BENE F I TS AT A GLANCE January 1, 2020 - December 31, 2020 I L January 1, 2020 - Dece ber 31, 2020
CONTENTS & CONTACT INFORMATION
Refer to this list when you need to contact one of your benefit vendors. For general information contact Human Resources.
BROKER Provider Name Broker Contact
M.E. Wilson Company
Amanda Sands
Provider Phone Number Provider Email Address
813-229-8021 Ext. 139 asands@mewilson.com
MEDICAL
page 6
Provider Name
FloridaBlue
Provider Phone Number Provider Web Address
800-352-2583
www.floridablue.com
HEALTH SAVINGS ACCOUNT (HSA)
page 8
Provider Name
Health Equity (866) 346-5800
Provider Phone Number Provider Web Address
www.healthequity.com
DENTAL
page 9
Provider Name
Lincoln
Provider Phone Number Provider Web Address
800-423-2765 www.lfg.com
VISION
page 10
Provider Name
Lincoln
Provider Phone Number Provider Web Address
800-423-2765 www.lfg.com
BASIC & VOLUNTARY LIFE AND DISABILITY
page 11
Provider Name
Reliance Standard
Provider Phone Number Provider Web Address
800-351-7500
www.reliancestandard.com
DISCLOSURE NOTICES
page 13
BENEFIT INFORMATION
Benefit
Who pays the cost?
Mezrah Consulting pays the majority of the employee portion of the medical plan. You may enroll your eligible dependents for an additional cost. Mezrah Consulting pays the entire cost of the employee only dental coverage. You may elect dental coverage for yourself and your eligible dependents and you will be responsible for the cost above what Mezrah Consulting contributes. You may elect vision coverage for yourself and your eligible dependents on a voluntary basis and you will be responsible for the cost.
Medical Insurance
YOUR BENEFITS PLAN
Mezrah Consulting offers a variety of benefits allowing you the opportunity to customize a benefits package that meets your personal needs. In the following pages, you’ll learn more about the benefits offered. You’ll also see how choosing the right combination of benefits can help protect you and your family’s health and finances – and your family’s future.
Dental Insurance
Vision Insurance
Basic Life Insurance
Mezrah Consulting pays the entire cost.
Voluntary Life Insurance
The employee pays the entire cost.
The employer pays the entire cost for Short Term and the employee pays the entire cost for Long Term.
Voluntary Short and Long Term Insurance
ELIGIBILITY
All Regular full-time employees are eligible to join the Mezrah Consulting Benefits Plan following 90 days of employment. 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;
WHEN CAN YOU ENROLL?
► A dependent who is older than 26 years of age, but less than 30 years of age may be eligible for medical benefits. To be eligible, a Dependent must: • Be unmarried and not have dependents of his or her own; AND
You can sign up for Benefits at any of the following times:
• After completing your initial eligibility period; • During the annual open enrollment period; • Within 30 days of a qualified family-status change.
Be a resident of Florida or a student; AND
•
• Not have coverage of their own, or covered under any other plan; AND
If you do not enroll at one of the above times, you must wait for the next annual open enrollment period.
Not entitled to benefits under Medicare
•
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BENEFIT INFORMATION
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CHOOSING YOUR BENEFITS
You must actively choose any benefit that you pay for, or share in the cost with Mezrah Consulting. 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, vision, health savings account (HSA)
• AFTER YOUR TAXES ARE CALCULATED – voluntary life/ accidental death & dismemberment and disability
MAKING CHANGES
Generally, you can only change your benefit choices during the annual benefits enrollment period. However, you may be able to change your benefit choices during the plan year if you have a change in status including:
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.
Your marriage
•
Your divorce or legal separation
•
Birth or adoption of an eligible child
•
Death of your spouse or covered child
•
• Change in your spouse’s work status that affects his or her benefits
WHEN COVERAGE ENDS
• Change in your work status that affects your benefits
Coverage will stop on the last day of the month in which employment with the company ends. Life insurance ends the last day of employment.
