Enrollment + Eligibility
Who is Eligible to Join the Benefit Plan?
You and your dependents are eligible to join the health and our company welfare benefit plans if you are a full-time employee regularly scheduled to work 30 hours per week You must be enrolled in the plan to add dependent coverage
Who is an Eligible Dependent?
• Your spouse to whom you are legally married
• Your dependent child under the maximum age specified in the Carriers’ plan documents including:
▪ Natural child
▪ Adopted child
▪ Stepchild
▪ Child for whom you have been appointed as the legal guardian
*Your child’s spouse and a child for whom you are not the legal guardian are not eligible
The Dependent Maximum Age Limits is up to age 26 The dependent does not need to be a fulltime student; does not need to be an eligible dependent on parent’s tax return; is not required to live with you; and may be unmarried or married
Once the dependent reaches age 26, coverage will terminate on the last day of the birth month
A totally disabled child who is physically or mentally disabled prior to age 26 may remain on the plan if the child is primarily dependent on the enrolled member for support and maintenance.
When Do Benefits Become Effective?
Your benefits become effective on the first day of hire as a full-time employee with Passion, Inc
Annual Open Enrollment?
Each year during the annual Open Enrollment Period, you are given the opportunity to make changes to your current benefit elections. To find out when the annual Open Enrollment Period occurs, contact Human Resources
Qualifying Event Changes
You are allowed to make changes to your current benefit elections during the plan year if you experience an IRS-approved qualifying change in life status The change to your benefit elections must be consistent with and on account of the change in life status.
IRS-approved qualifying life status changes include:
• Marriage, divorce or legal separation
• Birth or adoption of a child or placement of a child for adoption
• Death of a dependent
• Change in employment status, including loss or gain of employment, for your spouse or a dependent
• Change in work schedule, including switching between full-time and part-time status, by you, your spouse or a dependent
• Change in residence or work site for you, your spouse, or a dependent that results in a change of eligibility
• If you or your dependents lose eligibility for Medicaid or the Children’s Health Insurance Program (CHIP) coverage
• If you or your dependents become eligible for a state’s premium assistance subsidy under Medicaid or CHIP
If you have a life status change, you must notify the company within 60 days for changes in life status due to a Medicare or CHIP event and within 30 days of the other events
If you do not notify the company during that time, you and/or your dependents must wait until the next annual open enrollment period to make a change in your benefit elections
Medical
Receive virtual care and support
When you aren’t feeling your best physically, mentally, or emotionally or you need guidance managing a health condition, help is available. You can connect to the care you need by logging in to engage.ameriben.com You can have a video visit with a doctor 24/7 for common health issues and annual wellness visits. Care for mental and emotional health is available by appointment.1
Visit with a doctor for common medical concerns
Doctors are available anytime, with no long wait times and no appointments needed. They can help you with health issues, such as a cold or the flu, allergies, sore throat, migraines, or skin rashes. During your private and secure video visit, the doctor will assess your condition, provide a treatment plan, and send prescriptions to the pharmacy of your choice, if needed.2
Receive care for your behavioral health
If you’re feeling anxious or depressed, or having trouble coping, you can set up a video visit with a therapist, psychologist, or psychiatrist.3 Appointments can be scheduled within one to two weeks.1 Psychiatrists help manage medications; they do not provide counseling or talk therapy.4
1 Appointments subjectto availability.
2
3
4 Prescriptions
5
YOUR STEPSTO SAVINGS!
REALIZE THE TAX SAVINGS
Healthcare (FSA)
THE HEALTH CARE FLEXIBLE SPENDING ACCOUNT (FSA) CAN REIMBURSE YOU FOR ELIGIBLE EXPENSES YOU OR YOUR ELIGIBLE DEPENDENTS INCUR THAT ARE NOT PAID BY YOUR EXISTING HEALTH CARE PLAN.
• COVID-19 Related PPE 1 2 3
You can set aside pre-tax money into an account to be reimbursed for eligible medical expenses. Savings will depend on your tax bracket. For example, if you are taxed at 25% and you enroll for $3,050 you would save $762.50 in taxes.
ESTIMATE YOUR EXPENSES
Plan for your upcoming expenses and include your spouse and dependents, if eligible. A brief list of expenses can be found to the right. A comprehensive list of allowable expenses and an expense worksheet can be found at www.flores247.com.
