Leader's Casual Furniture 2020 Benefits at a Glance

Leader's Casual Furniture 2020 Benefits at a Glance

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

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DISCLOSURE NOTICES

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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.

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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 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.

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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

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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

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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. _________

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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

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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