• Change in residence or work site that affects your eligibility for coverage
• Change in your child’s eligibility for benefits
• Receiving Qualified Medical Child Support Order (QMCSO)
KEY BENEFIT TERMS
COBRA – A Federal law that allows workers and dependents who lose their medical, dental, or vision coverage to continue any of these coverages for a specified length of time by electing and paying for continuation benefits. Copayment – A flat fee that you pay for medical services, regardless of the actual amount charged by your doctor or another provider. This generally applies to physicians’ office visits and prescription drugs. Deductible – The amount you pay toward medical and dental expenses each year before the plan begins paying benefits. Out of Pocket Maximum – The maximum amount you will pay in deductibles, copayments and coinsurance during the year.
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MEDICAL INSURANCE
Mezrah Consulting offers two medical plans through FloridaBlue. To find participating providers go to www.floridablue.com and click on “Find a Doctor”, choose the appropriate provider type. The Low and the High plan use the BlueCare (HMO) Network.
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.
LOW BlueCare 15572 Essential (HSA)
HIGH BlueCare 14256 All Copay
IN-NETWORK: Plan or Calendar Year Basis
Calendar Year
Calendar Year
Deductible (Individual/Family)
$2,700 / $7,000
$1,000 / $3,000
Coinsurance
80% / 20%
80% / 20%
Maximum Out-of-Pocket (Individual/Family)
$5,000, $10,000
$4,000 / $8,000
Maximum Out-of-Pocket Includes
Deductible, Coinsurance & Copayments
Deductible, Coinsurance & Copayments
Lifetime Medical Maximum
Unlimited
Unlimited
PREVENTIVE CARE:
Wellness Immunizations Mammography/Colonoscopy COPAYMENTS: Primary Physician Office Visits – No Referral Required
Covered 100%
Covered 100%
Deductible & Coinsurance
$25 Copayment
Specialist Visits
Deductible & Coinsurance
$45 Copayment
Inpatient Hospital
Deductible & Coinsurance
$300/day to a Max of $1,500
Outpatient Surgery
Deductible & Coinsurance
$350 Copayment
Emergency Room
Deductible & Coinsurance
$300 Copayment
Urgent Care
Deductible & Coinsurance
$50 Copayment
OUTPATIENT DIAGNOSTIC SERVICES:
Lab Services
Deductible & Coinsurance
$100 Copayment
X-Ray Services
Deductible & Coinsurance
$60 Copayment
Complex Diagnostic
Deductible & Coinsurance
$250 Copayment
PRESCRIPTIONS: Retail (30 day supply)
$10 / $30 / $50 copays after Deductible
$15 / $60 / $100
Mail Order (90 day supply)
2 X retail
2 X retail
OUT-OF-NETWORK: Deductible (Individual/Family)
$5,600 / $11,200
In-Network Only
Maximum Out-of-Pocket (Individual/Family)
$11,600 / $23,200
In-Network Only
Lifetime Medical Maximum
Unlimited
In-Network Only
Coinsurance
50% / 50%
In-Network Only
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MEDICAL CONTRIBUTION SCHEDULE
LOW BlueCare 15572 (HSA)
HIGH BlueCare 14256 (All Copay)
Employee Cost Per Pay Period (24)
Employee Only
$ 48.43
$110.02
Employee + Spouse
$242.13
$365.31
Employee + Child(ren)
$213.07
$327.01
Family
$406.77
$582.30
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HEALTH SAVINGS ACCOUNT (HSA)
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.
IRS Annual Maximum HSA Contribution Limits (maximums include employer contributions)
2020
Employee Only
$3,550
Family
$7,100
Catch-up Amount for employees 55 years or older
Additional $1,000 annually
Mezrah’s Tax-Free HSA Contribution
SINGLE COVERAGE
FAMILY COVERAGE
$500
$500
Annual amount*
* Employer contributions: amount and frequency deposited to your Health Savings Account will be determined by Mezrah Consulting and will not exceed the plan year contribution amount.
