Benefits at A Glance - Explain My Benefits

Benefits at A Glance
PLAN YEAR: 1/1/15 – 12/31/15
Contents & Contact Information
Refer to this list when you need to contact one of your benefit vendors. For general information contact Human Resources.
NEW HIRE ENROLLMENT INFORMATION:
Provider Phone Number
Provider Web Address
321-296-8060
http://scheduling.explainmybenefits.biz
MEDICAL:
Provider Name
Provider Phone Number
Provider Web Address
Aetna
800-445-5299
www.Aetna.com
HEALTH SAVINGS ACCOUNT (HSA):
Page
6
Page
7
page 8-11
BENEFIT RESOURCE CENTER (BRC):
Provider Name
Provider Phone Number
Provider e-mail Address
Benefit Resource Center
855-USI-6699
[email protected]
page 12
DENTAL:
Provider Name
Provider Phone Number
Provider Web Address
Guardian
888-600-1600
www.guardiananytime.com
VISION:
Provider Name
Provider Phone Number
Provider Web Address
Guardian
888-600-1600
www.guardiananytime.com
VOLUNTARY LIFE:
Provider Name
Provider Phone Number
Provider Web Address
Lincoln Financial Group
1-800-423-2765
www.lfg.com
page 13
page 14
page 15
VOLUNTARY SHORT TERM AND LONG TERM DISABILITY:
Provider Name
Lincoln Financial Group
Provider Phone Number
1-800-423-2765
Provider Web Address
www.lfg.com
page 16
PAYROLL DEDUCTIONS:
page 17
*Please note that rates for voluntary life, voluntary STD, voluntary LTD, critical care, accident, & group universal life
will be available on the EMB enrollment site.
SUPPLEMENTAL BENEFITS
Provider Name
Provider Phone Number
Provider Web Address
DISCLOSURE NOTICES
page 18-30
Trustmark
1-800-918-8877
www.trustmark.com
page 31-35
Benefit Information
Your Benefits Plan
Eligible dependents include:
Baer's Furniture offers a variety of benefits allowing you the
opportunity to customize a benefits package that meets your personal
needs.
> Your spouse, unless you are legally separated or divorced;
> Your married or unmarried natural children, step-children living
with you, legally adopted children and any other children for
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.
whom you have legal guardianship,
> Newborn to age 30.
►
A dependent who is older than 26 years of age, but less than
30 years of age may be eligible for medical benefits through
the end of the calendar year with no qualifications or coverage
restrictions..
Benefit
Who pays the cost?
Medical Insurance
Employer & Employee
Dental Insurance
Employee
Voluntary Vision
Employee
Voluntary Life
Employee
Short Term Disability
Employee
Long Term Disability
Employee
 During the annual open enrollment period;
Accident
Employee
 Within 30 days of a qualified family-status change.
Critical Illness
Employee
If you do not enroll at one of the above times, you must wait for the
Universal Life Events
Employee
next annual open enrollment period.
When Can You Enroll?
You can sign up for Benefits at any of the following times:
 After completing initial eligibility period;
Eligibility
All Regular full-time employees are eligible to join the. 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.
3
Benefit Information
Choosing Your Benefits
You must actively choose any benefit that you pay for, or share in the
cost with Baer's Furniture.
Your part of the cost is automatically taken out of your paycheck.
> Before your taxes are calculated – medical, dental, and vision
Making Changes
Generally, you can only change your benefit choices during the
annual benefits enrollment period. However, you may be able to
change your benefit choices at anytime if you have a change in status
including:
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.
> 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
Pre-Existing Conditions Limitations
Notice
Effective 1/1/2014, in accordance with The Patient
Protection and Affordable Care Act, there is no longer any
pre-existing conditions limitations for newly covered
employees or dependents or current employees or
dependents covered by the medical plans.
> Change in your child’s eligibility for benefits
> Receiving Qualified Medical Child Support Order (QMCSO)
If you do not notify Human Resources within 30 days of a
family status change, you will have to wait until the next
annual enrollment period to make benefit changes unless you
have another family status change.
When Coverage Ends
Coverage will stop on the last day of the month in which
employment with the company ends.
