benefits at a glance...billed the claim, then contact your doctor or claims advocate at usi. if the...

PLAN YEAR: 1/1/18 – 12/31/18

Benefits at A Glance

Contents & Contact Information

Refer to this list when you need to contact one of your benefit vendors. For general information contact Human Resources.

NEW HIRE ENROLLMENT INFORMATION: page 5Provider Phone Number 1-321-296-8060Provider Web Address www.explainmybenefits.biz/baers

MEDICAL & RX: page 7-8Provider Name Meritain – An Aetna CompanyProvider Phone Number 1-800-925-2272Provider Web Address www.meritain.com

WELLNESS PROGRAM: page 9

HEALTH SAVINGS ACCOUNT (HSA): page 10-13

BENEFIT RESOURCE CENTER (BRC): page 14Provider Name Benefit Resource CenterProvider Phone Number 1-855-USI-6699Provider e-mail Address [email protected]

DENTAL: page 15Provider Name GuardianProvider Phone Number 1-888-600-1600Provider Web Address www.guardiananytime.com

VISION: page 16Provider Name GuardianProvider Phone Number 1-888-600-1600Provider Web Address www.guardiananytime.com

VOLUNTARY TERM LIFE/AD&D: page 17Provider Name Mutual of OmahaProvider Phone Number 1-800-877-5176Provider Web Address www.mutualofomaha.com

VOLUNTARY SHORT TERM AND LONG TERM DISABILITY: page 18Provider Name Mutual of Omaha Provider Phone Number 1-800-877-5176Provider Web Address www.mutualofomaha.com

VOLUNTARY CRITICAL ILLNESS: page 19Provider Name Mutual of OmahaProvider Phone Number 1-800-877-5176Provider Web Address www.mutualofomaha.com

PAYROLL DEDUCTIONS: page 20*Please note that rates for voluntary life, voluntary STD, voluntary LTD and critical care will be available on the EMB enrollment site.

SUPPLEMENTAL BENEFITS page 21-30Provider Name TrustmarkProvider Phone Number 1-800-918-8877Provider Web Address www.trustmarksolutions.com

Provider Name American Public LifeProvider Phone Number 1-800-256-8606Provider Web Address www.ampublic.com

DISCLOSURE NOTICES page 31-42

Your Benefits Plan

Baer's Furniture offers a variety of benefits allowing you

the opportunity to customize a benefits package that

meets your personal needs.

In the following pages, you’ll learn more about the

benefits offered. You’ll also see how choosing the right

combination of benefits can help protect you and your

family’s health and finances – and your family’s future.

Eligible dependents include:

> Your spouse, unless you are legally separated or

divorced;

> 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 Can You Enroll?

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.

Eligibility

All Regular full-time employees are eligible to join the. Benefits Plan on the 1st of the month following 60 days. “Regular Full-Time Employees” must be regularly scheduled and working at least 30 hours per week.

You may also enroll your dependents in the Benefits Plan when you enroll.

Benefit Information

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Benefit Who pays the cost?

Medical Employer & Employee

Dental Employee

Vision Employee

Voluntary Life Employee

Short Term Disability Employee

Long Term Disability Employee

Accident Employee

Critical Illness Employee

Universal Life Events Employee

Choosing Your BenefitsYou must actively choose any benefit that you pay for, or share in the cost with Baer's Furniture.

Your part of the cost is automatically taken out of your paycheck.

Before your taxes are calculated – medical, dental, and vision

Making Changes

Generally, you can only change your benefit choices during the annual benefits enrollment period. However, you may be able to change your benefit choices at anytime if you have a change in status including:

> Your marriage

> Your divorce or legal separation

> Birth or adoption of an eligible child

> Death of your spouse or covered child

> Change in your spouse’s work status that affects his or her benefits

> Change in your work status that affects your benefits

> Change in residence or work site that affects your eligibility for coverage

> Change in your child’s eligibility for benefits

> Receiving Qualified Medical Child Support Order (QMCSO)

If you do not notify Human Resources within 30days of a family status change, you will have towait until the next annual enrollment period tomake benefit changes unless you have anotherfamily status change.

When Coverage EndsCoverage will stop on the last day of the month in which employment with the company ends.

Why do I pay for benefits with before-tax money?

There is a definite advantage to paying for some

benefits with before-tax money:

Taking the money out before your taxes are

calculated lowers the amount of your pay that is

taxable. Therefore, you pay less in taxes.