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)
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DENTAL INSURANCE
Mezrah Consulting offers dental coverage through Lincoln Financial . The Dental PPO Plans allow you to use in-network or out-of- network benefits. If out-of-network dentists are used, you will be responsible for paying the difference between Aetna’s allowed amount and what the dentist may charge, also known as “balance billing”. The charts below provides a brief overview of the plans.
LOW Dental PPO Plan
In-Network
Out-of Network*
Calendar Year Deductible Individual
$25 $75
$75
$225
Family
Annual Maximum
$1,750
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
Covered in full
Covered 80% after deductible
Covered 80% after deductible Covered 70% after deductible
Covered 50% after deductible Covered 40% after deductible
Bridges Dentures Orthodontia Services
Not covered
Children only under the age of 19
• Subject to balance billing. Please refer to your plan document for specific details.
Dental PPO Plan Employee Cost Per Pay Period
Employee Only
$ 0.00
Employee + Spouse
$13.76
Employee + Child(ren)
$14.84
Family
$31.36
5
VISION INSURANCE
Mezrah Consulting offers vision coverage through Lincoln Financial. 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.
Vision
In-Network
Out-of-Network
Routine Eye Exams
$10 Copayment
Reimbursed up to 40
Reimbursed from $40 to $80 Depending on type of lenses
Lenses *
$25 Copayment
Frames
$130 allowance
Reimbursed up to $45
Contact Lenses
$130 allowance
Reimbursed up to $125
Frequency Exam
Once every 12 months Once every 12 months
Lenses or contact lenses
Frame
Once every 24 months
• Covered lenses include single vision, bifocal, trifocal and lenticular.
• Lenses, Frames & Contacts are limited to either one pair of contacts or frames/lenses per calendar year.
Employee Cost Per Pay Period
Employee Only
$ 3.38 $ 6.41 $ 7.52 $10.57
Employee + Spouse Employee + Child(ren)
Family
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BASIC AND VOLUNTARY LIFE AND AD&D INSURANCE
Mezrah Consulting provides all full-time employees working 30 or more hours per week the option to purchase voluntary life insurance coverage through a group plan. The chart below provides an overview of the plan.
Basic Life Insurance
Reliance Standard
$15,000 **The Basic Life insurance is paid 100% by Mezrah Consulting.**
Employee Only
Voluntary Life and AD&D Insurance
Reliance Standard
Increments of $10,000 up to a maximum of 5x salary or $500,000, whichever is less. Minimum Election: $10,000
Employee Only
Employees Under Age 65 No evidence of insurability up to max of $100,000 (newly eligible employees only).
Increments of $5,000 up to a maximum of 50% of employee amount or $250,000, whichever is less. Minimum Election: $5,000
Spouse
Spouses Under Age 65
No evidence of insurability up to max of $30,000 (newly eligible dependents only).
At age 65, benefits reduce by 35% of original amount, at age 70, benefits reduce by 35% of in force amount.
Benefit Reduction Schedule
Children
$10,000
Accidental Death & Dismemberment
Matches elected life amount
VOLUNTARY LIFE Life Rates per $10,000 of benefit (Spouse rate is based on employee’s age )
EMPLOYEE ELECTION:
Age Employee/ Spouse Child Life
_____________________ Benefit Amount / 10,000 x___________________ Monthly Rate = ___________________ x12 /24 =____________________ Per Pay Contribution _____________________ Benefit Amount / 10,000 x____________________ Monthly Rate = ___________________ ) = ____________________ x12 /24 =____________________ Per Pay Contribution SPOUSE ELECTION:
<29
$1.15
$2.03
30-34
$1.25
35-39
$1.35
40-44
$1.95
45-49
$3.05
50-54
$4.55
55-59
$6.85
60-64
$10.75
65-69
$18.25
CHILD(REN) ELECTION: $10,000 Example – Voluntary Life and Ad&d – 10k Per Pay Contribution = $ 1.02
70-74
$32.65
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SHORT TERM DISABILITY
The plan provides for short-term income continuation if you become disabled due to non-occupational injury or sickness. Benefits commence the 15 th day after the onset of an illness or injury. Your benefit will be 50% of your basic weekly salary to a max of $800. The maximum duration is 11 weeks. Short Term Disability is paid for 100% by Mezrah Consulting.
