2020 open enrollment guide - explain my benefits · 2019. 10. 30. · this brochure summarizes the...

2020 Open Enrollment Guide

Open Enrollment Guide 2

Table of Contents Benefit Resource Center ......................................................................................................................................... 3

A Message to Our Employees ................................................................................................................................. 4

Benefits for You & Your Family ............................................................................................................................... 5

EMB Enroll ............................................................................................................................................................... 6

Medical Benefits Overview ..................................................................................................................................... 7

Prescription Discounts .......................................................................................................................................... 12

Baer's Furniture’s Wellness Initiatives .................................................................................................................. 13

Health Savings Accounts ....................................................................................................................................... 14

Health Savings Accounts – Frequently Asked Questions ...................................................................................... 15

Health Savings Accounts – Frequently Asked Questions ...................................................................................... 16

Health Savings Accounts Banking Information ..................................................................................................... 17

Dental Insurance ................................................................................................................................................... 18

Vision Insurance .................................................................................................................................................... 19

Voluntary Life and Accidental Death & Dismemberment Insurance ................................................................... 20

Voluntary Disability Insurance .............................................................................................................................. 21

Voluntary Critical Illness ....................................................................................................................................... 22

2020 Payroll Deductions ....................................................................................................................................... 23

Supplemental Benefits .......................................................................................................................................... 24

Supplemental Benefits .......................................................................................................................................... 25

Contacts ................................................................................................................................................................ 36

Important Legal Notices ........................................................................................................................................ 37

This brochure summarizes the benefit plans that are available to Baer's Furniture Company, Inc. eligible employees and their dependents. Official plan documents, policies and certificates of insurance contain the details, conditions, maximum benefit levels and restrictions on benefits. These documents govern your benefits program. If there is any conflict, the official documents prevail. These documents are available upon request through the Human Resources Department. Information provided in this brochure is not a guarantee of benefits.


Benefit Resource Center

Call the Benefit Resource Center (“BRC”), We’re Here to Help!

We speak insurance. Our Benefits Specialists can help you with:

� Deciding which plan is the best for you

� Benefit plan & policy questions

� Eligibility & claim problems with carriers

� Information about claim appeals & process

� Allowable family status election changes

� Transition of care when changing carriers

� Claim escalation, appeal & resolution

� Medicare basics with your employer plan

� Coordination of benefits

� Finding in-network providers

� Access to care issues

� Obtaining case management services

� Group disability claims

� Filing claims for out-of-network services

[email protected] | Toll Free: 855-874-0835 | Monday-Friday 8am-5pm EST


A Message to Our Employees

The Benefits Open Enrollment Period Is Here! Baer’s Furniture is committed to provide a comprehensive benefits package to our employees for the

following year. As healthcare costs continue to rise, Baer’s Furniture strives to keep pace with healthcare

trends and to provide choices for medical insurance to meet the needs of our employees and to manage the

increased costs. Considering present inflation and increased government regulation, we are very pleased to

announce a minimal annual increase in the cost of medical insurance for our employees. All other insurance

plans will continue for the next year with no increase in current premium costs. We will have our open

enrollment meetings to provide information about our benefits at all our locations. It is very important that all

our employees attend a meeting to be informed. Family members are welcome to attend as well. We will

continue to use our online benefits system with Explain My Benefits to renew enrollment or make changes in

benefits for 2020. All the information and pricing will be available when the portal is open during the first two

weeks of December 2019.

The Baer Family.


Benefits for You & Your Family

Baer's Furniture is pleased to announce our 2020

benefits program. Please read the information

provided in this guide carefully. For full details

about our plans, please refer to the summary plan

descriptions. Listed below are the Baer's Furniture

benefits available during open enrollment:

� Medical

� Dental

� Vision

� Short Term Disability

� Long Term Disability

� Voluntary Life

� Wellness Plan

� Accident Insurance

� Critical Illness

Who is Eligible? Full-Time employees working at least 30 hours a

week and their eligible dependents may participate

in the Baer's Furniture benefit program.

Generally, for the Baer's Furniture benefit program,

dependents are defined as:

� Your spouse, unless you are legally

separated or divorced, domestic partner

same or opposite gender;

� Your married or unmarried natural

children, step-children living with you,

legally adopted children and any other

children for 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.

When and How Do I Enroll? Open enrollment meetings will begin to be

conducted in November. Our enrollment portal will

open in December.

All eligible employees are required to complete the

enrollment process, even if you do not wish to make

any changes to your benefits.

You can sign up for Benefits at any of the following

times:

• After completing initial eligibility period;

• During the annual open enrollment period;

• Within 30 days of a qualified family-status

change.

If you do not enroll at one of the above times, you

must wait for the next annual open enrollment

period.

When is My Coverage Effective? The effective date for your benefits is January 1,

2020. If you are a New Hire your benefit effective

date will be first of the month following 60 days.

Changing Coverage During the Year You can change your coverage during the year when

you experience a qualified change in status, such as

marriage, divorce, birth, adoption, placement for

adoption, or loss of coverage. The change must be

reported to the Human Resources Department

within 30 days of the event. The change must be

consistent with the event.

For example, if your dependent child no longer

meets eligibility requirements, you can drop

coverage only for that dependent.


EMB Enroll

WHEN IS OPEN ENROLLMENT?

Online Benefit Enrollment system open: December 2nd – 13th

All Enrollments must be completed using EMB ENROLL.

HOW TO ENROLL IN YOUR BENEFITS

1. Access the On-Line Enrollment at: www.explainmybenefits.com/baers

2. Review your Benefit Guide along with the brochures and videos on the page.

3. Click the Open Enrollment Button

4. Please follow the instructions on the page and proceed to your enrollment

5. Complete your enrollment

6. IMPORTANT: RECORD YOUR CONFIRMATION NUMBER _________________________

IMPORTANT THIS YEAR: All benefit eligible employees must confirm a benefit enrollment using EMB ENROLL whether you are electing benefits, keeping benefits the same, making changes, or waiving all benefits. This is a requirement this year.

HOW YOU CAN BE PREPARED?

1. Please have the dates of birth and social security numbers of dependents when you enroll. 2. Look for emails, brochures and other information to be distributed prior to your Open Enrollment!!! 3. View Benefit Resource Portal for more information about the Open Enrollment Process, review your

benefit guide and learn about the voluntary benefits offered.

www.explainmybenefits.com/baers


Medical Benefits Overview Baer's Furniture offers 2 medical plans the HNOnly (Core Plan) and the HNOption w/ HSA (Buy Up). Both plans

utilize the Aetna provider network. In order to verify a participating provider please visit ww.mymeritain.com,

Scroll down to the Provider Network Finder, enter provider network name: Aetna. Once you click Aetna, start

your search. One can chose from provider types, hospitals and facilities, medical conditions or procedures.

The chart on the following page is a brief outline of the plan. Please refer to the summary plan description for

complete plan details.