Key Benefit Terms
COBRA – A Federal law that allows workers and dependents who
lose their medical, dental, or vision coverage to continue any of these
coverages for a specified length of time by electing and paying for
continuation benefits.
Coinsurance – The percentage of the medical or dental charge that
you pay after the deductible has been met.
Copayment – A flat fee that you pay for medical services, regardless
of the actual amount charged by your doctor or another provider.
This generally applies to physicians’ office visits and prescription
drugs.
Deductible – The amount you pay toward medical and dental
expenses each calendar year before the plan begins paying benefits.
Out of Pocket Maximum – The maximum amount you will pay in
coinsurance during the calendar year
4
Getting more from your
Health Care Dollars
Member Resources
Aetna Navigator ® Secure Member Website – Aetna Navigator is
your secure member website. It’s where you go to:
Find doctors, dentists, pharmacies & hospitals
Get an ID card
Look up a claim
You’re mobile. So are we.
Check your coverage
Keep track of health care costs
It’s personalized for you and your family
It’s easy to get started – www.aetna.com
You can also get a summary of your doctor visits, medical tests,
prescriptions and other health activities. Look up health topics.
Complete a Health Assessment
Beginning Right® Maternity Program
Helping you and your baby grow healthy – together
You get the Beginning Right Maternity management program with
your Aetna plan.
Information for a healthier pregnancy – You will get materials on –
Prenatal care – Preterm labor symptoms – What to expect
before/after delivery – Newborn care and more
Special attention for Pregnancy risks
Solid support to quit smoking
Prescription Drug Benefits at a Reduced Cost – Did you know
you can obtain prescription drugs at local retailers at a reduced cost
and sometimes even free? Publix offers a variety of generic Oral
Antibiotic medications to you absolutely free. Bring in your
prescription for an approved medication and receive it FREE, up to a
14-day supply. Publix recently approved a medication for diabetes.
CVS, Target, Walgreens & WalMart also offer over 400 generic
prescriptions for $4 and a 90 day supply for approx. $10 . Remember
DO NOT show your Aetna ID card to receive these benefits, or you
will be charged your Aetna drug rate.
In addition to the network of physicians, hospitals, emergency
rooms, and urgent care clinics, you also have the option of going
to the convenient care clinics located within some grocery and
drug stores, for minor illness such as ear aches, colds, flu and so
on. By selecting one of these providers, you pay only the regular
office visit copay; a significant savings over the emergency room
and urgent care copayments.
Please visit the various websites for locations, hours of
operations and scope of services.
CVS Minute Clinic: www.cvs.com
Walgreen’s Take Care Clinic: www.walgreens.com
Aetna Discount Programs
Gym Memberships
Eyeglasses and contacts
Weight-loss programs ( Jenny Craig® - Nutrisystem® - eDiets® )
Chiropractic visits
Massage therapy
Acupuncture
Hearing aids and more
Personal Health Record
Access family history details
Review your office visits, prescriptions, conditions & treatments
Get a health summary
Download & share your information easily with health care providers
Receive important medical alerts
http://healthyis.aetna.com/personalhealth
24-hour Nurse Line for Health Questions
1.
2.
3.
Call a registered nurse toll-free
Visit member site www.aetna.com
Listen to Audio Health Library
Frequently Asked Questions About Your Medical Plan
Q.
What should I do if I have a problem getting a claim paid?
A.
Start by contacting the carrier’s member services number to determine the
nature of the problem. If the issue is the way the doctor or other service provider has
billed the claim, then contact your doctor or Claims Advocate at USI. If the insurance
company has an eligibility issue, contact Human Resources for assistance.
Q.
What is the difference between brand formulary, brand non-formulary, and
generic drugs?
A.
Brand formulary is a prescription drug that is listed on the formulary (i.e., a list of
prescription drugs covered by the plan). These drugs are protected by a patent issued
to the original innovator or marketer. Brand non-formulary drugs are patent protected
but are not listed. A generic equivalent drug can become available when the patent
protection runs out, and is deemed equal in therapeutic power to the brand name
originals.
Q.