LONG TERM DISABILITY
The plan provides for long-term income continuation if you become disabled and cannot perform some of the material duties of your regular occupation on a full-time basis subject to certain conditions and limitations. Please refer to the plan document for further details. Benefits commence after three months after the onset of the disability. The benefit is 60% of your basic monthly earnings to a monthly maximum of $6,000. If elected, the employee pays 100% of the Long-Term Disability premium.
VOLUNTARY LONG-TERM DISABILITY
Age
Rate
<20
$ .08
PREMIUM CALCULATION
25-29
$ .10
30-34
$ .15
Monthly Pay
$__________
35-39
$ .21
/ 100.00
40-44
$ .43
= $________
45-49
$ .56
Rate per $100 (Insert your rate based off table to the left) x __
50-54
$ .81
___
55-59
$ .80
X 12______
60-64
$ .76
/ 24 ___
65-69
$ .88
Per Pay Premium =$___________
70+
$ .88
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REQUIRED ANNUAL EMPLOYEE DISCLOSURE NOTICES
THE NEWBORNS’ AND MOTHERS’ HEALTH PROTECTION ACT OF 1996
WOMEN’S HEALTH AND CANCER RIGHTS ACT OF 1998 The Women’s Health and Cancer Rights Act of 1998 requires Mezrah Consulting to notify you, as a participant or beneficiary of the Mezrah Consulting Health and Welfare Plan, of your rights related to benefits provided through the plan in connection with a mastectomy. You, as a participant or beneficiary, have rights to coverage to be provided in a manner determined in consultation with your attending physician for: 1. All stages of reconstruction of the breast on which the mastectomy was performed; 2. Surgery and reconstruction of the other breast to produce a symmetrical appearance; and 3. Prostheses and treatment of physical compilations of the mastectomy, including lymphedema. These benefits are subject to the plan’s regular deductible and co-pay. For further details, refer to your Summary Plan Description. Keep this notice for your records and call Human Resources for more information. The law allows for continued coverage for dependent children who are covered under your group health plan as a student if they lose their student status because of a medically necessary leave of absence from school. This law applies to medically necessary leaves of absence that begin on or after January 1, 2010 If your child is no longer a student, as defined in your Certificate of Coverage, because he or she is on a medically necessary leave of absence, your child may continue to be covered under the plan for up to one year from the beginning of the leave of absence. This continued coverage applies if your child was (1) covered under the plan and (2) enrolled as at student at a post-secondary educational institution (includes colleges, universities, some trade schools and certain other post-secondary institutions). Your employer will require a written certification from the child’s physician that states that the child is suffering from a serious illness or injury and that the leave of absence is medically necessary. MICHELLE’S LAW
The Newborns’ and Mothers’ Health Protection Act of 1996 prohibits group and individual health insurance policies from restricting benefits for any hospital length of stay for the mother or newborn child in connection with childbirth; (1) following a normal vaginal delivery, to less than 48 hours, and (2) following a cesarean section, to less then 96 hours. Health insurance policies may not require that a provider obtain authorization from the health insurance plan or the issuer for prescribing any such length of stay. Regardless of these standards an attending health care provider may, in consultation with the mother, discharge the mother or newborn child prior to the expiration of such minimum length of stay. 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; 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. 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. 4. Require a mother to give birth in a hospital; or SECTION 111
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REQUIRED ANNUAL EMPLOYEE DISCLOSURE NOTICES continued
HIPAA PRIVACY POLICY FOR FULLY-INSURED PLANS WITH NO ACCESS TO PHI
PATIENT PROTECTION:
If the Group Health Plan generally requires the designation of a primary care provider who participates in the network and who is available to accept you or your family members. For children, you may designate a pediatrician as the primary care provider. You do not need prior authorization from the carrier or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology. The health care professionals, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre- approved treatment plan or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, or for information on how to select a primary care provider, and for a list of the participating primary care providers, contact the Plan Administrator or refer to the carrier website. It is your responsibility to ensure that the information provided on your application is accurate and complete. Any omissions or incorrect statements made by you on your application may invalidate your coverage. The carrier has the right to rescind coverage on the basis of fraud or misrepresentation. 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. CHILDREN’S HEALTH INSURANCE PROGRAM REAUTHORIZATION ACT (CHIPRA) OF 2009
