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Leader's Casual Furniture 2020 Benefits at a Glance
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2022 At A Glance GR EAT E R OKLAHOMA CITY AT A GLANCE TABLE OF CONTENTS Location & Demographics.....
BENEF I TS AT A GLANCE January 1, 2020 December 31, 2020
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CONTENTS & CONTACT INFORMATION
Refer to this list when you need to contact one of your benefit vendors. For general information contact Human Resources.
BROKER Provider Name Broker Contact
M.E. Wilson Company
Amanda Sands
Provider Phone Number Provider Email Address
813-229-8021 Ext. 139 [email protected]
MEDICAL
page 3
Provider Name
Florida Blue
Provider Phone Number Provider Web Address
1-800-583-9072 www.bcbsfl.com
DENTAL
page 5
Provider Name
Guardian
Provider Phone Number Provider Web Address
800-541-7846
www.guardiananytime.com
VISION
page 6
Provider Name
Guardian
Provider Phone Number Provider Web Address
800-541-7846
www.guardiananytime.com
DISABILITY
page 7
Provider Name
Principal
Provider Phone Number Provider Web Address
1-800-247-4695
www.principal.com
VOLUNTARY LIFE
page 9
Provider Name
Principal
Provider Phone Number Provider Web Address
1-800-247-4695
www.principal.com
SUPPLEMENTAL BENEFITS
page 10
Provider Name
Colonial Life
Provider Phone Number Provider Web Address
1-800-325-4368
www.coloniallife.com
HOW TO ENROLL
page 11
DISCLOSURE NOTICES
page 14
BENEFIT INFORMATION
Benefit
Who pays the cost?
Your employer pays the majority of the employee portion of the medical plan. You may enroll your eligible dependents for an additional cost. You may elect dental coverage for yourself and your eligible dependents on a voluntary basis and you will be responsible for the cost. You may elect vision coverage for yourself and your eligible dependents on a voluntary basis and you will be responsible for the cost.
YOUR BENEFITS PLAN
Medical Insurance
Leader’s Casual Furniture offers a variety of benefits allowing you the opportunity to customize a benefits package that meets your personal needs. In the following pages, you’ll learn more about the benefits offered. You’ll also see how choosing the right combination of benefits can help protect you and your family’s health and finances – and your family’s future.
Dental Insurance
Vision Insurance
Voluntary Benefits
The employee pays the entire cost.
ELIGIBILITY
All Regular full-time employees are eligible to join Leader’s Casual Furniture Benefits Plan on the 1st of the month following 60 days. “Regular Full- Time Employees” must be regularly scheduled and working at least 30 hours per week.
You may also enroll your dependents in the Benefits Plan when you enroll.
Eligible dependents include:
Your legal spouse & domestic partner.
•
• Your married or unmarried natural children, step-children living with you, legally adopted children and any other children for whom you have legal guardianship, who are:
Under 26 years of age;
►
WHEN CAN YOU ENROLL?
► A dependent who is older than 26 years of age, but less than 30 years of age may be eligible for medical benefits. To be eligible, a Dependent must: • Be unmarried and not have dependents of his or her own; AND
You can sign up for Benefits at any of the following times:
• After completing your initial eligibility period; • During the annual open enrollment period; • Within 30 days of a qualified family-status change.
Be a resident of Florida or a student; AND
•
Not have coverage of their own, or covered under any other plan; AND
•
Not entitled to benefits under Medicare
•
If you do not enroll at one of the above times, you must wait for the next annual open enrollment period.
1
BENEFIT INFORMATION
?
CHOOSING YOUR BENEFITS
You must actively choose any benefit that you pay for, or share in the cost with Leader’s Casual Furniture. Your part of the cost is automatically taken out of your paycheck. There are two ways that the money can be taken out:
WHY DO I PAY FOR BENEFITS WITH BEFORE-TAX MONEY?
There is a definite advantage to paying for some benefits with before-tax money: Taking the money out before your taxes are calculated lowers the amount of your pay that is taxable. Therefore, you pay less in taxes.
• BEFORE YOUR TAXES ARE CALCULATED – medical, dental, and vision • AFTER YOUR TAXES ARE CALCULATED – voluntary benefits
MAKING CHANGES
If you fail to notify Human Resources within 30 days of a family status change, you will be required to wait until the next annual enrollment period to make benefit changes unless you have another family status change.