When should I go the Urgent Care vs. Emergency Room?
A.
For non-life threatening injury/illness after normal doctor’s office hours.
Baer’s Furniture 2015 New Hire Benefits Enrollment
New Hire Enrollment Process:
All New Hires will schedule a telephonic appointment to speak with a benefits counselor from
our technology & benefits communication vendor, Explain My Benefits. During this appointment
you will be making an active decision on your medical, dental, and vision benefit elections.
We are also excited to offer Voluntary Benefits through Lincoln Financial Group and Trustmark
Insurance. These benefits are offered to strengthen your overall benefits package. During your
initial enrollment only there is a Guaranteed Issue opportunity. This is important as no
medical underwriting will be required!!!
Instructions on How to Schedule Your Appointment:
1. Go to: http://scheduling.explainmybenefits.biz
2. Select Baer’s Furniture New Hire Enrollment from the drop box.
3. The Company ID is: baers
4. Choose your preferred Enrollment Date and Time
5. Enter your Name and phone number.
6. Send yourself an email confirmation of your Enrollment Appointment
7. Call the Explain My Benefits Call Center at the time of your appointment :
321-296-8060 Option #1
How Can You Be Prepared?
1. Please bring the dates of birth and SSN of dependents to your enrollment meeting.
2. Please review your Benefits Guide. NEW Voluntary Benefits offered
GUARANTEED ISSUE!! Look for brochures and emails being distributed before
the enrollment
for more information!!!
Please contact Explain My Benefits with any questions
321.296.8060 ext. 303
6
Medical Insurance
Baer's Furniture offers 2 medical plans from Aetna. To find participating providers go to www.Aetna.com.
The chart below provides a brief comparison of the plans. This chart is intended only to highlight the benefits available and should not
be relied upon to fully determine your coverage. If the below illustration of benefits conflicts in any way with the Summary Plan
Description (SPD), the SPD shall prevail. It is recommended that you review your exact description of services and supplies that are
covered, those which are excluded or limited, and other terms and conditions of coverage.
MEDICAL PLAN DESIGN & FINANCIAL COMPARISONS
Plan Year 1/1/2015 - 12/31/2015
Aetna
Dual Option
HNOption H.S.A.
HNOnly
IN-NETWORK:
Buy Up Plan
Low Plan
Plan Year / Contract Year Basis
Calendar Year
Calendar Year
Deductible (Individual / Family)
$2,500/$5,000
$5,500/$11,000
Maximum Out-of-Pocket (Individual / Family)
$5,000/$10,000
$6,350/$12,700
Out-of Pocket Max Includes
Lifetime Major Medical Maximum
Coinsurance
Routine Preventive Services
Wellness
Immunizations
*Mammography/Colonoscopy
CO-PAYS
PCP Required / Open Access
Ded, coins, copays and Rx
Unlimited
80%
Ded, coins, copays and Rx
Unlimited
50%
100%
100%
100%
100%
100%
100%
Open Access
Open Access
Office Visits/Consultations for Illness/Injury
20% after CYD
$35 copay
Specialist Visits
Inpatient Hospital
Outpatient Surgery
Emergency Room
Urgent Care
OUTPATIENT DIAGNOSTIC SERVICES
Lab Services
X-Ray Services
Complex Diagnostic
PRESCRIPTIONS
Deductible (Individual / Family)
Retail (30 day supply)
Mail Order (90 day supply)
OUT-OF-NETWORK:
Deductible (Individual / Family)
20% after CYD
20% after CYD
20% after CYD
20% after CYD
20% after CYD
$75 copay
50% after CYD
50% after CYD
$300 copay
$50 copay
20% after CYD
20% after CYD
20% after CYD
$0
$75 copay
$300 copay
CYD then,
30% / 30% / 50%
30% / 30% / 50%
$200/$400 ded
$15/$20/50%
2x
Maximum Out-of-Pocket (Individual / Family)
Lifetime Major Medical Maximum
Coinsurance
*Age and Frequency schedule apply
$5,000/$10,000
$10,000/$20,000
Unlimited
60%
Not Covered
7
Health Savings Accounts
(HSA)
Health Savings Accounts
A health savings account (HSA) is an account funded to help you save for future medical expenses not covered by your
insurance plan, including the deductible, coinsurance and even vision and dental expenses. You must be enrolled in a
HSA compatible health plan to be eligible, there are certain advantages to putting money into these accounts, including
favorable tax treatment and the ability to roll unused funds over from year to year.