I. No access to protected health information (PHI) except for summary health information for limited purpose and enrollment / dis-enrollment information. Neither the group health plan nor the plan sponsor (or any member of the plan sponsor’s workforce) shall create or receive protected health information (PHI) as defined in 45 C.F.R. § 160.103 except for (1) summary health information for purpose of (a) obtaining premium bids or (b) modifying, amending, or terminating the group health plan, and (2) enrollment and dis-enrollment information. The group health plan is a fully-insured group health plan sponsored by the “Plan Sponsor”. The group health plan and the plan sponsor intend to comply with the requirements of 45 C.F.R. § 164.530 (k) so that the group health plan is not subject to most of HIPAA’s privacy requirements.
II. Insurer for group health plan will provide privacy notice
The insurer for the group health plan will provide the group health plan’s notice of privacy practices and will satisfy the other requirements under HIPAA related to the group health plan’s PHI. The notice of privacy practices will notify participants of the potential disclosure of summary health information and enrollment / dis-enrollment information to the group health plan and the plan sponsor.
III. No intimidating or retaliatory acts
The group health plan shall not intimidate, threaten, coerce, discriminate against, or take other retaliatory action against individuals for exercising their rights , filing a complaint, participating in an investigation, or opposing any improper practice under HIPAAA.
IV. No Waiver
The group health plan shall not require an individual to waive his or her privacy rights under HIPAA as a condition of treatment, payment, enrollment or eligibility. If such an action should occur by one of the plan sponsor’s employees, the action shall not be attributed to the group health plan.
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REQUIRED ANNUAL EMPLOYEE DISCLOSURE NOTICES continued
MEDICARE PART D
When will you pay a higher premium (penalty) to join a Medicare drug Plan? You should also know that if you drop or lose your current coverage with FloridaBlue and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For more information about this notice or your current prescription drug coverage… Contact our office for further information (see contact information below). NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through FloridaBlue changes. You also may request a copy of this notice at any time. For more information about your options under Medicare prescription drug coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: • Call your State Health Insurance Assistance Program (see your copy of the Medicare & You handbook for their telephone number) for personalized help, • Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1- 877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778). 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. • Visit www.medicare.gov
This notice applies to employees and covered dependents who are eligible for Medicare Part D. Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with FloridaBlue and about your options under Medicare’s prescription drug Plan. If you are considering joining, you should compare your current coverage including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare through Medicare prescription drug plans and Medicare Advantage Plan (like an HMO or PPO) that offer prescription drug coverage. All Medicare prescription drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. FloridaBlue has determined that the prescription drug coverage offered by the Welfare Plan for Employees of Mezrah Consulting under the FloridaBlue option are, on average for all plan participants, expected to pay out as much as the standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. You should also know that if you drop or lose your coverage with FloridaBlue and don’t enroll in Medicare prescription drug coverage after your current coverage ends, you may pay more (a penalty) to enroll in Medicare prescription drug coverage later. ______________________________________________________ You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15 th to December 7 th . However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What happens to your current coverage if you decide to join a Medicare Drug Plan? If you decide to join a Medicare drug plan, your current FloridaBlue coverage will not be affected. You can keep this coverage if you elect part D and this plan will coordinate with Part D coverage. If you decide to join a Medicare drug plan and drop your current FloridaBlue coverage, be aware that you and your dependents will be able to get this coverage back. When can you join a Medicare Drug Plan?