Generally, you can only change your benefit choices during the annual benefits enrollment period. However, you may be able to change your benefit choices during the plan year if you have a change in status including:
Your marriage
•
Your divorce or legal separation
•
Birth or adoption of an eligible child
•
Death of your spouse or covered child
•
• Change in your spouse’s work status that affects his or her benefits
WHEN COVERAGE ENDS
• Change in your work status that affects your benefits
Coverage will stop on the last day of the month in which employment with the company ends.
• Change in residence or work site that affects your eligibility for coverage
• Change in your child’s eligibility for benefits
• Receiving Qualified Medical Child Support Order (QMCSO)
KEY BENEFIT TERMS
COBRA – A Federal law that allows workers and dependents who lose their medical, dental, or vision coverage to continue any of these coverages for a specified length of time by electing and paying for continuation benefits. Copayment – A flat fee that you pay for medical services, regardless of the actual amount charged by your doctor or another provider. This generally applies to physicians’ office visits and prescription drugs. Deductible – The amount you pay toward medical and dental expenses each year before the plan begins paying benefits. Out of Pocket Maximum – The maximum amount you will pay in deductibles and copayments during the year.
2
MEDICAL INSURANCE
Leader’s Casual Furniture offers medical plan options through FloridaBlue. To find participating providers go to www.bcbsfl.com and click on “Find a Doctor”, choose the appropriate provider type. In Step 2: Network Name, choose “BlueCare or BlueOptions”. Complete the remaining information and click Search.
The chart below provides a brief overview of the medical plans. This chart is intended only to highlight the benefits available and should not be relied upon to fully determine your coverage. If the below illustration of benefits conflicts in any way with the Summary Plan Description (SPD), the SPD shall prevail. It is recommended that you review your exact description of services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.
OPTION 1 BLUECARE 71
OPTION 2 BLUEOPTIONS 05905
OPTION 3 BLUECARE 54
OPTION 4 BLUECARE 52
IN-NETWORK: Plan Year or Calendar Year Basis Deductible (Individual / Family)
Calendar Year
Calendar Year
Calendar Year
Calendar Year
$5,000 / $10,000
$7,000 / $14,000
$5,000 / $10,000
$1,500 per person
Coinsurance
80% / 20%
70% / 30%
70% / 30%
70% / 30%
Maximum Out-of-Pocket (Individual/Family) Maximum Out-of-Pocket Includes Lifetime Major Medical Maximum
$7,900/ $15,800
$7,350 / $14,700
$6,350 / $12,700
$6,350 / $12,700
Deductible, Coinsurance & Copayments
Deductible, Coinsurance & Copayments
Deductible, Coinsurance & Copayments
Deductible, Coinsurance & Copayments
Unlimited
Unlimited
Unlimited
Unlimited
PREVENTIVE CARE:
Wellness Immunizations Mammography/Colonoscopy COPAYMENTS: Referral Required Office Visits/Consultations for Illness/Injury
Covered 100%
Covered 100%
Covered 100%
Covered 100%
No (PCP Required)
No
No (PCP Required)
No (PCP Required)
$10 Copayment
$50 Copayment
$40 Copayment
$40 Copayment
Specialist Visits
$100 Copayment
$75 Copayment
$65 Copayment
$65 Copayment
Inpatient Hospital
Deductible & Coinsurance Deductible & Coinsurance $250 copay + Deductible & Coinsurance
Deductible & Coinsurance Deductible & Coinsurance
Deductible & Coinsurance Deductible & Coinsurance
Deductible & Coinsurance Deductible & Coinsurance
Outpatient Surgery
Emergency Room
Deductible & Coinsurance
$300 Copay
$300 Copayment
Urgent Care
$75 Copayment
Deductible & Coinsurance
$85 Copay
$85 Copayment
OUTPATIENT DIAGNOSTIC SERVICES: Lab Services
Covered 100%
Covered 100%
Covered 100%
Covered 100%
X-Ray Services
Deductible & Coinsurance Deductible & Coinsurance