Who Can Have an HSA?
Any adult can contribute to an HSA if you:
· Have coverage under an HSA-qualified, high-deductible health plan (HDHP)
· Have no other first-dollar medical coverage (other types of insurance, including specific injury or accident,
disability, dental care, vision care, or long-term care insurance are permitted)
· Are not enrolled in Medicare or Tricare
· Cannot be claimed as a dependent on someone else’s tax return
Contributions to your HSA would be made by you. The total contributions are limited annually. If you make a
contribution, you can deduct the contributions (even if you do not itemize deductions) when completing your federal
income tax return.
Contributions to the account must stop once you are enrolled in Medicare. However, you can keep the money in your
account and use it to pay for medical expenses tax-free.
HDHPs
You must have coverage under the Baer's Furniture HDHP to open and contribute to an HSA.
HSA Contributions
You can make a contribution to your HSA each year that you are eligible. Contributions from all sources can be no
more than:
· Self-only coverage: $3,350 in 2015
· Family coverage: $6,650 in 2015
Individuals ages 55 and older can also make additional “catch-up” contributions. The maximum annual catch-up
contribution is $1,000.
8
Frequently Asked Questions
About HSA Plan Usage
How do I manage my HSA?
Your Health Savings Account (HSA) is your account; the HSA dollars are your dollars. Since you are the account
holder or HSA beneficiary, you manage your HSA account. You may choose when to use your HSA dollars or when
not to use your HSA dollars. HSA dollars pay for any eligible expense. Most commonly, the HSA account holder will
use HSA dollars to pay the out-of-pocket expenses (i.e., deductible and coinsurance) associated with their high
deductible plan.
What expenses are eligible for reimbursement from my HSA?
HSA dollars may be used for qualified medical expenses incurred by the account holder and his or her spouse and
dependents. Qualified medical expenses are outlined within IRS Section 213(d). In summary the IRS Section 213(d)
states that “the expense has to be primarily for the prevention or alleviation of a physical or mental defect or illness”.
In addition to qualified medical expenses, the following insurance premiums may be reimbursed from an HSA:
· COBRA premiums
· Health insurance premiums while receiving unemployment Benefits
· Any health insurance premiums paid, other than for a Medicare supplemental policy, by individuals ages 65
and over
Are dental and vision care qualified medical expenses under an HSA?
Yes, as long as these are deductible under the current rules. For example, cosmetic procedures, like cosmetic
dentistry, would not be considered qualified medical expenses.
What expenses are NOT eligible for reimbursement from my HSA?
The following expenses may not be reimbursed from an HSA:
· Premiums for Medicare supplemental policies
· Expenses covered by another insurance plan
· Expenses incurred prior to the date the HSA was established
· Over-the-counter drugs purchased without a prescription (except insulin)
What is a coverage gap?
This is the gap between total out-of-pocket expenses associated with your high-deductible health plan and your HSA
dollars. For example, assume that you have a $2,000 deductible, a $4,000 maximum out-of-pocket, and either you or
your employer has contributed $2,000 to your HSA account. If your medical costs incurred exceed $4,000 for the
year, then you are financially obligated to pay the difference between your total maximum out-of-pocket ($4,000) and
your HSA balance ($2,000) - ($4,000 - $2,000 = $2,000)
What happens when my HSA funds run out?
You may be financially responsible for any eligible medical expenses that fall within the coverage gap.
Can I use my HSA dollars for non-eligible expenses?
Money withdrawn from an HSA account to reimburse non-eligible medical expenses is taxable income to the account
holder and subject to a 20 percent tax penalty - unless over age 65, disabled or upon death of the account holder.
When can I start using my HSA dollars?
You can use your HSA dollars immediately following your HSA account activation and once contributions have been
made.