Benefit Coverage

Dual Option

HNOnly (Core Plan) HNOption w/HSA (Buy Up)

Schedule of Benefits In-Network Benefits

In-Network

Plan Year / Contract Year Basis Calendar Year Calendar Year

Deductible (Individual / Family) $5,500 / $11,000 $2,500 / $5,000

Maximum Out-of-Pocket

(Individual / Family) $6,350 / $12,700 $4, 500 / $ 6,750

Out of Pocket Max Includes Deductible, coinsurance,

copays & Rx Deductible, coinsurance,

copays & Rx

Lifetime Major Medical Maximum Unlimited Unlimited

Coinsurance 50% 80%

Preventative

Wellness 100% 100%

Copays

Open Access Yes Yes

Office Visits/Consultations for

llness/Injury $35 copay 20% after CYD

Specialist Visits $75 copay 20% after CYD

Inpatient Hospital 50% after CYD 20% after CYD

Outpatient Surgery 50% after CYD 20% after CYD

Emergency Room $300 copay 20% after CYD

Urgent Care $50 copay 20% after CYD

Complex Diagnostic $300 copay 20% after CYD

Prescriptions*

RX Deductible (per calendar year) $200 Individual / $400 Family CYD

Retail Pharmacy (30 Day Supply) $15/$20/50% 30%/30%/50%

Mandatory Mail Order

(90 day supply) $30/$40/50% 30%/30%/50%

Out of Network

Deductible (Ind/Fam)

Not Covered

$5,000 / $10,000

Maximum Out-of-Pocket (Ind/Fam) $10,000 / $20,000

Lifetime Major Medical Maximum Unlimited

Coinsurance 60%

CYD: Calendar Year Deductible

*After two retail fills for maintenance medication the member would be notified that they must use the mail order pharmacy or

local CVS retail pharmacy for any future fills of their maintenance medication.

Reach a doctor 24/7The Teladoc® solutionBaer’s Furniture Company, Inc.

Teladoc is the on-demand healthcare solu on that gives you the medical care you need, when you need it. You can talk to a doctor any me, anywhere about non-emergent medical condi ons.

Benefits of Teladoc Saves me and money

There is no copay for this service Quicker recovery from illness Convenient prescrip ons Choice of consulta on method Great health means peace of mind

With Teladoc, you can talk to a doctor 24/7/365 by phone, online video or mobile app. Use Teladoc for medical advice and care when:

Your primary care doctor is not open. You are at home, traveling or do not want to take

me off work to see a doctor. You need a prescrip on or refi lls*.

*Please note, there is no guarantee you will be prescribed medica on.

Highly qualified, experienced doctorsWhen you use Teladoc, your medical questions will be answered by a highly qualified doctor. Teladoc doctors are:

Experienced—with an average of over 10–15 years in practice.

Progressive—using the latest technology to provide excellent care.

U.S. board certified and state licensed. Specially trained in telemedicine.

Contact a Teladoc physician at 1.800.362.2667, or by visiting www.MyDrConsult.com.

© 2015 Teladoc, Inc. All rights reserved. Teladoc and the Teladoc logo are registered trademarks of Teladoc, Inc. and may not be used without wri en permission. Teladoc does not replace the primary care physician. Teladoc does not guarantee that a prescrip on will be wri en. Teladoc operates subject to state regula on and may not be available in certain states. Teladoc does not rescribe DEA controlled substances, non therapeu c drugs and certain other drugs which may be harmful because of their poten al for abuse. Teladoc physicians reserve the right to deny care for poten al misuse of services. Teladoc phone consulta ons are available 24 hours, 7 days a week while video consulta ons are available during the hours of 7am to 9pm, 7 days a week.

Our members love Teladoc“We had a good experience with the doctor. She called and talked to me, and gave great service. I had no problem picking up my prescription. This is a really good service.”

Allergies Bronchi s Cold/fl u Headaches/migraines Eye/ear infec on

Rash/skin infec ons Sinus infec ons Stomachache/

diarrhea Urinary tract

infec ons

Common conditions treated:

There’s more than one way to reach a doctor

By phone. Just call 1.800.362.2667.

Online. Simply request a video consulta on online at www.MyDrConsult.com.

On the go. You can download the Teladoc mobile app by visi ng the App Store or Google Play.

10/22/2019

Baer's Furniture Prescription Drug Benefits

Maintenance Medications Requirement – Effective January 1, 2019 Effective January 1, 2019, all maintenance medications must be obtained through CVS or WellDyneRx Prescription Delivery Service pharmacy provider. WellDyneRx offers free delivery of medications to your home, work or doctor’s office. If you and/or your covered dependent(s) are taking a maintenance medication, please follow the important steps detailed below to start filling your prescriptions with WellDyneRx.

Important Things to Do

1. Register for WellDyneRx Prescription Delivery Service

You will need to create an account by providing your insurance,

contact, health, and payment information. Register online or by mail:

• Online: www.WellDyneRx.com

• Mail: Complete and mail the enclosed registration form. You

will need to provide a payment method before ordering your

first prescription by entering a credit, debit, FSA, or HSA card

online or by calling Member Services at 1-888-479-2000.

2. Ask your doctor to send a NEW 90-day prescription to

WellDyneRx. Prescriptions cannot be transferred from a retail

pharmacy.

• E-prescribe: WellDyneRx Prescription Delivery

• Fax: 1-877-221-1259 or 1-888-830-3608

For more information about WellDyneRx Prescription Delivery Service, visit our website at www.WellDyneRx.com. Sincerely,

WellDyneRx

Enclosure: WellDyneRx Prescription Delivery Registration Form

Maintenance Medications

Maintenance medications are prescription drugs commonly used to treat chronic or long-term conditions. These conditions usually require regular, daily use of medicines. Examples of maintenance medications are those used to treat conditions such as:

• Asthma

• Depression

• Diabetes

• High blood pressure

• High cholesterol

Medicines can be expensive, and WellDyneRx provides ways to help members manage their prescription drug costs. Your benefit plan uses one of these options, called step therapy.

What is step therapy?Step therapy is a program that helps you and your doctor choose medicine that is right for you.

WellDyneRx has certain medicines that we recommend you try first when treating some health conditions. Trying certain drugs first before trying others is called step therapy.

» Step One Drugs – Lower-cost options This first step requires you to use a lower-cost medicine before you can use a more expensive Step Two drug. The lower-cost options are usually generic medicines. They can provide the same health benefits as higher-cost medicines.

» Step Two Drugs – Brand name drugs Step Two drugs are brand name medicines that usually cost more than Step One or generic medicines. They’re recommended only if a Step One medicine doesn’t work for you.

What if my doctor prescribes a Step Two drug?

When a pharmacist puts your prescription into the system, they receive an alert if the medication is part of the step therapy program.

Your pharmacy will not automatically change your prescription if you have a Step Two drug. Your doctor must write a new prescription for you to switch to a Step One drug. If your doctor thinks a Step One drug is not a good choice for you, they can request approval of a Step Two medicine from WellDyneRx.