Deductible & Coinsurance Deductible & Coinsurance
$65 copay
$65 Copayment
Complex Diagnostic
$200 copay
$200 Copayment
PRESCRIPTIONS:
Retail (30 day supply)
$10 / $50 / $80
$10 / $50 / $80
$10 / $50 / $80
$10 / $50 / $80
Mail Order (90 day supply)
2.5 X retail
2.5 X retail
2.5 X retail
2.5 X retail
OUT-OF-NETWORK:
Deductible (Individual /
$14,000 / $28,000
Family)
Maximum Out-of-Pocket
$15,500 / $30,000
(Individual/Family)
In-Network Only
In-Network Only
In-Network Only
Unlimited
Lifetime Major Medical
Maximum
50% / 50%
Coinsurance
3
MEDICAL CONTRIBUTION SCHEDULE
Smoker Employee Pays (Per Pay Period)
Option 1 BlueCare 71
Non Smoker Employee Pays (Per Pay Period)
Total Monthly Cost
Employee Only
$ 530.77
$ 64.55
$ 87.62
Employee + Spouse
$1,263.22
$402.60
$425.68
Employee + Child(ren)
$ 976.61
$212.63
$235.70
Family
$1,655.98
$526.18
$549.26
Smoker Employee Pays (Per Pay Period)
Option 2 BlueOptions 5905
Non Smoker Employee Pays (Per Pay Period)
Total Monthly Cost
Employee Only
$ 586.59
$ 90.31
$113.39
Employee + Spouse
$1,396.09
$463.92
$487.00
Employee + Child(ren)
$ 1,079.32
$260.03
$283.11
Family
$1,830.16
$606.57
$629.65
Smoker Employee Pays (Per Pay Period)
Option 3 BlueCare 54
Non Smoker Employee Pays (Per Pay Period)
Total Monthly Cost
Employee Only
$ 579.14
$ 86.87
$109.95
Employee + Spouse
$1,378.35
$455.74
$478.81
Employee + Child(ren)
$1,065.61
$253.70
$276.78
Family
$1,806.91
$595.84
$618.92
Smoker Employee Pays (Per Pay Period)
Option 4 BlueCare 52
Non Smoker Employee Pays (Per Pay Period)
Total Monthly Cost
Employee Only
$ 585.28
$ 89.70
$112.78
Employee + Spouse
$1,392.95
$462.48
$485.55
Employee + Child(ren)
$1,076.90
$258.91
$281.99
Family
$1,826.05
$604.68
$627.75
4
DENTAL INSURANCE
Leader's Casual Furniture offers dental coverage through Guardian. The Dental PPO Plans allow you to use in-network or out-of-network benefits. If out-of-network dentists are used, you will be responsible for paying the difference between Guardian’s allowed amount and what the dentist may charge, also known as “balance billing”. The charts below provides a brief overview of the plans.
DMO
PPO
Calendar Year Deductible
In-Network
Out-of-Network
Individual
$0
$25
$50
Family
$0
$75
$150
Annual Maximum
Unlimited
$1,500
$1,500
Diagnostic & Preventative
Exams
Fee Schedule
100%, no deductible
100%, no deductible
Cleanings
Fee Schedule
100%, no deductible
100%, no deductible
Fluoride
Fee Schedule
100%, no deductible
100%, no deductible
X-Rays
Fee Schedule
100%, no deductible
100%, no deductible
Sealants
Fee Schedule
100%, no deductible
100%, no deductible
Regular Restorative Services
*12 Month Waiting Period for late applicants
Amalgam Fillings
Fee Schedule
90%, after deductible
80%, after deductible
Extractions – Single Tooth
Fee Schedule
90%, after deductible
80%, after deductible
Endodontics (Root Canal)
Fee Schedule
90%, after deductible
80%, after deductible
Periodontics (Gum Disease)
Fee Schedule
90%, after deductible
80%, after deductible
Major Services
*No Waiting Period
*12 Month Waiting Period for late applicants
Crowns
Fee Schedule
60%, after deductible
50%, after deductible
Bridges
Fee Schedule
60%, after deductible
50%, after deductible
Dentures
Fee Schedule
60%, after deductible
50%, after deductible
Orthodontia
Child
Fee Schedule
50%, no deductible
Adult
Fee Schedule
50%, no deductible
Lifetime Max
N/A
$1,500
DHMO Employee Cost Per Pay Period
PPO Employee Cost Per Pay Period
Employee Only
$ 6.99
$17.22
Employee + Spouse
$13.99
$36.41
Employee + Child(ren)
$15.74
$38.74
Family
$25.33
$61.68
5
VISION INSURANCE
Leader's Casual Furniture offers vision coverage through Guardian. The Guardian vision network consists of optometrists, ophthalmologist opticians and optical retailers. You have the option of visiting any provider, however by choosing a participating provider, you receive the highest level of benefits.