9
Frequently Asked Questions
About HSA Plan Usage - continued
How do I pay my physician or network facility at time of service with my HSA dollars?
You may request that the network provider submit your claim to your health plan. You should make sure that your
provider has your most up-to-date insurance information. Once the medical claim has been processed, if applicable,
out-of-pocket expenses will be billed. At this time you may choose to use your HSA Debit card to pay for any out-ofpocket expenses, or you may choose to pay with your own money and receive reimbursement at a later date. You
should always ask that your medical claim be submitted to the health plan before you seek reimbursement from your
HSA. This procedure will ensure that provider discounts are applied. Also, remember to keep all medical receipts and
Explanation of Benefits (EOBs) for tax purposes.
What if I have HSA dollars left in my account at year-end?
The money is yours to keep. It will continue to be available for you and your health care costs next year.
What happens to my HSA dollars if I leave Baer's Furniture?
The funds are yours to keep. You may elect one of the following options:
· Leave your funds in your current HSA account
· Transfer your funds to an HSA with your new employer
· Transfer your funds to another qualifying account within 60 days
Can I use the money in my account to pay for my dependents’ medical expenses?
You can use the money in your account to pay for medical expenses for yourself, your spouse or your dependent
children. You can pay for the unreimbursed expenses of your spouse and dependent children even if they are not
covered by your HDHP.
Can couples establish a “joint” account and both make contributions to the account, including “catch-up”
contributions?
“Joint” HSA accounts are not permitted. Each spouse should consider establishing an account in their own name. This
allows you both to make catch-up contributions when each spouse is 55 or older.
My employer offers an FSA – can I have both an FSA and an HSA?
You can have both types of accounts, but only under certain circumstances. General Flexible Spending Accounts
(FSAs) will probably make you ineligible for an HSA. If your employer offers a “limited purpose” (limited to dental, vision
or preventive care) or “post-deductible” (pay for medical expenses after the plan deductible is met) FSA, then you can
still be eligible for an HSA.
Can I shift my IRA funds to my HSA?
Owners of individual retirement accounts that are enrolled in a high-deductible health plan can shift IRA funds to an
HSA without facing a tax penalty. The IRS allows a one-time transfer that does not exceed your maximum HSA
contribution limit.
Can I borrow against the money in my HSA?
No. You may not borrow against it or pledge the funds in it. For more information on prohibited activities see Section
4975 of the Internal Revenue Code.
10
HSA Banking Information
Opening your Health Savings Account
Follow the steps below to open your Health Savings Account (HSA).
Step 1: Medical Plan Enrollment
Enroll in the Baer’s HSA compatible HDHP Plan.
Step 2: Contribution
Determine how much you plan to contribute to your HSA account before taxes.
Step 3: HSA Establishment
Varies by bank, use their instructions. Chose a bank of your choice, open and deposit money into your HSA right
away so you are prepared if you have a health event. You or anyone else can deposit money into the HSA at
anytime.
11
Benefit Resource Center
Services
Toll-free benefit call center available to:
•
•
•
•
•
•
•
•
Answer questions regarding your health and other
benefit plans
• Network: Is my doctor on the plan?
• Plan Coverage: Does my plan cover this?
• Billing: I received a bill from my provider, do I need
to pay?
Once you’ve tried, but need help understanding how a
carrier paid your claim
Specialist support to help you with complex claims issues
Medical appeals information and support
Life event (family status) rules – what changes can I
make?
Life Insurance Beneficiary form requirements
How do I complete an Evidence of Insurability form and
where do I send it?
What happens if I have coverage under two different
medical plans?
12
Dental Insurance
Baer's Furniture offers two dental plans through Guardian.
Guardian’s DMO is an in-network only dental plan. There are no benefits for out-of-network dentists. There are no
plan maximums or deductibles.
The DPPO 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 Guardian’s allowed amount and what the dentist may charge.