If you have questions about your pharmacy benefits, please visit www.WellDyneRx.com and click “Members” or call the Member Services number shown on your member ID card.

UNDERSTANDING STEP THERAPY

Your WellDyneRx Benefit Plan

Member Materials

Your benefit plan uses tools such as step therapy that can help control your costs.

6.2018 © WellDyneRx

For questions, please contact WellDyneRx MemberServices at the number listed on your ID Card.

www.WellDyneRx.com

US Specialty Care, WellDyneRx’s wholly-owned specialty pharmacy, is an industry-leading provider of specialty medications. We are committed to providing personalized care to each member, ensuring they have the tools necessary to understand and manage their condition. We will work with you, your doctors and nursing staff to create a personalized treatment plan that will provide you with the best possible outcomes. Our experienced pharmacy staff will provide you with complete patient support.

Working together to improve your health

US Specialty Care understands that patients who use specialty medications require special, personalized care, that’s why we will pair you with a Patient Care Advocate. Your Patient Care Advocate will work with you to deliver the right care. Our pharmacy fully supports you through:

» Medication delivery: We know that getting your medication on time is important. Your medications will be carefully packaged in a temperature controlled pack and discreetly shipped to ensure confidentiality and stability.

» Insurance and financial assistance coordination: US Specialty Care will coordinate your benefits and insurance coverage, assist with obtaining prior authorizations, and identify additional options to lower costs. When possible, they will direct you to grants and/or other financial assistance to help bridge benefit gaps.

» Expert Support: Once you enroll, you will be assigned a Patient Care Advocate who is familiar with your disease state. Your Patient Care Advocate will provide you with the support needed to manage your condition and schedule prescription refills.

Getting startedTo get started, ask your doctor to send your prescription to US Specialty Care electronically or by fax to 800-530-8589. Your doctor can also speak with our experienced team of pharmacists by calling 800-641-8475. Your Patient Care Advocate will contact you to help you enroll in our specialty pharmacy program, schedule your medication delivery, and help you manage your medical supplies.

With US Specialty Care, you’ll have the peace of mind knowing that you have access to the medications, tools and resources to manage your health. To learn more about US Specialty Care, contact us at 800-641-8475 or visit www.USSpecialtyCare.com.

ADVANCED SPECIALTY PHARMACY SERVICES

9.2018 © WellDyneRx

www.USSpecialtyCare.com


Prescription Discounts

Baers Furniture is always looking to protect its employees pockets when it can. Take a look at the various

pharmacy discounts available to you simply for being a consumer. You do not need to be a member of the

medical plan in order to participate in any of these programs. For more information please visit the websites

below and keep in mind that certain restrictions will apply.

Publix offers a variety of prescription medications free for as long as your doctor prescribes them, 30 days’

worth at a time. Those include:

• Metformin (for diabetes).

• Lisinopril (for high blood pressure).

• Amlodipine (for high blood pressure and angina).

Publix also offers a free 14-day supply of some common antibiotics:

• Amoxicillin

• Ampicillin

• Sulfamethoxazole/Trimethoprim (SMZ-TMP)

• Ciprofloxacin (excluding Ciprofloxacin XR)

• Penicillin VK

Visit: www.publix.com

Walmart $4 Prescriptions. Save big on 30-day generic medications & spend just $10 on 90-day

prescriptions. No insurance necessary. Find your medication list at: www.walmart.com

GoodRx gathers current prices and discounts to help you find the lowest cost pharmacy for your

prescriptions. The average GoodRx customer saves $276 a year on their prescriptions.

• GoodRx is 100% free.

• No personal information required.

Visit their website at www.goodrx.com or download their app.


Baer's Furniture’s Wellness Initiatives

As most of you now know, Baer’s Furniture launched a new employee wellness program in 2015 which

offered employees the opportunity to save on their future medical premiums.

Participating in the Baer’s Furniture Wellness Program helps all of us better manage or avoid chronic

conditions such as hypertension, diabetes, high cholesterol, and depression, which can subtract years from

our lives. The journey toward a better lifestyle is never easy, however with support, commitment, and

consistency, each of us can achieve our individual health and wellness goals. Today, it is more important than

ever to take an active role in your personal health and therefore, Baer’s Furniture wants you to know that we

are here to provide the tools and incentives to help.

Going to see your doctor for a yearly wellness exam is one of the best ways to manage your health. Preventive

care often leads to identifying health problems early and increasing your chances for successful treatment

and/or cure. Now that these services are covered by all health plans, it's just that much easier to achieve and

maintain optimal health.

Just 3 steps to improve your health and save…..

Step 1 Complete an annual physical with your primary care physician (PCP). Your doctor will need to

complete & sign the company-provided Physician Form to confirm you had your annual physical. Physician

visits completed between November 1, 2019 & October 31, 2020 will be accepted. If enrolled in the health plan, your annual physical and standard preventive lab work should be covered in full once every 365 days.

Step 2 Complete the Preventive Screening form. Take the preventive screening form to your scheduled

doctor’s visit to be completed and signed by the attending physician. One exam needs to be completed

between November 1, 2019 & October 31, 2020. For the list of screenings that are accepted please refer to

the wellness packet.

Step 3 Send both forms to Wellworks on or prior to November 1, 2020. Submit BOTH your physician form and

preventive screening form together to Wellworks. See instructions listed on the forms regarding how to send

them.

*New hires: Hired after 5/1/20 will receive incentive.

By completing the above steps, you will receive…

Incentives: For completing the annual physical and the preventive screening form, you will receive a discount

on your medical premiums beginning January 1, 2021.

Your health plan is committed to helping you achieve your best health. Rewards for participating in a wellness program are available

to all employees. If you think you might be unable to meet a standard for a reward under this wellness program, you might qualify for

an opportunity to earn the same reward by different means. Contact us 954-946-8001 ext. 215 and we will work with you (and, if you

wish, with your doctor) to find a wellness program with the same reward that is right for you in light of your health status.

Be Healthy & Save!


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 an 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: $3,550 in 2020

· Family coverage: $7,100 in 2020

Individuals ages 55 and older can also make additional “catch-up” contributions. The maximum annual catch-

up contribution is $1,000.


Health Savings Accounts – Frequently Asked Questions

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.


Health Savings Accounts – Frequently Asked Questions

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-of-pocket 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.


Health Savings Accounts 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 any time.


Dental Insurance

Baer's Furniture offers two dental plans through Guardian. Guardian’s DHMO 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.