Vision – (Davis Vision)
In-Network
Out-of-Network
Eye Exam (every 12 months)
$10 Copay
$50 allowance
Lenses** (every 12 months)
Single Vision
$10 Copay
$48 allowance
Bifocal Lenses
$10 Copay
$67 allowance
Trifocal Lenses
$10 Copay
$86 allowance
Frames (every 24 months)
$150 allowance + 20% discount
$48 retail allowance
Contact Lenses
Elective
$120 allowance + 15% discount
$105 allowance
Medically Necessary
Covered 100%
$210 allowance
• Covered lenses include single vision, bifocal, trifocal and lenticular.
• Lenses, Frames & Contacts are limited to either one pair of contacts or frames/lenses per calendar year.
Employee Cost Per Pay Period
Employee Only
$3.07
Employee + 1
$5.53
Family
$9.54
6
SHORT TERM DISABILITY INSURANCE
SHORT TERM DISABILITY
Leader’s Casual Furniture provides all active employees working 30 or more hours per week the option to purchase short term disability insurance coverage through a group plan, at the employee’s cost.
Short Term Disability
Benefit Percentage
60% of basic earnings
Maximum Weekly Benefit
$1,000 per week
Benefits commence on the 8th day for an accident Benefits commence on the 8th day for a sickness
Elimination Period
Duration of Benefit
25 weeks
Definition of Earnings
Base Salary
Employee Rate Per $10 of Weekly Benefit
$.69
Voluntary STD Premium Calculation Worksheet
To calculate your approximate STD bi-weekly premium, follow these steps:
STEP 1 Enter your bi-weekly pay
1. _________
Multiply the number on line 1 by 26, then divide by 52. This is your weekly pay (this amount cannot exceed $1,667)
STEP 2
2. _________
STEP 3 Multiply the amount in Step 2 by 60%.
3. _________
STEP 4 Monthly rate:
4. __$.69____
STEP 5 Multiply the amount on Line 3 by the rate entered on Line 4.
5. _________
Divide the amount on Line 5 by 10 and enter the amount on Line 6 to get your monthly payroll deduction. Multiply the amount on Line 6 by 12, then Divide by 26 to get your approximate bi-weekly payroll deduction.
STEP 6
6. _________
STEP 7
7. _________
7
LONG TERM DISABILITY INSURANCE
LONG TERM DISABILITY Leader’s Casual Furniture provides all active employees working 30 or more hours per week the option to purchase Long term disability insurance coverage through a group plan, at the employee’s cost.
Long Term Disability
Benefit % of Monthly Covered Payroll
50% of basic earnings
Monthly Maximum
$6,000 per month
Elimination Period
Benefits commence on the 180th day
Benefit Duration
Social Security Normal Retirement Age (SSNRA)
Definition of Earnings
Salary
VOLUNTARY LONG-TERM DISABILITY Monthly Rates per $100 of benefit
AGE
Rates per $100 of benefit
PREMIUM CALCULATION
< 24
$0.48
Annual Pay
1. $__________
25-29
$0.45
30-34
$0.51
Divide Annual Pay by 12
2. $__________
35-39
$0.69
Find rate on table below
3. $__________
Multiply the amount on line 2 by appropriate rate for your age entered on line 3.
4. $__________
40–44
$1.09
45-49
$1.16
Divide the amount on line 4 by 100 5. $__________ and enter the amount on line 5 to get your monthly payroll deduction. Multiply the amount on Line 5 by 12, 6. $__________ then divide by 26 to get your approximate bi-weekly payroll deduction
50–54
$1.82
55-59
$1.81
60-64
$1.87
65-69
$1.10
70+
$0.81
8
VOLUNTARY LIFE INSURANCE
VOLUNTARY LIFE INSURANCE
Leader’s Casual Furniture provides all active employees working 30 or more hours per week the option to purchase life insurance coverage through a group plan, at the employee’s cost. The chart below provides an overview of the plan. Please note that anyone enrolling outside of their initial open enrollment period is considered a late entrant and will be subject to medical underwriting.
Voluntary Life Insurance
Employee Life
Increments of $10,000 up to $500,000
Under Age 70: $150,000 Age 70 and over” $10,000
Employee Guarantee Issue
Spouse Life
Increments of $5,000 up to 50% of the employee’s coverage (Maximum $200,000)
Under Age 70: $30,000 Age 70 and over” $10,000
Spouse Guarantee Issue
Dependent Life
$5,000 or $10,000, not to exceed 50% of employee amount
Accidental Death & Dismemberment (AD&D)
Included Equal to voluntary life amount
Age Employee Spouse Child
VOLUNTARY LIFE Monthly Life Rates per $1,000 of benefit Includes AD&D Cost