Guardian
DHMO U30
Low Plan
In-Network
Deductible
Individual
Family
Annual Maximum
N/A
N/A
Individual
None
Age Limitation
$50
$150
D0120
D1110
D1203
D0272
D1351
No Charge
No Charge
No Charge
No Charge
No Charge
D2150
D7140
D3320
D4211
No Charge
No Charge
$120 - $170
No Charge
D2791
D6211
D5110
$395.00
$381 - $575
$381 - $575
$100
$300
$1,000
Deductible
Waived
Diagnostic & Preventative
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
Orthodontics
Lifetime Maximum
Guardian
DPPO K7
Buy Up Plan
Out-of
In-Network
Network
100%
Deductible
Applies
80%
Deductible Applies
80%
70%
Deductible Applies
$2,500
Child to age 19
50%
40%
Not Covered
13
Vision Insurance
Baer's Furniture offers a vision plan through Guardian. This vision plan provides coverage both in and out of network.
The chart below provides a brief overview of the plan.
Guardian
Vision
In-Network
Out-of-Network
Single
$25 copay
$48 allowance
Bifocal
$25 copay
$67 allowance
Trifocal
$25 copay
$86 allowance
Contact Lenses
85% of amount over $120
$105 allowance
Frames
80% of amount over $120
$48 allowance
Exams
$15 copay
$50 allowance
Lenses
Frequency
Exam
Once every 12 months
Lenses or contact lenses
Once every 12 months
Frame
Once every 24 months
Lens Options
(Tints, coating, UV, anti-reflective
lenses, polycarbonate & progressive
lenses)
Members receive additional fixed copayments on lens options including
anti-reflective and Scratch-resistant coatings. After copay, standard
polycarbonate available at no charge for dependents less than 19 years
old.
Additional Pairs
Courtesy discount on a second pair of eyeglasses. This discount is
available for 12 months after the covered eye exam and available through
the Davis Vision Network provider who sold the initial pair of eyeglasses.
Laser Vision Correction
Up to 25% off the usual charge or 5%. No discounts off promotional price.
14
Voluntary Life Insurance
Baer’s Furniture provides all active employees working 25 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 Term Life
All F/T, 30 hrs or more
Eligible Employee Benefit
Employee
Spouse
$10,000 to $300,000
50% EE amt to $150,000
Dependent Life
$10,000
Employee Guarantee Issue
$200,000
Spouse Guarantee Issue
$30,000
Accelerated Death Benefit 50% death benefit, $250,000 max
Waiver of Premium Benefit
Portable/Convertible
Benefit Reduction
Yes
Yes w/o E of I
35% age 70, add'l 35% age 75
Note: Please see your Benefits Representative for a Beneficiary Designation Form.
The only time you can enroll in guaranteed issue voluntary life insurance, is at the date you first
become eligible to enroll. If you do not enroll then and later decide that you would like to enroll, you
will be required to complete a medical questionnaire and go through medical underwriting. The
insurance carrier reserves the right to decline coverage based on medical information obtained on the
medical questionnaire.
15
Disability Insurance
Voluntary Disability Income Benefits
Baer’s Furniture provides all active employees working 25 or more hours per week the option to purchase Short Term
and Long Term Disability coverage through a group plan. When you enroll in short term or long term disability you pay
the full cost through payroll deductions.
In the event you become disabled from a non work-related injury or sickness, disability benefits are provided as a
source of income. You are not eligible to receive short-term disability benefits if you are receiving workers’
compensation benefits.
Short Term Disability
Employee Definition
Monthly Benefit
Elimination Period
Pre-Existing Limitation
All F/T, 30 hrs or more
60% to $1,000
15 days
3/12
Duration of Benefits
11 weeks
Contribution Type
Voluntary
Long Term Disability
Employee Definition
Monthly Benefit
Elimination Period
Duration of Benefits
Own Occupation
Pre-Existing
Conditions
Contribution Type
All F/T, 30 hrs or more
60% to $5,000
90 days
Later of 65 or SSNRA
24 months
3/12
Voluntary
The only time you can enroll in guaranteed issue Short Term or Long Term Disability is at the date you
first become eligible to enroll. If you do not enroll then and later decide that you would like to enroll, you
will be required to a complete a medical questionnaire and go through medical underwriting. The
insurance carrier reserves the right to decline coverage based on medical information obtained on the
medical questionnaire.