Benefit Coverage

Guardian

DHMO 30 Low Plan

Guardian

DPPO K7 Buy Up Plan

Schedule of Benefits In-Network Benefits Out-of-Network Benefits

Deductible

Individual $0 $50 $100

Family $0 $150 $300

Waived for Preventive Care N/A Yes Yes

Annual Maximum

Per Person Unlimited $1,000 $1,000

Diagnostic & Preventive CDT Codes No Charge Deductible Waived Deductible Applies

Exams D0120

Cleanings D1110

Fluoride D1203

X-Rays D0272

Sealants D1351

$0 100% 80%

Regular Restorative Services CDT Codes Various copays apply Deductible Applies Deductible Applies

Amalgam Fillings D2150

Extractions Single Tooth D7140

Endodontics (Root Canal) D3320

Periodontics (Gum Disease) D4211

$0

$0

$120 - $170

$0

80% 70%

Major CDT Codes Various copays apply Deductible Applies Deductible Applies

Crowns D2791

Bridges D6211

Dentures D5110

$395

$381 - $575

$381 - $575

50%

40%

Orthodontia

Age Limitation Child to age 19 Not Covered Not Covered

Lifetime Maximum $2,500 - $2,800


Vision Insurance

Baer's Furniture provides Vision Insurance through Guardian. The chart below is a brief outline of the plan.

Please refer to the summary plan description for complete plan details.

Benefit Coverage Guardian

Vision

Copay In-Network Benefits Out-of-Network Benefits

Routine Exams (Annual) $15 copay $50 Allowance

Vision Materials

Materials Copay $25 copay

Lenses Covered every 12 months

Single

$25 copay

$48 Allowance

Bifocal $67 Allowance

Trifocal $86 Allowance

Contact Lenses Covered every 12 months

Elective 85% of amount over $120 $105 Allowance

Medically Necessary $0 $210 Allowance

Frames Covered every 24 months

Covered Services 80% of amount over $120 $48 Allowance

Lens Options

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. (Tints, coating, UV, anti-reflective lenses, polycarbonate & progressive lenses)

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.


Voluntary Life and Accidental Death & Dismemberment Insurance

Baer’s Furniture provides all active employees working 30 or more hours per week the option to purchase life

insurance coverage through a group plan with Mutual of Omaha.

The chart below provides an overview of the plan.

Benefit Coverage Voluntary Term Life/AD&D

Eligible Employees All Full-Time employees working 30 hours or more

Employee Minimum: $10,000, Maximum: 5x annual salary, up to $300,000

Spouse Minimum: $5,000, Maximum: 100% of employee benefit, up to $150,000

Dependent Life Minimum: $10,000, Maximum: 100% of employee benefit, up to $10,000

Guarantee Issue

Employee: 5x annual salary, up to $200,000

Spouse: 100% of employee benefit, up to $30,000

Dependent: 100% of employee benefit

Accelerated Death Benefit 80% death benefit, $240,000 max

Waiver of Premium Benefit Yes

Portable / Convertible Yes, without having to provide Evidence of Insurability

Benefit Reduction At age 70, amounts reduce to 65%

At age 75, amounts reduce to 30%

AD&D

(Accident Death & Dismemberment)

For you and your spouse;

The Principal Sum amount is equal to the amount of life insurance benefit.

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 may 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.


Voluntary Disability Insurance

Baer’s Furniture provides all active employees working 30 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 Insurance Baer's Furniture offers a short-term disability option through Mutual of Omaha Insurance Company This

benefit covers 60% of your weekly base salary up to $1,000/week. The benefit begins after 14 days of injury or

illness and lasts up to 11 weeks. Please see the summary plan description for complete plan details.

Benefit Coverage Short-Term Disability

Employee Definition All Full-Time employees working 30 hours or more

Weekly Benefit 60% of your before-tax weekly earnings, up to $1,000

Elimination Period On the 15th day of your disabling injury or illness

Pre-Existing Limitation Any condition you receive medical attention for in the 3 months prior to your effective date of

coverage that results in a disability during 6 months of coverage, would not be covered.

Duration of Benefits Up to 11 weeks

Long-Term Disability Insurance Baer's Furniture offers long-term income protection through Mutual of Omaha Insurance in the event you

become unable to work due to a non-work-related illness or injury. This benefit covers 60% of your monthly

base salary up to $5,000 Benefit payments begin after 90 days of disability. See Certificate of Coverage for

benefit duration. Please see the summary plan description for complete plan details.

Benefit Coverage Long-Term Disability

Employee Definition All Full-Time employees working 30 hours or more

Monthly Benefit 60% of your before-tax monthly earnings, up to $5,000

Elimination Period 90 days

Duration of Benefits If you become disabled prior to age 62, benefits are payable to age 65, your Social Security

Normal Retirement Age or 3.5 years, whichever is longest. At age 62 (and older), the benefit

period will be based on a reduced duration schedule.

Own Occupation 2 years

Pre-Existing Conditions Any condition you receive medical attention for in the 3 months prior to your effective date of

coverage that results in a disability during 12 months of coverage, would not be covered.

The only time you can enroll in 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.


Voluntary Critical Illness

The signs pointing to a critical illness are not always clear and may not be preventable, but our coverage can

help offer financial protection in the event you are diagnosed. Mutual of Omaha Insurance group voluntary

critical illness coverage provides a lump-sum cash benefit to help you cover the out-of-pocket expenses

associated with a critical illness.

Benefit Category & Condition Voluntary Critical Illness

Heart/Circulatory:

Heart Attack, Heart Transplant, Stroke:

Heart Valve Surgery, Coronary Artery Bypass, Aortic Surgery:

100%

25%

Organ

Major Organ Transplant/Placement on UNOS List, End-Stage Renal

Failure:

Acute Respiratory Distress Syndrome (ARDS):

100%

25%

Childhood/Developmental (Benefits only available to children)

Cerebral Palsy, Structural Congenital Defects, Genetic Disorders,

Congenital Metabolic Disorders, Type 1 Diabetes:

100%

Cancer

Cancer (Invasive)

Bone Marrow Transplant

Carcinoma in Situ, Benign Brain Tumor

100%

50%

25%

Coverage Minimum Guarantee Issue Maximum

For you (Available as a flat benefit) $10,000 $10,000 $10,000

Spouse (Available as a flat benefit) $10,000 $10,000 $10,000

Child(ren) (Benefit for each child) N/A $3,000 $3,000


2020 Payroll Deductions

The Charts below show the bi-weekly payroll deduction amounts for each of the benefits offered.

Medical

Employee Bi-Weekly Contributions

Aetna HNOnly

with wellness

HNOnly

without wellness

HN Option

HSA with wellness

HN Option

HSA without wellness

Employee $44.00 $64.00 $72.00 $104.00

Employee & Spouse $399.00 $432.00 $408.00 $506.00

Employee & Child(ren) $298.00 $354.00 $357.00 $453.00

Family $623.00 $720.00 $714.00 $800.00

Dental


Guardian DHMO 30 Low Plan DPPO K7 Buy Up Plan

Employee $5.62 $15.96

Employee & Spouse $11.24 $33.40

Employee & Child(ren) $12.51 $40.02

Family $18.14 $53.44

Vision


Vision

Employee $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


Supplemental Benefits

Accident and Universal Life Customer Service: 1-800-918-8877 Claims: 1- 877-201-9373

Trustmark Employee Employee &

Spouse

Employee &

Children Family

Bi-weekly Rates $9.50 $16.14 $22.92 $29.58

Sample rates are shown for illustrative purposes only; actual payroll deduction amount may vary based on rounding calculations.

