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2020 | Benefit Guide Class 1 Eligible Employees THE TOOLS FOR A HEALTHY WORKFORCE


Welcome to your benefits! Making the right choice is important. This Benefit Guide will help you understand the benefit choices you can make before your enrollment deadline. We want our team and their families to be happy and healthy. Whether that means keeping fit, eating right, knowing your health risks or changing lifestyle behaviors, your well-being is important to you, your family, your coworkers and Ultra Steak.

At Ultra Steak, we are committed to a comprehensive employee benefit program that helps our employees stay healthy, feel secure, and maintain a work/life balance. Whether staff members are already enrolled in Ultra Steak benefits, learning more about benefits makes it easier for you to use them. This Benefit Guide will help you understand your benefits as you consider your choices.

The information in this Benefit Guide is presented for illustrative purposes and is based on information provided by the employer and 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 Benefit Guide 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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Table of Contents

Section One | About Your Benefits

Section Three | Financial Protection Benefits

How to Enroll

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Life and AD&D

18

Who is Eligible

6

Disability

19

What to Keep in Mind

7

Employee Assistance Program

20

What to Know

8

Voluntary Accident

21

Voluntary Critical Illness

22

PerkSpot

23

Section Two | Health Benefits Medical Benefits

10

myCigna Registration

11

MotivateMe

13

Contacts - Page 24 Cigna Allied Affordable Care Plan Allstate PerkSpot Human Resources

Importance Of Preventive Care 14 Dental

15

Vision

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Section 1 | About Your Benefits


How to Enroll 2020 Open Enrollment

November 18 - November 25 All Eligible employees must enroll! *Current benefits will not roll over to 2020 if not you do not enroll*

Before You Start: 1. Review the plan options within this benefits guide to determine who is an eligible dependent and which plan you would like to enroll in to best fit your needs. 2. Have the following personal information for you and the eligible family member(s) you are enrolling: • Legal names • Dates of birth • Social security numbers • Names and addresses of beneficiaries for life insurance

To Enroll: 1. Go to MyPay at https://hralliance.net/ee to log in 2. You may start your enrollment under the To Do tab or the Benefits tab 3. Go through the enrollment step by step as instructed on the screen 4. Print the submission confirmation for recordkeeping in case of future discrepancies

Need help? • For log in help or password reset, contact your manager or supervisor. • For additional benefits information E-mail benefits@ultrasteak.com 5


Who is Eligible Eligible Employee •

The following employee groups who work an average of 30 hours or more per week: • Exempt employees of Ultra Steak, CMS, Ultra Steak Affiliates, Aspen Creek, and Texas Roadhouse • Non-exempt support staff of Ultra Steak, CMS, and Ultra Steak Affiliates • Non-exempt kitchen & service managers of Aspen Creek and Texas Roadhouse • Non-exempt assistant kitchen & service managers of Aspen Creek and Texas Roadhouse

Eligible Spouse •

Legal spouse of the same or opposite sex.

Eligible Dependents •

Employee or employee’s spouse’s children, which include natural children, stepchildren, legally adopted children, children from whom you have a legal guardianship up to age 26, and a child of any age who resides with you and who has medically certified as disabled prior to his/her 26th birthday and who is primarily dependent upon your support.

When Can You Make Benefit Changes? Open Enrollment: Your once-a-year opportunity to change plans, add or drop eligible dependents from coverage, and change your coverage levels. The only other opportunity you have to make changes is if you experience a Qualifying Life Event. Qualifying Life Events (QLE): A qualified change in status during the year such as marriage, divorce, birth or adoption, a change in your or your spouse’s employment, takes place. Benefit changes will be effective the day of the QLE, as long as you submit changes within 30 days from the date of your qualified life event. Examples of Qualifying Life Events include: • Birth or adoption of a child(ren) • Marriage or divorce • Death of spouse and/or dependent(s) • Loss or gain of certain types of other coverage • Other events as the Plan Administrator determines to be permitted under I.R.S. Section 125 or other applicable guidelines issued by the Internal Revenue Service If QLEs are not submitted within 30 days, you will have to wait until the next Open Enrollment to make benefit changes, or add or drop dependent coverage. Within 30 days following the qualifying life event, please contact Human Resources or submit your changes through https://hralliance.net/ee.

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What to Keep in Mind You will need to go online to enroll in: • • • • • •

Medical Dental Vision Voluntary Life Accident Critical Illness

You must enroll in company-sponsored plans: • Basic Life and AD&D • Short-Term Disability • Long-Term Disability Beneficiary designation is required for Basic Life and AD&D and Voluntary Life plans.

*Current benefits will not roll over to 2020 if not you do not enroll!