16
Payroll Deductions
The Charts below show the bi-weekly payroll deduction amounts for each of the benefits offered.
Medical
Aetna
HSA HNO
HNO Only
Employee Only
$45.00
$25.00
Employee + Spouse
$220.00
$195.00
Employee + Child(ren)
$180.00
$160.00
Family
$370.00
$335.00
Dental
Guardian
DHMO U30
DPPO K7
Employee Only
$5.40
$13.88
Employee + Spouse
$10.81
$29.04
Employee + Child(ren)
$12.03
$34.80
Family
$17.44
$46.47
Vision
Guardian
Vision
Employee Only
$2.75
Employee + Spouse
$4.63
Employee + Child(ren)
$4.72
Family
$7.47
*Please note that rates for voluntary life, voluntary STD, voluntary LTD, critical care,
accident, and group universal life will be available on the EMB enrollment site.
17
Supplemental Benefits
•Accident
•Universal Life
Costumer Service:
Claims:
•Critical Illness
Costumer Service:
800-918-8877
877-201-9373
877-815-9256
*For questions on claims or benefits contact applicable
carrier above for the supplemental benefits.
Note: Please see your Benefits Representative for a Beneficiary Designation Form.
The only time you can enroll in guaranteed issue voluntary life insurance, is at the date you first become eligible to enroll. If
you do not enroll then and later decide that you would like to enroll, you will be required to complete a medical questionnaire
and go through medical underwriting. The insurance carrier reserves the right to decline coverage based on medical
information obtained on the medical questionnaire.
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30
HealthCare Reform and You
The Patient Protection and Affordable Care Act & The Health Care and Education Affordability Reconciliation Act of 2010, together, create
the most comprehensive health insurance reform ever under taken in recent history by our Country.
Many of the new law’s required changes have already been incorporated into company health plans across the country since the effective
date in September of 2010. However, there will be many more changes taking place in the months to come, as more guidance is issued by
the government to employers, insurance carriers and individuals.
One of the key requirements of the new law beginning in 2014, is the mandate that all U.S. citizens & legal residents either carry health
insurance or pay an income tax penalty. While the tax penalty is not too severe in the first year, it becomes progressively more costly each
year thereafter.
Penalties for failing to buy coverage
Tax penalties for failing to buy coverage are phased in according to the following schedule:
In 2014, the greater of $95 or 1% of taxable income;
In 2015, the greater of $325 or 2% of taxable income;
In 2016, the greater of $695 or 2.5% of taxable income; and
After 2016, the penalty is indexed for inflation.
However, there are two ways to avoid the tax penalty:
You can buy coverage for you and your family through your place of employment, if your employer offers such coverage. That coverage
must meet certain standards set by the law in order for you and the employer to escape respective tax penalties. The coverage must meet
certain minimum coverage standards (Generally pays at least 60% of your covered medical expenses) and must be considered
“affordable” (Employer cannot charge you a premium for single or employee only coverage greater than 9.5% of
your W-2 earnings for the year). The 9.5% would apply to annual salaries of up to about $45,000.
Or, you can provide coverage for you and your family through a Federally run Insurance Exchange that is supposed to be up and running
by 1/1/2014. Essentially, an Exchange is an interactive site where an individual can go to research, evaluate and buy health plans. The
State of Florida chose not to set up a state run exchange, so the Federal government will take over that responsibility.
If you obtain coverage through an Exchange:
The Exchange will 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)
You may only obtain coverage through an Exchange if you are not participating in your employer’s plan.
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.
31
Required Annual Employee Disclosure Notices
Required Annual Employee Disclosure Notices
The Newborns’ and Mothers’ Health
Women’s Health and Cancer Rights
Protection Act of 1996
Act of 1998
The Newborns’ and Mothers’ Health Protection Act of 1996 prohibits group and
The Women’s Health and Cancer Rights Act of 1998 requires Baer’s Furniture to notify
individual health insurance policies from restricting benefits for any hospital length of
you, as a participant or beneficiary of the Baer’s Furniture Health and Welfare Plan, of
stay for the mother or newborn child in connection with childbirth; (1) following a
your rights related to benefits provided through the plan in connection with a
normal vaginal delivery, to less than 48 hours, and (2) following a cesarean section, to
mastectomy. You, as a participant or beneficiary, have rights to coverage to be
less than 96 hours. Health insurance policies may not require that a provider obtain
provided in a manner determined in consultation with your attending physician for:
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;
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.