American Public Life Group Hospital Indemnity Insurance. Customer Service & Claims: 1-800-256-8606

Bi-Weekly Rates Employee Employee &

Spouse

Employee &

Children Family

Plan 1 $9.87 $18.35 $13.27 $21.44

Plan 2 $14.99 $27.81 $20.89 $33.35

The premium and amount of benefits vary dependent upon plan selected at time of application. Premium includes the plan selected and any

applicable rider premium.

*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.


Supplemental Benefits Baer’s Furniture provides Supplemental Limited Benefit Group Hospital Indemnity insurance through

American Public Life. This benefit helps cover out-of-pocket expenses related to Hospital Confinement and/or

medically necessary Outpatient Treatment related to an injury or sickness.

Summary of Benefits Plan 1 Plan 2 Daily Hospital Confinement Benefit (per day) $100 $100 Benefit Riders Intensive Care/Coronary Care Unit Rider (per day)

$200

$200 Annual First Occurrence Hospital Rider (per calendar year) $1,000 $2,000 Base Policy Daily Hospital Confinement Benefit-Pays a daily indemnity benefit when a covered person is confined as an inpatient in a Hospital for at least 24

hours for a covered injury or sickness. The maximum benefit period for any one period of confinement is 180 days unless the confinement is due to a

mental or emotional disorder. When the confinement is due to a mental or emotional disorder, the maximum benefit period for any one period of

confinement will not exceed 30 days. The Hospital confinement must be at the direction of or under the supervision of a physician for benefits to be

payable. Exclusions APL does not cover Hospital confinements or other losses in the policy or riders: due to hernia, adenoids, tonsils, varicose veins and appendix. For

the complete listing of exclusions please refer to your benefit booklet from American Public Life. Termination of Policy APL may end the coverage of a policyholder if fewer persons are insured than the policyholder’s application requires. The policyholder or APL may

terminate the policy on any premium due date after the first policy anniversary date, subject to 60 days written notice. Premium Changes The premium rates may be changed by APL on the first anniversary date of the policy or any premium due date thereafter. Benefit Rider(s) All riders are part of the policy/certificate to which it is attached and are subject to all the provisions, conditions, limitations and exclusions of the

policy/certificate that are not in conflict with the provisions of the rider. Intensive Care/Coronary Care Unit Rider Pays a daily indemnity benefit when a covered person is confined in a Hospital’s intensive care or coronary care unity due to a covered injury or

sickness. The maximum benefit period for any one period of confinement in an intensive care or coronary care unit is 20 days. Each period of

confinement must be separate by at least 30 days. This benefit pays in addition to the Hospital confinement benefit. A step-down unit is not

considered an intensive care unit. Annual First Occurrence Hospital Rider Pays an indemnity benefit the first time in a calendar year a covered person is confined as an inpatient in a Hospital. The Hospital confinement must

be due to a covered injury or sickness; begin while this rider is in force; and be at the direction of and under the supervision of a physician. The

benefit is payable once each calendar year for each covered person and the first day of confinement must be in a calendar year the rider is in effect

in order for the benefit to be payable. Termination of Rider(s) Coverage The rider(s) will terminate: when the insured’s coverage terminates under the policy/certificate to which the rider is attached; when any premium for

the rider is not paid by the end of the grace period; or when the insured gives APL a written request to terminate the rider. Coverage on a dependent

terminates under the rider when the dependent ceases to meet the definition of dependent as defined in the policy/certificate.

2020 Special Benefits Opportunity for Baer’s Furniture EmployeesProtect your family, finances and future with these valuable benefits from Trustmark.

Voluntary Benefits

See reverse for more information on available benefits.

Trustmark Universal LifeEvents® Insurance with Accelerated Death Benefit for Long-Term Care ServicesTwo-in-one protection to fit your needs.Trustmark Universal LifeEvents is permanent life insurance. In addition to providing a death benefit, it can help pay for long-term care services. Universal LifeEvents® gives you a higher death benefit during your working years and an accelerated death benefit that never reduces. Your price won’t increase due to age, and your policy builds cash value over time.

Death benefit reduces to one-third at the latter of age 70 or the 15th policy anniversary.

Universal LifeEvents

Death Benefit

Living Benefits

Before Age 70 $50,000 $50,000

After Age 70 $16,667 $50,000

Benefit amounts shown are samples and not a guarantee.

You get a higher benefit for the same rate with Universal LifeEvents than you would with a standard plan. It’s more affordable because the death benefit reduces after age 70 (when you may need it less.) Your benefits to help with long-term care never reduce.

Up to double your max life insurance benefit!Example: $50,000 policy

$50,000Collect 4% of your benefit amount per month for up to 25 months to help pay for long-term care services.

$50,000 Plus, if you collect living benefits, your full death benefit is still available for beneficiaries.

$100,000 Total max benefit!

©2019 Trustmark Insurance Company A112-2424_Baers (10-19)

Products underwritten by Trustmark Insurance Company and Trustmark Life Insurance Company of New York.

Rated A- (Excellent) for financial strength by A.M. Best.

trustmarksolutions.com

You care.We listen.

Products underwritten by Trustmark Insurance Company, Lake Forest, Illinois. In New York, Universal Life and Universal LifeEvents are underwritten by Trustmark Life Insurance Company of New York, Albany, New York. Trustmark®, LifeEvents®, Trustmark Critical HealthEvents® and Trustmark Paycheck Protect® are registered trademarks of Trustmark Insurance Company. Trustmark Hospital StayPaySM is a trademarks of Trustmark Insurance Company. Underwriting conditions may vary, and determine eligibility for the offer of insurance. A waiting period may apply before benefits are payable. Benefits may not be available in all states; benefits, availability, exclusions and limitations may vary by state and may be named differently. Pre-existing condition limitations may apply. For more details on costs, coverage details and available benefits, speak with a benefit counselor or enroller and/or consult additional pre-enrollment materials; you may also write to the company. Your policy/certificate and outline of coverage, if applicable, will contain complete information.

Trustmark®: 100+ Years of Service and Financial StrengthTrustmark was founded in 1913 by railroad employees who wanted to provide more security for injured or disabled coworkers. They formed an association called Brotherhood of All Railway Employees and for more than a century since, Trustmark has provided reliable insurance protection to workers and families across the nation. With a personalized, caring approach to insurance, Trustmark today remains committed to the same principles that inspired those founding workers: helping people increase their well-being and achieve peace of mind.

Take your policy with you if you change jobs or retire.

Easy payments with automatic payroll deduction.

Apply for family members.

Benefits paid in addition to any other insurance you have.

Cash benefits to use however you like.

