after deductible 50% after deductible
Cost for coverage (per paycheck)
Employee
$ 8.74
$13.27
Employee + Spouse Employee + Child(ren) Employee + Family
$20.48 $22.01 $33.19
$31.12 $33.43 $50.42
• Subject to balance billing. Please refer to your plan document for specific details.
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Vision
Detwiler’s Farm Market offers vision coverage through Sunlife Financial. The vision plan allows you the flexibility to see any provider. Your provider may ask you to pay expenses at the time of service and then file a claim for reimbursement. Below is a list of the reimbursement schedule.
Vision VSP Provider Network
IN-NETWORK
EXAMS
Every 12 months
$10 Copay
LENSES
Every 12 months
Single vision Lined bi-focal Lined tri-focal Lenticular
$25 Copay (lens add-ons may be available at a discount of 20% off retail prices)
FRAMES
Every 24 months
$25 Copay provides $130 allowance + 20% discount on overage
CONTACT LENSES (in lieu of glasses)
Every 12 months
Elective
Up to a $130 allowance
Medically Necessary
$25 Copay
OUT-OF-NETWORK EXAMS
Reimbursed up to $52
LENSES
Reimbursed up to $55-$125 depending on lenses
FRAMES
Reimbursed up to $57
CONTACT LENSES (in lieu of glasses)
Reimbursed up to $105 Cost for coverage (per paycheck)
Employee
$2.89 $5.79 $6.37 $9.26
Employee + Spouse Employee + Child(ren) Employee + Family
The chart below provides a brief overview of the vision plan. 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.
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Life and AD&D
Basic Life & AD&D
$10,000 **The Basic Life & AD&D insurance is paid 100% by Detwiler’s Farm Market**
Employee Life
Voluntary Life Insurance
Employee Life
Increments of $10,000 up to $500,000
$200,000 < age 65 $ 50,000 age 65-69 $ 10,000 age 70+ (for timely entrants/ newly eligible employees)
Employee Guarantee Issue
Spouse Life
Increments of $5,000 up to lesser of 50% of employee's amount or $250,000.
Spouse Guarantee Issue $50,000 (for timely entrants/ newly eligible employees)
Dependent Life
$1,000 increments up to lesser of 10% of the employee’s amount or $10,000
AD&D
Included – Equal to life amount
At age 65: 35% reduction At age 70: 60% reduction At age 75: 75% reduction At age 80: 85% reduction
Benefit Reduction Schedule
Disability
Short Term Disability
Detwiler’s Farm Market offers voluntary short term disability (STD) insurance to all active full time employees. The benefit begins on the 15 th day of accident or sickness and pays 60% of your weekly earning to a maximum of $1,250. The benefit will pay up to a maximum of 11 weeks.
The employee pays 100% of the Short Term Disability premium. Refer to the online enrollment system for cost.
Long Term Disability
Detwiler’s Farm Market offers voluntary long term disability insurance to all active full time employees. The benefit starts to pay once the short term disability benefit is exhausted, or after 90 days from the accident or sickness. The benefit pays 60% of your monthly earnings to a maximum of $15,000. The benefit can continue until you are no longer disabled or SSNA (Social Security Normal Retirement Age).
The employee pays 100% of the Long Term Disability premium. Refer to the online enrollment system for cost.
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No Cost Programs
We are pleased to offer the below programs through The Hartford. These extra services are included as part of your Basic Life/AD&D provided by Detwiler’s Farm Market.
Travel Assistance with ID Theft Protection
The following services are available to all employees through Generali Global Assistance: • Medical consultation, evaluation, and referral • Hospital admission • Critical care monitoring • Prescription assistance • Legal and interpreter referrals Emergency medical evacuation •
This is not medical insurance. No claims for reimbursement will be accepted. Spouse business travel excluded. If you or your family member needs assistance while more than 100+ miles away from home for 90 days or less, call Within the U.S.: 1-800-243-6108 Outside the U.S.: 202-828-5885 Your membership number: GLD - 09012
Beneficiary Assist
Getting through a loss is hard. Getting support shouldn’t be. The Hartford offers you Beneficiary Assist counseling that can help you or your beneficiaries (named in your policy) cope with emotional, financial and legal issues that arise after a loss. Includes unlimited phone contact with a counselor, attorney or financial planner and five face-to-face sessions for up to a year from the date a claim is filed.