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.
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
Section 111
covered under the plan for up to one year from the beginning of the leave of absence.
Effective January 1, 2009 group health plans are required by Federal government to
enrolled as at student at a post-secondary educational institution (includes colleges,
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
This continued coverage applies if your child was (1) covered under the plan and (2)
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.
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
Required
Annual Employee Disclosure Notices continued
- Continued
HIPAA Privacy Policy for Fully-Insured
Plans with no Access to PHI
The group health plan is a fully-insured group health plan sponsored
by the “Plan Sponsor”. The group health plan and the plan sponsor
intend to comply with the 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.
Patient Protection:
If the Group Health Plan generally requires the designation of a primary care provider
who participates in the network and who is available to accept you or your family
members. For children, your may designate a pediatrician as the primary care
provider.
You do not need prior authorization from the carrier or from any other person
(including a primary care provider) in order to obtain access to obstetrical or
gynecological care from a health care professional in the network who specializes in
I.
II.
III.
IV.
No access to protected health information (PHI) except for
summary health information for limited purpose and enrollment /
dis-enrollment information.
obstetrics or gynecology. The health care professionals, however, may be required to
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.
For a list of participating health care professionals who specialize in obstetrics or
Insurer for group health plan will provide privacy notice
comply with certain procedures, including obtaining prior authorization for certain
services, following a pre-approved treatment plan or procedures for making referrals.
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
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.
Children’s Health Insurance Program
No intimidating or retaliatory acts
Reauthorization Act (CHIPRA) of 2009
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.
Effective April 1, 2009, a special enrollment period provision is added to comply with
No Waiver
coverage, you may be able to enroll yourself and/or your dependent(s). However, you
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.
on the basis of fraud or misrepresentation.
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
must enroll within 60 days after the date eligibility is lost. If you or a dependent
becomes eligible for premium assistance under an applicable State Medicaid or CHIP
plan to purchase coverage under the group health plan, you may be able to enroll
yourself and/or your dependent(s). However, you must enroll within 60 days after you
or your dependent is determined to be eligible for State premium assistance. Please
note that premium assistance is not available in all states.
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Required
Annual
Disclosure
Required
Annual
EmployeeEmployee
Disclosure Notices
- ContinuedNotices
- 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 Aetna 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.
Aetna has determined that the prescription drug overage offered by the
Welfare Plan for Employees of Baer’s Furniture under the Aetna 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 Aetna 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 15th to December 7th.
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 Aetna 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 Aetna 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 Aetna 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 Aetna changes. You also may
request a copy of this notice at any time.
For more information about your options under Medicare prescription drug
coverage…
More detailed information about Medicare plans that offer prescription drug coverage
is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail
every year from Medicare. You may also be contacted directly by Medicare drug
plans. For more information about Medicare prescription drug coverage:
>
Visit www.medicare.gov
>
Call your State Health Insurance Assistance Program (see your copy of the
Medicare & You handbook for their telephone number) for personalized help,
>
Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-4862048.
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 1-800325-0778).
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.
Name of Entity/Sender:
Contact--Position/Office:
Address:
Phone Number:
Baer's Furniture
Susan Scovin
1589 NW 12th Ave.
Pompano Beach, FL 33069
954-946-8007 ext. 215
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Notes
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The information in this Benefits Summary is presented for illustrative purposes and is based on information
provided by the employer. The text contained in this Summary was taken from various summary plan
descriptions and benefit information. While every effort was taken to accurately report your benefits,
discrepancies or errors are always possible. In case of discrepancy between the Benefits Summary and the
actual plan documents, the actual plan documents will prevail. All information is confidential, pursuant to
the Health Insurance Portability and Accountability Act of 1996. If you have any questions about this
summary, contact Human Resources.
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