What to Keep in Mind 1. Budget vs. Preferences: When choosing a medical plan, it is important to look at your budget, your preferences, and the age and health of you and your covered dependents (if applicable). Cost of coverage, including payroll contributions and how you and the plan pay for services throughout the year, are all things you should consider when selecting a plan. 2. Network Coverage: • Cigna Open Access Plus (OAP) – You are not required to select a Cigna OAP network provider, but it is your responsibility to know whether the physician, hospital, or other medical provider you select for your care is a participating OAP network provider. If you elect to receive care from an out-of-network provider, your deductible and out-of-pocket costs will be higher. • Allied Minimum Value Plan (MVP) – Unlike the Cigna plan, there is no provider network with this MVP. However, this plan is based on the Medicare-allowable fee schedule. Members may be balancedbilled if providers do not accept the Medicare reimbursement level. 3. Preventive Care: Preventive care, which is 100% covered under the medical plans, allows you to obtain early diagnosis and treatment to help avoid more serious health problems. Your preventive care services may include immunizations, physical exams, lab work, and X-rays. During your preventive visit, your doctor will determine what tests or health screenings are right for you based on factors like age, gender, overall health status, personal health history, and current health condition. 7


What to Know

Key Words Out of Pocket Maximum: The most you will have to pay for covered medical expenses in a plan year. Deductible: The amount you will pay before your insurance will pay any medical expenses. Premium: The amount deducted from your paycheck to purchase health coverage. Copay: A specified amount that you are required to pay at the time of each doctor/hospital visit or drug prescription. Employee Coinsurance: The percentage of a medical expense that you are required to pay after your deductible is met.

Take Note 1. Individual vs. Family: When looking at your medical plan, the Annual Deductible and Out-of-Pocket Maximum are listed with an individual or family option. If you choose coverage for Employee only, you would look at the individual deductible and out-of-pocket maximum. If you choose coverage for Employee + Spouse, Employee + Child(ren) or Family, you would look at the family deductible and out-of-pocket maximum. 2. Prescription Tier Descriptions • Generic (Lowest Copay) – Offers the greatest value within a therapeutic class. Some of these are generic equivalents of brand-name drugs. • Formulary (Medium Copay) – Generally more affordable brand name drugs. Other drugs are on this tier because they are “preferred” within their therapeutic classes, based on clinical effectiveness and value. • Non-Formulary (Highest Copay) – Higher cost brand names. Some non-formulary drugs may have generic equivalents. In addition, some drugs on this tier may have been evaluated to be less cost effective than equivalent drugs on lower tiers.

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Section 2 | Health Benefits


Medical Benefits Please see Plan Document for full details. Plan Features

Cigna OAP (In-Network)

Allied MVP

Annual Deductible • Individual • Family

$1,000 $2,000

$2,000 $4,000

Out-of-Pocket Max (OOPM) Including Deductible • Individual • Family

$2,000 $4,000

$6,450 $12,900

Preventive Care Services

100% covered, deductible waived

100% covered, deductible waived

Physician’s Office Visits: Primary Care and Specialist Care

$20 copay

90% after deductible has been met

Urgent Care Services

$35 copay

90% after deductible has been met

80% after deductible

90% after deductible has been met

Emergency Room Services

$150 copay

90% after deductible has been met

Prescription Drug Out-ofPocket Maximum • Individual • Family

$1,000 $2,000

Inpatient and Outpatient Services

Generic

$10 copay

Formulary

$25 copay

Non-Formulary

$40 copay

No separate Prescription Drug Out-Of-Pocket Maximum Discount Drug Card (drugs to be purchased from pharmacy at reduced cost and submitted for reimbursement at 90%)

Spousal Surcharge If your spouse is eligible for another employer’s medical insurance but they want to enroll in Ultra Steak’s Cigna plan, you will be subject to a $100 spousal surcharge per month. When you enroll your spouse online, you will be required to answer questions about your spouse’s eligibility for benefits.

Cigna OAP (Per Pay)

Cigna OAP with Spousal Surcharge

Allied MVP (Per Pay)

Employee

$90.63

$90.63

$48.85

Employee + Spouse

$190.33

$236.48

$449.85

Employee + Child(ren)

$163.14

$163.14

$449.85

Family

$290.62

$336.18

$449.85

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myCigna Registration If you enroll in the Cigna plan, make sure to register on the myCigna.com and/or download the myCigna app.

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myCigna Registration (continued)

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Cigna MotivateMe If you enroll in the Cigna medical plan, you can earn rewards for taking healthy actions.