ENROLL AND MANAGE YOUR ACCOUNT
Contact your Human Resources Department to find out how to enroll for this benefit. Flores will send a custom Participant ID number via mail or email to help you manage your account. Contact information can be found on the back of this flyer.
ELIGIBLE EXPENSES
• Medical co-payments, co-insurance and deductibles
• Routine wellness visits
• Prescription expenses
• Vision expenses (including eye exams, eyeglasses and contact lenses)
• LASIK surgery
• Dental expenses (excluding cosmetic procedures)
• Orthodontia payments
• Hearing expenses
• Over-the-counter Medications
• Menstrual Care Items
Dental
Good dental care is critical to your overall well-being. With Unum Dental insurance, you can get the attention your teeth need at a cost you can afford Unum Dental allows you to see any dentist you choose To get the most from your benefits and reduce out-of-pocket costs, choose an in-network provider by utilizing our large national network These providers have agreed to file your claims and uphold the highest quality standards You can find in-network providers at https://www unumdentalcare com/
Your Deductible $50 individual / $150 Family
Calendar Year Maximum: Applies to preventive, basic, and major services $1,000 combined In-network and Out-of-Network
Preventive & Diagnostic Services: Exams, Cleanings & Bitewing X-Rays, Fluoride, Sealants
Basic Services: Filings, Simple Extractions, Oral Surgery, Emergency Treatment, Repair of Crown, Denture, or Bridge
Major Services: Crowns, Bridgework, Full & Partial Dentures, Implants, Inlays and Onlays, Endodontics, Periodontal Maintenance.
(Children up to age 19)
(Deductible waived)
After Deductible
After Deductible
EyeMed’s Vision Care, offers easy access to thousands of conveniently located vision care providers. By having access to a nationwide network, it offers convenient, accessible options for eye care including optometrists, ophthalmologists, opticians and many leading optical retailers, such as Private Practitioners, LensCrafters, Target Optical, most Sears Optical, Pearl Vision and JC Penny Optical locations
EyeMed Vision- Plan Highlights
Life and Accidental Death + Dismemberment (AD+D)
BASIC LIFE AND AD&D
Basic Term Life means that you keep the coverage for a set period of time, or “term ” If you die during that term, the money can help your family pay for basic living expenses, final arrangements, tuition and more AD&D Insurance is also available, which can pay a benefit if you survive an accident but have certain serious injuries It can pay an additional amount if you die from a covered accident Your employer is offering this coverage at no cost to you.
Company Paid Basic Life | Unum
Benefit Amount 1x Annual Salary up to $200,000
Coverage
Cost 100% Employer Paid
VOLUNTARY LIFE AND AD&D
You choose the amount of coverage that’s right for you, and you keep coverage for a set period of time, or “term ” If you die during that term, the money can help your family pay for basic living expenses, final arrangements, tuition and more AD&D Insurance is also available, which pays a benefit if you survive an accident but have certain serious injuries It pays an additional amount if you die from a covered accident With Voluntary Life and AD&D you are able to select coverage for your spouse and / or child(ren) You must elect coverage for yourself before adding coverage for a dependent.
Vision Contributions (pretax) Per Pay Period – 24 per year
Employee Paid Voluntary Life | Unum
Benefit Amount - Employee 5x annual salary up to a max of $500,000 | increments of $10,000
Benefit Amount – Spouse Cannot exceed 100% of EE amount up to a max of $250,000 | increments of $5,000
Benefit Amount – Child (age 6 months –26 years) Cannot exceed 100% of EE amount up to a max of $10,000 | increments of $1,000
Life and Accidental Death + Dismemberment
(AD+D)
Voluntary Employee and Spouse Term Life and AD&D Calculations
Benefit Amount / $1,000 x Rate from Table = Monthly Cost Monthly Cost x 12 / 24 = Per Pay Period Deduction
continued Voluntary Term Life and A D&D Rates (Spous e Term Life and A D&D is bas ed on employ ee age)
Benefit Amount / $1,000 x 0.24 = Monthly Cost Monthly Cost x 12 / 24 = Per Pay Period Deduction
EOI (evidence of insurability) is required if your election for you or your eligible dependent(s) exceeds the guaranteed issue maximum or if you add or increase coverage for you or your eligible dependents after your initial eligibility period. Coverage will not be effective until approved by the carrier.