Date: 1/1/2020 Name of Entity/Sender: Mezrah Consulting Contact--Position/Office: Human Resources 5350 W. Kennedy Blvd. Tampa, FL 33609 Phone Number: 813-367-1111
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New Health Insurance Marketplace Coverage Options and Your Health Coverage
Form Approved OMB No. 1210-0149 (expires 5-31-2020)
PART A: General Information When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance : the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace and employment-based health coverage offered by your employer. What is the Health Insurance Marketplace? The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014.
Can I Save Money on my Health Insurance Premiums in the Marketplace? You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your household income.
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.5% of your household income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit. 1 Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis.
How Can I Get More Information? For more information about your coverage offered by your employer, please check your summary plan description or contact:
Human Resources
The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area.
PART B: Information About Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to complete an application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace application.
3. Employer Name
4. Employer Identification Number (EIN)
59-3508884
Mezrah Consulting
5. Employer Address
6. Employer Phone Number
5350 W Kennedy Boulevard, Suite 2
7. City
8. State
9. Zip Code
Tampa
FL
33609
10. Who can we contact about employee health coverage at this job?
Human Resources
11. Phone Number (if different from above)
12. E-mail address
rwolff@mezrahconsulting.com
1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs
Here is some basic information about health coverage offered by this employer: • As your employer, we offer a health plan to:
X All Employees. Eligible employees are:
All Full Time Employees working at least 30 hours.
Some employees. Eligible employees are:
With respect to dependents:
•
X We do offer coverage. Eligible Dependents are:
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. A dependent who is older than 26 years of age, but less than 30 years of age may be eligible for medical benefits if the dependent is: • unmarried and not have dependents of his or her own; AND • Be a resident of Florida or a student; AND • Not have coverage of their own, or covered under any other plan; AND • Not entitled to benefits under Medicare
We do not offer coverage.
X If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be affordable, based on employee wages.
**Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through the Marketplace. The Marketplace will use your household income, along with other factors, to determine whether you may be eligible for a premium discount. If, for example, your wages vary from week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly employed mid-year, or if you have other income losses, you may still qualify for a premium discount.
If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's the employer information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your monthly premiums.
The information below corresponds to the Marketplace Employer Coverage Tool. Completing this section is optional for employers, but will help ensure employees understand their coverage choices.
13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months?
Yes (Continue)
13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for coverage? (mm/dd/yyyy) (Continue)
No (STOP and return this form to employee)
14. Does the employer offer a health plan that meets the minimum value standard*?
Yes (Go to question 15)
No (STOP and return form to employee)
15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don't include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and didn't receive any other discounts based on wellness programs.
50.13
a. How much would the employee have to pay in premiums for this plan?
$
b. How often?
Weekly
Every 2 weeks
X Twice a month
Monthly
Quarterly
Yearly
If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don’t know, STOP and return form to employee.
16. What change will the employer make for the new plan year?
Employer won’t offer health coverage
Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15)
a. How much would the employee have to pay in premiums for this plan?
$
_________________________
b. How often?
Weekly
Every 2 weeks
Twice a month
Monthly
Quarterly
Yearly
1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36(c)(2)(C)(ii) of the Internal Revenue Code of 1986)
NOTES
NOTES
The information in this Benefits Summary is presented for illustrative purposes and is based on information provided by your employer. The text contained in this Summary was taken from various summary plan descriptions and benefit information. While every effort was taken to accurately report your benefits, discrepancies or errors are always possible. In case of discrepancy between the Benefits Summary and the actual plan documents, the actual plan documents will prevail. All information is confidential, pursuant to the Health Insurance Portability and Accountability Act of 1996. If you have any questions about this summary, contact Human Resources.
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