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Importance of Preventive Care Did you know that if you are covered under one of the medical plans, your innetwork preventive care is covered at 100%? That’s right! That means $0 out of your pocket for your annual physicals and preventive exams and screenings. These exams and screenings help identify health risks early on, and in turn keep those out-of-pocket medical expenses in check.

out of your pocket*

Many exams involve running a complete panel of bloodwork. When was the last time you had your blood pressure checked? Your glucose levels? Knowing these critical numbers is the most important part of the visit. If you don’t know them, then it’s time to make an appointment! If you have additional questions about preventive care services, talk to your doctor or call Cigna.

INTERVENTION quit smoking lose weight

CANCER

TESTS BLOOD PRESSURE

SCREENINGS

DIABETES

MAMMOGRAMS AND COLONOSCOPIES

CHOLESTEROL

SCREENINGS SEXUALLY TRANSMITTED INFECTIONS

REGULAR VISITS WELL-WOMAN, WELL-BABY, AND WELL-CHILD

VA C C I N AT I O N S FLU, PNEUMONIA, MEASLES, POLIO, MENINGITIS AND OTHER DISEASES

* Some restrictions may apply. 14

H

eat healthy identify depression reduce alcohol use avoid sexually transmitted diseases

CARE FOR HEALTHY PREGNANCIES


Dental Please see Plan Document for full details.

Benefit Deductible • Individual • Family

$50 $150

Calendar Year Maximum Benefit

$1,000 per person

Preventive and Diagnostic Services Routine oral exams, bitewing x-rays, routine cleanings Basic Dental Service Emergency palliative treatment, fillings, simple extractions, oral surgery Major Dental Services Inlays, onlays, crowns and bridges, dentures Orthodontic Services - children only

100%, no deductible 80% after deductible 50% after deductible 50% to a lifetime maximum of $1,000

Cost Per Pay Employee

$3.74

Employee + Spouse

$25.85

Employee + Child(ren)

$26.98

Employee + Family

$41.94

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Vision Please see Plan Document for full details.

Exam (Once every 12 months)

Network Providers $10 copay

Non-Network Providers Up to $45

$25 copay

Single Vision: Up to $32 Bifocal: Up to $55 Trifocal: Up to $65 Lenticular: Up to $80

If medically necessary: Covered If elective: $150 retail allowance

If medically necessary: up to $210 If elective: Up to $120

$150 retail allowance

Up to $83

Prescription Lenses (Once every 12 months)

Contact Lenses (In lieu of glasses; once every 12 months) Frames (Once every 24 months)

Cost Per Pay Employee

$2.73

Employee + Spouse

$5.21

Employee + Child(ren)

$5.21

Employee + Family

$8.47

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Section 3 | Financial Protection Benefits


Life and AD&D Insurance Basic Life and AD&D

Ultra Steak provides Basic Life and Accidental Death and Dismemberment (AD&D) insurance at no cost to you. Benefits reduce when you reach a certain age. Please contact Human Resources for additional detail. Benefit Amount Owners, Executives and Market Partners

$500,000

Directors, Managing Partners and Supervisors

$250,000

Support Staff, Managers, and Assistant Managers

$100,000

Voluntary Life and AD&D

This is a voluntary plan that provides you the option to purchase coverage beyond the Basic Term Life Insurance provided by Ultra Steak. The premiums increase with age and coverage level, and are paid by the employee via payroll deduction. Benefits reduce when you reach a certain age. Please contact Human Resources for additional details. Voluntary Employee Life and AD&D Coverage Voluntary Dependent Life Coverage (Spouse)* Voluntary Dependent Life Coverage (Child)*

Benefit Amount Increments of $10,000 not to exceed 5 times your base salary and $200,000 Increments of $5,000 not to exceed 50% of employee amount, and overall maximum of $50,000 14 days to 6 months: $250 6 months to age 19 or 25 if full time student: Increments of $2,500 up to $10,000

* Spouse and child voluntary life coverage cannot be purchased without also purchasing Employee voluntary life coverage

Age Price

Per Pay Cost for Employee per $1,000 of Life and AD&D Insurance Coverage <30 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 $0.053 $0.058

$0.072

$0.099 $0.150 $0.275 $0.422

$0.496

$0.879 $1.692

Per Pay Cost for Spouse per $1,000 of Life and AD&D Insurance Coverage Age <30 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 Price

$0.060 $0.065

$0.079

$0.107 $0.157 $0.282 $0.430

$0.504

Voluntary Child Life Coverage Amount

Employee Contribution Per Pay

$2,500

$0.23

$5,000

$0.46

$7,500

$0.69

$10,000

$0.92

$0.887

If you have any questions about these benefits, please contact Human Resources. 18

75+ $4.470


Disability Insurance To assist our employees during illness or injury, Ultra Steak offers short term and long term disability benefits. If you have any questions about these benefits, please contact Human Resources. To file a Short Term Disability claim, call Cigna at (800) 362-4462.