Important Information
COBRA Continuation of Coverage
The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator. For additional information regarding COBRA qualifying events, how coverage is provided and actions required to participate in COBRA coverage, please see your Human Resources department
Newborns’ and Mothers’ Health Protection Act
The group health coverage provided complies with the Newborns’ and Mothers’ Health Protection Act of 1996 Under this law group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable ) In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
Premium Assistance under Medical and CHIP
If you or your children are eligible for Medicaid or CHIP (Children’s Health Insurance Program) and you are eligible for health coverage from your employer, your State may have a premium assistance program that can help you pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employersponsored health coverage but need assistance in paying their health premiums If you or your dependents are already enrolled in Medicaid or CHIP you can contact your State Medicaid or CHIP office to find out if premium assistance is available If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, you can contact your State Medicaid or CHIP office or dial 1877-KIDS NOW or www insurekidsnow gov to find out how to apply If you qualify, you can ask the State if it has a program that might help you pay the premiums for an employer-sponsored plan Please see Human Resources for a list of state Medicaid or CHIP offices to find out more about premium assistance
Special Enrollment Events
An Eligible Person and/or Dependent may also be able to enroll during a special enrollment period. A special enrollment period is not available to an Eligible Person and his or her dependents if coverage under the prior plan was terminated for cause, or because premiums were not paid on a timely basis
An Eligible Person and/or Dependent does not need to elect COBRA continuation coverage to preserve special enrollment rights Special enrollment is available to an Eligible Person and/or Dependent even if COBRA is elected Please be aware that most special enrollment events require action within 30 days of the event. Please see Human Resources for a list of special enrollment opportunities and procedures
Women’s Health and Cancer Rights Act
If you have had or are going to have a mastectomy , you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA) For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: All stages of reconstruction of the breast on which the mastectomy has been performed; Surgery and reconstruction of the other breast to produce a symmetrical appearance; and Prostheses and treatment of physical complications of the mastectomy, including lymphedemas These benefits will be provided subject to deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan If you would like more information on WHCRA benefits, call your plan administrator
Important Information
The Genetic Information Nondiscrimination Act (GINA) prohibits health benefit plans from discriminating on the basis of genetic information in regards to eligibility, premium and contributions. This generally also means that private employers with more than 15 employees, its health plan or “business associate” of the employer, cannot collect or use genetic information, (including family medical history information) The once exception would be that a minimum amount of genetic testing results make be used to make a determination regarding a claim You should know that GINA is treated as protected health information (PHI) under HIPAA The plan must provide that an employer cannot request or require that you reveal whether or not you have had genetic testing; nor can your employer require that you participate in a genetic test. An employer cannot use any genetic information to set contribution rates or premiums
Since key parts of the health care law took effect in 2014, there is 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. If your employer offers health coverage that meets the “minimum value” plan standard, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer’s health plan The “minimum value” plan standard is set by the Affordable Care Act Your health plans offered by Passion, Inc are ACA compliant plans (surpassing the “minimum value” standard), thus you would not be eligible for the tax credit offered to those who do not have access to such a plan
NOTE: If you purchase a health plan through the marketplace instead of accepting health coverage offered by your employer, then you will lose the employer contribution to the employer offered coverage Also, this employer contribution, as well as your employee contribution to employer offered coverage, is excluded from income for Federal and State income tax purposed
USERRA Notice
The Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) established requirements that employers must meet for certain employees who are involved in the uniformed services In addition to the rights that you have under COBRA, you (the employee) are entitled under USERRA lo continue the coverage that you (and your covered dependents, if any) had under the Passion, Inc. plan. You Have Rights Under Both COBRA and USERRA. Your rights under COBRA and USERRA are similar but not identical Any election that you make pursuant to COBRA will also be an election under USERRA, and COBRA and USERRA will both apply with respect to the continuation coverage elected If COBRA and USERRA give you different rights or protections, the law that provides the greater benefit will apply The administrative policies and procedures described in the attached COBRA Election Notice also apply to USERRA coverage, unless compliance with the procedures is precluded by military necessity or is otherwise impossible or unreasonable under the circumstances.
Definitions
"Uniformed services" means the Armed Forces, the Army National Guard, and the Air National Guard when an individual is engaged in active duty for training, inactive duty training, or full-time National Guard duty (i e , pursuant to orders issued under federal law), the commissioned corps of the Public Health Service, and any other category of persons designated by the President in time of war or national emergency.