With all Trustmark plans:

Trustmark Accident InsuranceAccidents happen – you can be prepared.Accident insurance from Trustmark pays you to help with the cost of covered accidents, at work or outside of work. It can help with stuff like medical co-pays and deductibles, getting to and from the hospital, and your everyday expenses. It covers accidental injuries like broken bones, burns and concussions. It also covers services like using an ambulance, checking into a hospital and getting physical therapy. Benefits are paid in cash, and you can use them for whatever you need most. You can also get paid for certain health screening tests.


Contacts

Have Questions? Need Help? Baer's Furniture is excited to offer access to the USI Benefit Resource Center (BRC), which is designed to

provide you with a responsive, consistent, hands-on approach to benefit inquiries. Benefit Specialists are

available to research and solve elevated claims, unresolved eligibility problems, and any other benefit issues

with which you might need assistance. The Benefit Specialists are experienced professionals and their primary

responsibility is to assist you.

The Specialists in the Benefit Resource Center are available Monday through Friday 8:00am to 5:00pm Eastern

& Central Standard Time at 855-874-0835 or via e-mail at [email protected]. If you need assistance outside

of regular business hours, please leave a message and one of the Benefit Specialists will promptly return your

call or e-mail message by the end of the following business day.

Please note, the BRC cannot answer any questions for Supplemental Benefits with American Public Life,

Trustmark or Critical Illness with Mutual of Omaha, as these products can be specific to the individual.

Please contact those carriers directly.

Please contact Human Resources to complete any changes to your benefits that are not related to your initial

or annual enrollment.

Carrier Customer Service

BENEFITS PLAN CARRIER PHONE NUMBER WEBSITE

Medical: HMO, PPO & RX Meritain Health - An Aetna Company 1-800-925-2272 www.meritain.com

Dental: DHMO & DPPO Guardian 1-888-600-1600 www.guardiananytime.com

Vision Guardian 1-888-600-1600 www.guardiananytime.com

Voluntary Life AD&D Mutual of Omaha Insurance 1-800-877-5176 www.mutualofomaha.com

Short Term Disability (STD) Mutual of Omaha Insurance 1-800-877-5176 www.mutualofomaha.com

Long Term Disability (LTD) Mutual of Omaha Insurance 1-800-877-5176 www.mutualofomaha.com

Voluntary Critical Illness Mutual of Omaha Insurance 1-800-877-5176 www.mutualofomaha.com

Supplemental Benefits Trustmark Insurance Company 1-800-918-8877 www.trustmarksolutions.com

Supplemental Benefits American Public Life 1-800-256-8606 www.ampublic.com


Important Legal Notices

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 was performed;

� Surgery and reconstruction of the other breast to produce a symmetrical appearance;

� Prostheses; and

� Treatment of physical complications of the mastectomy, including lymphedema. These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan.

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 child 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).

If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).

In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

Further, if you decline enrollment for yourself or eligible dependents (including your spouse) while Medicaid coverage or coverage under a State CHIP program is in effect, you may be able to enroll yourself and your dependents in this plan if:

� coverage is lost under Medicaid or a State CHIP program; or � you or your dependents become eligible for a premium assistance subsidy from the State.

In either case, you must request enrollment within 60 days from the loss of coverage or the date you become eligible for premium assistance. To request special enrollment or obtain more information, contact person listed at the end of this summary.

Under the ACA, dependent children are covered by the group health plan until age 26. Baer’s Furniture group health plan extends dependent coverage

beyond the ACA requirements, to age 30, so long as the child is covered as a student. If your child has extended coverage as a student but loses their

student status because they take a medically necessary, leave of absence from school your child may continue to be covered under the plan for up to

one year from the beginning of the leave of absence. This is available if, immediately before the first day of the leave of absence, your child was (1)

covered under the plan and (2) enrolled as a student at a post-secondary educational institution (includes colleges and universities). To obtain more

information, contact person listed at the end of this summary.

Baer’s Furniture wellness program is a voluntary wellness program available to all employees. The program is administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease, including the Americans with Disabilities Act of 1990, the Genetic Information Nondiscrimination Act of 2008, and the Health Insurance Portability and Accountability Act, as applicable, among others. If you choose to participate in the wellness program you will be asked to complete a voluntary health risk assessment or "HRA" that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (e.g., cancer, diabetes, or heart disease). You will also be asked to complete a biometric screening, which will include a blood test for total cholesterol, HDL, LDL, Triglyercides, Glucose. You are not required to participate in the blood test or other medical examinations. However, employees who choose to participate in the wellness program will receive incentives. Although you are not required to participate in the biometric screening (onsite or with your doctor), only employees who do so will receive the incentive.

MICHELLE'S LAW DISCLOSURE

NOTICE OF SPECIAL ENROLLMENT RIGHTS

NEWBORNS ACT DISCLOSURE - FEDERAL

THE WOMEN’S HEALTH CANCER RIGHTS ACT OF 1998 (WHCRA)

NOTICE REGARDING WELLNESS PROGRAMS


Protections from Disclosure of Medical Information. We are required by law to maintain the privacy and security of your personally identifiable health information. Although the wellness program and Baer’s Furniture may use aggregate information it collects to design a program based on identified health risks in the workplace, the wellness program will never disclose any of your personal information either publicly or to the employer, except as necessary to respond to a request from you for a reasonable accommodation needed to participate in the wellness program, or as expressly permitted by law. Medical information that personally identifies you that is provided in connection with the wellness program will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment. Your health information will not be sold, exchanged, transferred, or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the wellness program, and you will not be asked or required to waive the confidentiality of your health information as a condition of participating in the wellness program or receiving an incentive. Anyone who receives your information for purposes of providing you services as part of the wellness program will abide by the same confidentiality requirements. The only individual(s) who will receive your personally identifiable health information is (are) your doctor, a health coach or a registered nurse to provide you with services under the wellness program. In addition, all medical information obtained through the wellness program will be maintained separate from your personnel records, information stored electronically will be encrypted, and no information you provide as part of the wellness program will be used in making any employment decision. Appropriate precautions will be taken to avoid any data breach, and in the event a data breach occurs involving information you provide in connection with the wellness program, we will notify you immediately. You may not be discriminated against in employment because of the medical information you provide as part of participating in the wellness program, nor may you be subjected to retaliation if you choose not to participate. If you have questions or concerns regarding this notice, or about protections against discrimination and retaliation, please contact sue Scovin at [email protected] or at 954-946-8001 ext. 11103 Your health plan is committed to helping you achieve your best health. Rewards for participating in a wellness program are available to all employees. If you think you might be unable to meet a standard for a reward under this wellness program, you might qualify for an opportunity to earn the same reward by different means. Contact Human Resources Office and we will work with you (and, if you wish, with your doctor) to find a wellness program with the same reward that is right for you in light of your health status.