Voluntary Short Term Disability (STD) This benefit is paid for entirely by Ultra Steak. - Begins: on the 15th day of disability - Max Monthly Benefit: 60% of weekly salary up to a max of $2,000 - Max Benefit Duration: 26 weeks

Long Term Disability (LTD) This benefit is paid for entirely by Ultra Steak. - Begins: after the 180th day of disability - Max Monthly Benefit: 60% of salary up to $7,500 per month - Max Benefit Duration: Social Security Normal Retirement Age

Please see Plan Document for full details. 19


Employee Assistance Program (EAP) Ultra Steak provides an Employee Assistance Program (EAP) at no cost to you. This program offers 24/7 telephonic support, as well as three face-to-face visits to counselors who will provide confidential guidance and resources to help you and your family resolve personal problems that affect your lives. This program includes the following: • Work-Life Resources: 24/7 telephonic support to provide information and referrals on child care, parenting, elder care, pet care, and other personal convenience matters. • Legal Resources: Free 30-minute consultation, and up to a 25% discount on select fees. • Financial Resources: Free 30-minute consultation, and a 25% discount on select fees with network providers.

Call (800) 538-3543 or visit www.cignabehavioral.com/cgi to get started 20


Voluntary Accident Insurance Accident Insurance can help you pay for out-of-pocket expenses and medical costs beyond what is covered under your health insurance plan. Here are examples of the coverage amounts for certain accidents: Plan Feature Accidental Death Common Carrier Accidental Death Dismemberment

Dislocations or Fracture

Covered Individual

Coverage Amount

Employee Spouse Child

$30,000 $15,000 $7,500

Employee Spouse Child Employee Spouse Child Employee Spouse Child

$150,000 $75,000 $37,500 Up to $30,000 Up to $15,000 Up to $7,500 Up to $3,000 Up to $1,500 Up to $750

Initial Hospital Confinement Hospital Confinement (per day)

$750 $150

Intensive Care (per day)

$300

Ambulance â&#x20AC;˘ Ground â&#x20AC;˘ Air

$150 $450

Medical Expenses Coverage Tier

Up to $375 Employee Contribution (Per pay)

Employee

$6.76

Employee + Spouse

$12.56

Employee + Child(ren)

$13.58

Employee + Family

$16.44

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Voluntary Critical Illness Insurance Critical Illness Insurance can help you pay for expenses that arenâ&#x20AC;&#x2122;t covered under your health insurance plan by paying you a lump-sum cash benefit. Here are examples of the coverage amounts for certain illnesses: Critical Illness Heart Attack (100%)

Coverage Amount $10,000

Stroke (100%)

$10,000

Coronary Artery Bypass Surgery (25%)

$2,500

Major Organ Transplant (100%)

$10,000

End Stage Renal Failure (100%)

$10,000

Waiver of Premium (EE Only)

Yes

Cancer Critical Illness Invasive Cancer (100%)

Coverage Amount $10,000

Carcinoma in Situ (25%)

$2,500

Supplemental Critical Illness Benign Brain Tumor (100%)

Coverage Amount $10,000

Coma (100%)

$10,000

Complete Blindness (100%)

$10,000

Complete Hearing Loss (100%)

$10,000

Paralysis (100%)

$10,000

Non-Tobacco Employee Contribution (Per Pay) Issue Age EE, EE+CH EE + SP, FAM 18-29 $2.70 $4.44

Tobacco Employee Contribution (Per Pay) EE, EE + CH EE + SP, FAM $3.84 $6.16

30-39

$4.54

$7.22

$6.92

$10.78

40-49

$8.10

$12.56

$14.12

$21.58

50-59

$14.10

$21.56

$23.62

$35.82

60-63

$22.72

$34.48

$38.70

$58.46

64+

$29.62

$44.82

$51.04

$76.96

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PerkSpot Welcome to your Employee Discount Program!

Get Started Today!

ultrasteak.perkspot.com 23


Benefit Contacts Cigna (800) 244-6224 www.cigna.com or

• Medical • Prescription

• • • •

Dental Vision Basic and Voluntary Life Short-Term and Long-Term Disability • Employee Assistance Program (EAP)

or Allied (855) 442-3477 www.alliedbenefit.com Dental, Vision: (800) 244-6224 www.cigna.com STD Claims: (800) 362-4462 Life and Disability Questions: Contact Human Resources EAP: (800) 538-3543 or visit www.cignabehavioral.com/cgi

• Accident Insurance • Critical Illness Insurance

(800) 255-7828 www.allstate.com

• PerkSpot

www.ultrasteak.perkspot.com

• Human Resources

Human Resources (317) 588-6208 benefits@ultrasteak.com

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Profile for MJ Insurance

Ultra Steak Benefit Guide 2020 Class 1  

Ultra Steak Benefit Guide 2020 Class 1