"Service in the uniformed services" or "service" means the performance of duty on a voluntary or involuntary basis in the uniformed services under competent authority, including active duty, active and inactive duty for training, National Guard duty under federal statute, a period for which a person is absent from employment for an examination to determine his or her fitness to perform any of these duties, and a period for which a person is absent from employment to perform certain funeral honors duty. It also includes certain service by intermittent disaster response appointees of the National Disaster Medical System
Important Information
Duration of USERRA Coverage
General Rule: 24-Month Maximum When a covered employee takes a leave for service in the uniformed services, USERRA coverage for the employee (and covered dependents for whom coverage is elected) can continue until up to 24 months from the date on which the employee's leave for uniformed service began. However, USERRA coverage will end earlier if one of the following events takes place:
A premium payment is not made within the required time; You fail to return to work or to apply for reemployment within the time required under USERRA (see below) following the completion of your service in the uniformed services; You lose your rights under USERRA as a result of a dishonorable discharge or other conduct specified in USERRA.
Notice of Privacy Provision
This Notice of Privacy Practices (the "Notice") describes the legal obligations of Passion, Inc (the "Plan") and your legal rights regarding your protected health information held by the Plan under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH Act) Among other things, this Notice describes how your protected health information may be used or disclosed to carry out treatment, payment, or health care operations, or for any other purposes that are permitted or required by law We are required to provide this Notice of Privacy Practices to you pursuant to HIPAA
The HIPAA Privacy Rule protects only certain medical information known as "protected health information." Generally, protected health information is health information, including demographic information, collected from you or created or received by a health care provider, a health care clearinghouse, a health plan, or your employer on behalf of a group health plan, from which it is possible to individually identify you and that relates to:
• Your past, present, or future physical or mental health or condition;
• The provision of health care to you; or
• The past, present, or future payment for the provision of health care to you
If you have any questions about this Notice or about our privacy practices, please contact your Human Resources department. The full privacy notice is available with your Human Resources Department.
Important Notice About Your Prescription Drug Coverage & Medicare
CREDITABLE
Please read this notice carefully and keep it where you can find it This notice has information about your current prescription drug coverage with Passion, Inc and about your options under Medicare’s prescription drug coverage This information can help you decide whether or not you want to join a Medicare 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.
There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:
• Medicare prescription drug coverage became available in 2006 to everyone with Medicare You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage All Medicare 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
• Passion, Inc. has determined that the prescription drug coverage offered by the Ameriben/ Anthem plans are, on average for all plan participants, expected to pay out as much as 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
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 Passion, Inc coverage will not be affected Please review prescription drug coverage plan provisions/options under the certificate booklet provided by Ameriben / Anthem See pages 7- 9 of the CMS Disclosure of Creditable Coverage To Medicare Part D Eligible Individuals Guidance which outlines the prescription drug plan provisions/ options that Medicare eligible individuals may have available to them when they become eligible for Medicare Part D. If you do decide to join a Medicare drug plan and drop your current Passion, Inc coverage, be aware that you and your dependents may not 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 Passion, Inc 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 by 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 your carrier.
NOTE: You’ll getthisnoticeeachyear Youwillalsogetitbeforethe nextperiodyoucanjoinaMedicaredrugplan,andifthiscoverage through Passion, Inc changes Youalsomayrequestacopyofthis noticeatanytime
More detailed information about Medicare plans that offer prescriptiondrugcoverageisinthe “Medicare & You” handbook You’ll get a copy of the handbook in the mail every year from Medicare You may alsobe contacted directly by Medicaredrug plans For more information about Medicare prescription drug coverageVisitwwwmedicaregov CallyourStateHealthInsurance AssistanceProgram(seetheinsidebackcoverofyourcopyofthe “Medicare & You” handbook for their telephone number) for personalized help Call 1-800-MEDICARE (1-800-633-4227) TTY usersshouldcall1-877-486-2048.Ifyouhavelimitedincomeand resources, extra help paying for Medicare prescription drug coverageisavailable For information about this extra help,visit SocialSecurityonthewebatwwwsocialsecuritygov,orcallthem at1-800-772-1213(TTY1-800-325-0778)
Remember:KeepthisCreditableCoveragenotice Ifyoudecideto join one of the Medicare drug plans, you may be required to provideacopyofthisnoticewhenyoujointoshowwhetherornot youhavemaintainedcreditablecoverageand,therefore,whether ornotyouarerequiredtopayahigherpremium(apenalty)