As a participant in the Plan you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (“ERISA”). ERISA provides that all participants shall be entitled to:

Receive Information about Your Plan and Benefits

� Examine, without charge, at the Plan Administrator’s office and at other specified locations, the Plan and Plan documents, including the insurance contract and copies of all documents filed by the Plan with the U.S. Department of Labor, if any, such as annual reports and Plan descriptions.

� Obtain copies of the Plan documents and other Plan information upon written request to the Plan Administrator. The Plan Administrator may make a reasonable charge for the copies.

� Receive a summary of the Plan’s annual financial report, if required to be furnished under ERISA. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report, if any.

Continue Group Health Plan Coverage. If applicable, you may continue health care coverage for yourself, spouse or dependents if there is a loss of coverage under the plan as a result of a qualifying event. You and your dependents may have to pay for such coverage. Review the summary plan description and the documents governing the Plan for the rules on COBRA continuation of coverage rights.

Prudent Actions by Plan Fiduciaries. In addition to creating rights for participants, ERISA imposes duties upon the people who are responsible for operation of the Plan. These people, called “fiduciaries” of the Plan, have a duty to operate the Plan prudently and in the interest of you and other Plan participants. No one, including the Company or any other person, may fire you or discriminate against you in any way to prevent you from obtaining welfare benefits or exercising your rights under ERISA.

Enforce your Rights If your claim for a welfare benefit is denied in whole or in part, you must receive a written explanation of the reason for the denial. You have a right to have the Plan review and reconsider your claim.

Under ERISA, there are steps you can take to enforce these rights. For instance, if you request materials from the Plan Administrator and do not receive them within 30 days, you may file suit in federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $152 per day (up to a $1,527 cap per request), until you receive the materials, unless the materials were not sent due to reasons beyond the control of the Plan Administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, and you have exhausted the available claims procedures under the Plan, you may file suit in a state or federal court. If it should happen that Plan fiduciaries misuse the Plan’s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose (for example, if the court finds your claim is frivolous) the court may order you to pay these costs and fees.

Assistance with your Questions If you have any questions about your Plan, this statement, or your rights under ERISA, you should contact the nearest office of the Employee Benefits and Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits and Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210.

Questions regarding any of this information can be directed to: Ira Baer, Chief Financial Officer

1589 NW 12 Ave, Pompano Beach, Florida 33069 954-946-8007

[email protected]

STATEMENT OF ERISA RIGHTS

WELLNESS PROGRAM DISCLOSURE


THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Your Information. Your Rights. Our Responsibilities. Recipients of the notice are encouraged to read the entire notice. Contact information for questions or

complaints is available at the end of the notice.

Your Rights You have the right to:

• Get a copy of your health and claims records • Correct your health and claims records • Request confidential communication • Ask us to limit the information we share • Get a list of those with whom we’ve shared your information • Get a copy of this privacy notice • Choose someone to act for you • File a complaint if you believe your privacy rights have been violated

Your Choices You have some choices in the way that we use and share information as we:

• Answer coverage questions from your family and friends • Provide disaster relief • Market our services and sell your information

Our Uses and Disclosures We may use and share your information as we:

• Help manage the health care treatment you receive • Run our organization • Pay for your health services • Administer your health plan • Help with public health and safety issues • Do research • Comply with the law • Respond to organ and tissue donation requests and work with a medical examiner or funeral director • Address workers’ compensation, law enforcement, and other government requests • Respond to lawsuits and legal actions

Your Rights When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Get a copy of health and claims records

• You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this.

• We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct health and claims records

• You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to do this.

• We may say “no” to your request, but we’ll tell you why in writing, usually within 60 days. Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

• We will consider all reasonable requests and must say “yes” if you tell us you would be in danger if we do not.


Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations. • We are not required to agree to your request.

Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your health information for up to six years prior to the date you ask, who we shared it with, and why.

• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly. Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

• We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the information at the end of this notice.

• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

• We will not retaliate against you for filing a complaint.

Your Choices For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in payment for your care • Share information in a disaster relief situation If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

• In these cases, we never share your information unless you give us written permission: Marketing purposes Sale of your information

Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Help manage the health care treatment you receive We can use your health information and share it with professionals who are treating you. Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services. Pay for your health services We can use and disclose your health information as we pay for your health services. Example: We share information about you with your dental plan to coordinate payment for your dental work. Administer your plan We may disclose your health information to your health plan sponsor for plan administration. Example: Your company contracts with us to provide a health plan, and we provide your company with certain statistics to explain the premiums we charge.


Run our organization

• We can use and disclose your information to run our organization and contact you when necessary. • We are not allowed to use genetic information to decide whether we will give you coverage and the price of that

coverage. This does not apply to long term care plans. Example: We use health information about you to develop better services for you. How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html. Help with public health and safety issues We can share health information about you for certain situations such as:

• Preventing disease • Helping with product recalls • Reporting adverse reactions to medications • Reporting suspected abuse, neglect, or domestic violence • Preventing or reducing a serious threat to anyone’s health or safety

Do research We can use or share your information for health research. Comply with the law We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. Respond to organ and tissue donation requests and work with a medical examiner or funeral director

• We can share health information about you with organ procurement organizations. • We can share health information with a coroner, medical examiner, or funeral director when an individual die.

Address workers’ compensation, law enforcement, and other government requests We can use or share health information about you:

• For workers’ compensation claims • For law enforcement purposes or with a law enforcement official • With health oversight agencies for activities authorized by law • For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions We can share health information about you in response to a court or administrative order, or in response to a subpoena. Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information. • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your

information. • We must follow the duties and privacy practices described in this notice and give you a copy of it. • We will not use or share your information other than as described here unless you tell us we can in writing. If you

tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our web site (if applicable), and we will mail a copy to you.


Important Notice from Baer’s Furniture About Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it. This notice has information about your current

prescription drug coverage with Baer’s Furniture 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:

1. 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.

2. Baer’s Furniture has determined that the prescription drug coverage offered by the offered plan is, 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 15thto 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 Baer’s Furniture coverage will not be affected. You can keep this coverage and it will coordinate with Part D coverage. If you do decide to join a Medicare drug plan and drop your current Baer’s Furniture coverage, be aware that you and your dependents will be able to get this coverage back (during open enrollment or in the case of a special enrollment opportunity).

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 Baer’s Furniture 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 the person listed below for further information 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 Baer’s Furniture 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 the inside back cover of 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 1-877-486-2048. 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 1-800-325-0778).

Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).

Date: January 1, 2020 Name of Entity/Sender: Baer’s Furniture Contact--Position/Office: Ira Baer, Chief Financial Officer Address: 1589 NW 12 Avenue, Pompano Beach, FL 33069 Phone Number: 954-946-8007


Premium Assistance Under Medicaid and the

Children’s Health Insurance Program (CHIP)

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your

state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP

programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance

programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more

information, visit www.healthcare.gov.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, 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, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or

www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you

pay the premiums for an employer-sponsored plan.