For more information, call: 1-800-411-7239
Estate Guidance Will Services
Create a simple will from the convenience of your home. Whether your assets are few or many, it’s important to have a will. Through The Hartford you have access to EstateGuidance ®. It helps you protect your family’s future by creating a will online – backed by online support from licensed attorneys.
Visit: www.estateguidance.com
Use code: WILLHLF
Funeral Concierge Services
Helps provide peace of mind when it’s needed most. The Hartford’s Funeral Concierge offers a suite of online tools and live support to help guide you through key decisions. It allows for pre-planning, documentation of wishes, and even offers cost comparisons of funeral related expenses. After a loss, this service includes family advocacy and professional negotiation of funeral prices with local providers – often resulting in significant savings. Hartford’s Funeral Concierge is through Everest Funeral Package, LLC.
For more information, call: 1-866-854-5429 Visit: www.everestfuneral.com/hartford Use code: HFEVLC
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Share Fund
The Staples Share Fund, founded in 2014, offers financial relief to associates experiencing severe financial hardship due to events such as:
Natural Disasters Illness or Injury
• •
• Death of an immediate family member • Spouse or Domestic Partner’s unemployment • Homelessness • Domestic Abuse • Military Deployment
The Share Fund provides grants of up to $4,000 per fiscal year to help with some of the following:
Rent or Mortgage
• • • •
Basic Utilities
Food
Emergency/Temporary Housing
• Funeral Expenses for an Immediate Family Member
All full and part-time Detwiler’s Farm Market associates are eligible to apply.
To Apply: ➢ Contact your local HR Representative and complete an application ➢ Submit supporting documentation via Fax or email
Contact the Share Fund Team StaplesShareFund@staples.com Fax: (508) 382-1544
Or visit our website for more details at www.staplessharefund.org
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Voluntary Benefits
Critical Illness including Cancer
• Hartford’s Critical Illness Product provides for an insured to receive a benefit payment upon diagnosis of any qualified and covered critical illness or condition up to $10,000 or $20,000 depending on which level of coverage you elect. • Conditions include, but are not limited to: • heart attack • Stroke • Paralysis • Coma • Cancer
Accident
• 24 hour coverage for both on and off the job accidents • Provides a fixed benefit for accidental injuries such as fractures and dislocations and related expenses, such as emergency room visits and physical therapy. Daily hospital and ICU benefits are also included, as well as an Accidental Death and Dismemberment provision.
Gap Plan
• Covers certain portions of the employee’s cost (co-insurance, co-pays and deductibles) for covered hospital expenses up to an annual maximum of $2,000 • Includes benefits for in-hospital expenses such as hospital confinements and emergency room treatment.
Supplemental
Refer to The Hartford handouts for additional information and cost
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Online Enrollment
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Online Enrollment
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Required Annual Employee Disclosure Notices 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 Detwiler’s Farm Market to notify you, as a participant or beneficiary of the Detwiler’s Farm Market 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 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.
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;
MICHELLE’S LAW
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.
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.
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 Required Annual Employee Disclosure Notices
Detwiler’s Farm Market HR | 813-555-5555 5109 W. Main, Tampa, FL 33609
Your Information. Your Rights. Our Responsibilities. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Your Rights When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get a copy of your health and claims records
• You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this. • We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee. • You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to do this. • We may say “no” to your request, but we’ll tell you why in writing within 60 days. • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. • We will consider all reasonable requests, and must say “yes” if you tell us you would be in danger if we do not.