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your

employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called

a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for

premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at

www.askebsa.dol.gov or call 1-866-444-EBSA (3272).

If you live in one of the following states, you may be eligible for assistance paying your employer health plan

premiums. The following list of states is current as of January 31, 2020. Contact your State for more information

on eligibility –

ALABAMA – Medicaid FLORIDA – Medicaid Website: http://myalhipp.com/ Phone: 1-855-692-5447

Website: http://flmedicaidtplrecovery.com/hipp/ Phone: 1-877-357-3268

ALASKA – Medicaid GEORGIA – Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: [email protected] Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

Website: Medicaid www.medicaid.georgia.gov - Click on Health Insurance Premium Payment (HIPP) Phone: 404-656-4507

ARKANSAS – Medicaid INDIANA – Medicaid Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)

Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/ Phone: 1-877-438-4479 All other Medicaid Website: http://www.indianamedicaid.com

IOWA – Medicaid KANSAS – Medicaid Website: http://dhs.iowa.gov/hawk-i Phone: 1-800-257-8563

Website: http://www.kdheks.gov/hcf/ Phone: 1-785-296-3512

KENTUCKY – Medicaid NEW HAMPSHIRE – Medicaid

Website: https://chfs.ky.gov Phone: 1-800-635-2570

Website: https://www.dhhs.nh.gov/oii/hipp.htm Phone: 603-271-5218 Toll-Free: 1-800-852-3345, ext 5218


LOUISIANA – Medicaid NEW JERSEY – Medicaid and CHIP Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 1-888-695-2447

Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710

MAINE – Medicaid NEW YORK – Medicaid

Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1-800-442-6003 TTY: Maine relay 711

Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831

MASSACHUSETTS – Medicaid NORTH CAROLINA – Medicaid Website: http://www.mass.gov/eohhs/gov/departments/masshealth/ Phone: 1-800-862-4840

Website: https://dma.ncdhhs.gov/ Phone: 919-855-4100

MINNESOTA – Medicaid NORTH DAKOTA – Medicaid Website: https://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-programs/programs-and-services/other-insurance.jsp

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825

MISSOURI – Medicaid OKLAHOMA – Medicaid and CHIP Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm

Website: http://www.insureoklahoma.org Phone: 1-888-365-3742

MONTANA – Medicaid OREGON – Medicaid and CHIP Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084

Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075

NEBRASKA – Medicaid PENNSYLVANIA – Medicaid Website: http://www.ACCESSNebraska.ne.gov Phone: (855) 632-7633 Lincoln: (402) 473-7000 Omaha: (402) 595-1178

Website: http://www.dhs.pa.gov/provider/medicalassistance/healthinsurancepremiumpaymenthippprogram/index.htm Phone: 1-800-692-7462

NEVADA – Medicaid RHODE ISLAND – Medicaid Medicaid Website: http://dhcfp.nv.gov Medicaid Phone: 1-800-992-0900

Website: http://www.eohhs.ri.gov/ Phone: 855-697-4347

SOUTH CAROLINA – Medicaid VIRGINIA – Medicaid and CHIP Website: https://www.scdhhs.gov Phone: 1-888-549-0820

Medicaid Website: http://www.coverva.org/programs_premium_assistance.cfm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm CHIP Phone: 1-855-242-8282

SOUTH DAKOTA - Medicaid WASHINGTON – Medicaid Website: http://dss.sd.gov Phone: 1-888-828-0059

Website: http://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/premium-payment-program Phone: 1-800-562-3022 ext. 15473


To see if any other states have added a premium assistance program since January 31, 2020, or for more information on special enrollment rights, contact either:

U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/agencies/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565 Paperwork Reduction Act Statement

According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a

collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number.

The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by

OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a

collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also,

notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of

information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512.

The public reporting burden for this collection of information is estimated to average approximately seven minutes per

respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of

this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee

Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue,

N.W., Room N-5718, Washington, DC 20210 or email [email protected] and reference the OMB Control Number 1210-

0137.

OMB Control Number 1210-0137 (expires 12/31/2020)

TEXAS – Medicaid WEST VIRGINIA – Medicaid Website: http://gethipptexas.com/ Phone: 1-800-440-0493

Website: http://mywvhipp.com/ Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)

UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP

Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669

Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf Phone: 1-800-362-3002

VERMONT– Medicaid WYOMING – Medicaid Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427

Website: https://health.wyo.gov/healthcarefin/medicaid/ Phone: 307-777-7531


New Health Insurance Marketplace Coverage

Options and Your Health Coverage

PART A: General Information When key parts of the health care law take effect in 2014, there will be 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.

What is the Health Insurance Marketplace?

The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The

Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible

for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance

coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014.

Can I Save Money on my Health Insurance Premiums in the Marketplace?

You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or

offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on

your household income.

Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?

Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible

for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be

eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does

not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your

employer that would cover you (and not any other members of your family) is more than 9.5% of your household

income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the

Affordable Care Act, you may be eligible for a tax credit.1

Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your

employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer

contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for

Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-

tax basis.

How Can I Get More Information?

For more information about your coverage offered by your employer, please check your summary plan description or

contact Susan Scovin, Human Resources Manager.

The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the

Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health

insurance coverage and contact information for a Health Insurance Marketplace in your area.

1 An employer - sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs

covered by the plan is no less than 60 percent of such costs.

Form Approved OMBNo.1210-0149 (expires 5-31-2020)


PART B: Information About Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to complete an

application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered

to correspond to the Marketplace application.

Here is some basic information about health coverage offered by this employer:

• As your employer, we offer a health plan to:

All employees. Eligible employees are:

Some employees. Eligible employees are:

• With respect to dependents:

We do offer coverage. Eligible dependents are:

We do not offer coverage.

If checked, this coverage meets the minimum value standard*, and the cost of this coverage to you is

intended to be affordable, based on employee wages.

** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium

discount through the Marketplace. The Marketplace will use your household income, along with other

factors, to determine whether you may be eligible for a premium discount. If, for example, your wages vary

from week to week (perhaps you are an hourly employee or you work on a commission basis), if you are

newly employed mid-year, or if you have other income losses, you may still qualify for a premium discount.

If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's the

employer information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your

monthly premiums.

• An employer - sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs

covered by the plan is no less than 60 percent of such costs (Section 36 B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)

1. Employer name

Baer’s Furniture

2. Employer Identification Number (EIN)

59-1212401

3. Employer address

1589 NW 12 Ave

4. Employer phone number

954-946-8007

5. City

Pompano Beach

6. State

Florida

7. ZIP code

33069

8. Who can we contact about employee health coverage at this job?

Ira Baer, Chief Financial Officer

9. Phone number (if different from above) 10. Email address

[email protected]

x

x

Full Time employee working 30 hours or more a week.

Spouse, Domestic Partner (same and opposite gender), natural children, step children, children of domestic partner and adopted

children.

x


Notes


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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2020 open enrollment guide - explain my benefits · 2019. 10. 30. · this brochure summarizes the...

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