Ask us to correct health and claims records
Request confidential communications
Ask us to limit what we use or share
• You can ask us not to use or share certain health information for treatment, payment, or our operations. • We are not required to agree to your request, and we may say “no” if it would affect your care.
Get a list of those with whom we’ve shared information
• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly
Choose someone to act for you
• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. • We will make sure the person has this authority and can act for you before we take any action. • You can complain if you feel we have violated your rights by contacting us using the information at the top of this page. • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or
File a complaint if you feel your rights are violated
visitingwww.hhs.gov/ocr/privacy/hipaa/complaints/. • We will not retaliate against you for filing a complaint.
Your Choices For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
• Share information with your family, close friends, or others involved in payment for your care • Share information in a disaster relief situation • Contact you for fundraising efforts
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we nevershare your information unless you give us written permission:
• Marketing purposes • Sale of your information
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Required Annual Employee Disclosure Notices continued Required Annual Employee Disclosure Notices
Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways.
Help manage the health care treatment you receive
• You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this. • We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee. • We can use and disclose your information to run our organization and contact you when necessary. • We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long term care plans.
Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services.
Run our organization
Example: We use health information about you to develop better services for you
Pay for your health services
• We can use and disclose your health information as we pay for your health services.
Example: We share information about you with your dental plan to coordinate payment for your dental work
Administer your plan
• We may disclose your health information to your health plan sponsor for plan administration.
Example: Your company contracts with us to provide a health plan, and we provide your company with certain statistics to explain the premiums we charge.
How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
• We can share health information about you for certain situations such as: • Preventing disease • Helping with product recalls • Reporting adverse reactions to medications • Reporting suspected abuse, neglect, or domestic violence • Preventing or reducing a serious threat to anyone’s health or safety
Do research
• We can use or share your information for health research.
Comply with the law
• We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests and work with a medical examiner or funeral director Address workers’ compensation, law enforcement, and other government requests
• We can share health information about you with organ procurement organizations. • We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
• We can use or share health information about you: • For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official • With health oversight agencies for activities authorized by law • For special government functions such as military, national security, and presidential protective services • We can share health information about you in response to a court or administrative order, or in response to a subpoena.
Respond to lawsuits and legal actions
17
Required Annual Employee Disclosure Notices continued Required Annual Employee Disclosure Notices
Our Responsibilities
• We are required by law to maintain the privacy and security of your protected health information. • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. • We must follow the duties and privacy practices described in this notice and give you a copy of it. • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of This Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our web site, and we will mail a copy to you.
Effective 12/01/2018
This Notice of Privacy Practices applies to the following organizations. Detwiler’s Farm Market
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.
18
Required Annual Employee Disclosure Notices - Continued Required Annual Employee Disclosure Notices
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 Detwiler’s Farm Market 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 Detwiler’s Farm Market 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:
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 Detwiler’s Farm Market 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. Detwiler’s Farm Market has determined that the prescription drug coverage offered by the Welfare Plan for Employees of Detwiler’s Farm Market under the Detwiler’s Farm Market 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 Detwiler’s FarmMarket 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. _______________________________________________________
Visit www.medicare.gov
•
• Call your State Health Insurance Assistance Program (see your copy of the Medicare & You handbook for their telephone number) for personalized help, • Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1- 877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325- 0778). Remember: Keep this notice. If you enroll in one of the new plans approved by Medicare which offer prescription drug coverage, you may be required to provide a copy of this notice when you join to show that you are not required to pay a higher premium amount.
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 Detwiler’s Farm Market 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 Detwiler’s Farm Market coverage, be aware that you and your dependents will be able to get this coverage back.
Date:
12/01/2019
Name of Entity/Sender: Contact--Position/Office:
Detwiler’s FarmMarket HR 5109 W. Main Street Tampa, FL 33609
Phone Number:
813-555-5555
19
General Notice of COBRA Rights
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. 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.
20
General Notice of COBRA Rights
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.
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.
There are also ways in which this 18-month period of COBRA continuation coverage can be extended:
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. 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 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.
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