Key Benefit TermsCOBRA – A Federal law that allows workers and dependents who lose their medical, dental, or vision coverage to continue any of these coverages for a specified length of time by electing and paying for continuation benefits.Coinsurance – The percentage of the medical or dental charge that you pay after the deductible has been met.Copayment – A flat fee that you pay for medical services, regardless of the actual amount charged by your doctor or another provider. This generally applies to physicians’ office visits and prescription drugs.Deductible – The amount you pay toward medical and dental expenses each calendar year before the plan begins paying benefits.Out of Pocket Maximum – The maximum amount you will pay in coinsurance during the calendar year

Benefit Information

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Pre-Existing Conditions LimitationsNoticeEffective 1/1/2014, in accordance with The PatientProtection and Affordable Care Act, there is no longerany pre-existing conditions limitations for newlycovered employees or dependents or currentemployees or dependents covered by the medicalplans.

Frequently Asked Questions About Your Medical Plan

Q. What should I do if I have a problem getting a claim paid?

A. Start by contacting the carrier’s member services number to determine the

nature of the problem. If the issue is the way the doctor or other service provider has

billed the claim, then contact your doctor or Claims Advocate at USI. If the insurance

company has an eligibility issue, contact Human Resources for assistance.

Q. What is the difference between brand formulary, brand non-formulary, and

generic drugs?

A. Brand formulary is a prescription drug that is listed on the formulary (i.e., a list of

prescription drugs covered by the plan). These drugs are protected by a patent issued

to the original innovator or marketer. Brand non-formulary drugs are patent protected

but are not listed. A generic equivalent drug can become available when the patent

protection runs out, and is deemed equal in therapeutic power to the brand name

originals.

Q. When should I go the Urgent Care vs. Emergency Room?

A. For non-life threatening injury/illness after normal doctor’s office hours.

Prescription Drug Benefits at a Reduced Cost – Did you know you can obtain prescription drugs at local retailers at a reduced cost and sometimes even free? Publix offers a variety of generic Oral Antibiotic medications to you absolutely free. Bring in your prescription for an approved medication and receive it FREE, up to a 14-day supply. Publix recently approved a medication for diabetes. Walgreens, WalMart, Winn-Dixie & Sam’s Club also offer generic prescriptions for $4 and a 90 day supply for approx. $10 . Remember DO NOT show your ID card to receive these benefits, or you will be charged your insurances drug rate.

In addition to the network of physicians, hospitals, emergency rooms, and urgent care clinics, you also have the option of going to the convenient care clinics located within some grocery and drug stores, for minor illness such as ear aches, colds, flu and so on. By selecting one of these providers, you pay only the regular office visit copay; a significant savings over the emergency room and urgent care copayments.

Please visit the various websites for locations, hours of operations and scope of services.

CVS Minute Clinic: www.cvs.com

Walgreen’s Take Care Clinic: www.walgreens.com

Getting more from yourHealth Care Dollars

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Member Resources

24-hour access to tools you can really use at www.myMERITAIN.com.

Please note that Meritain is an Aetna Company. The Meritain Health member website, www.myMERITAIN.com, is designed to provide a secure, user and family-friendly, one-stop-shop for you to access the account and claims information you can use to manage your health and wellness.

We’re committed to providing you with all the basics you expect, along with added features to support a healthy lifestyle, assist you with medical decisions, and give insight into the maximization of your healthcare dollars.

Go to www.myMERITAIN.com to log in to our secure site.New users can create an account by following the easy instructions. You’ll need your health plan ID Card the first time.

Return users, just sign in using your username and password. The first time you access the site, you will be prompted to re-register with a new username and password for enhanced security. Then take advantage of the smart, safe resources your health plan offers, right at your fingertips.

Privacy Regulations.Members over 18 years of age have partially protected information according to HIPAA Privacy Regulations. Members over 18 having difficulty creating an account with their SSN, please contact Meritain Health Customer Service at: 1.800.925.2272.

At myMERITAIN.com you can:

Look up health and wellness topics in our online medical library.

Find the status of a claim.

Find network doctors, clinics and hospitals.

Look up prescription and over-the-counter drug information.

Order ID Cards.

Medical Insurance

Baer's Furniture offers 2 medical plans the HNOnly (Core Plan) and the HNOption (Buy Up). Both plans utilize the Aetnaprovider network. In order to verify a participating provider please visit www.mymeritain.com, Scroll down to the ProviderNetwork Finder, enter provider network name: Aetna. Once you click Aetna, start your search. One can chose fromprovider types, hospitals and facilities, medical conditions or procedures.

The chart below provides a brief comparison of the plans. This chart is intended only to highlight the benefits availableand should not be relied upon to fully determine your coverage. If the below illustration of benefits conflicts in any waywith the Summary Plan Description (SPD), the SPD shall prevail. It is recommended that you review your exactdescription of services and supplies that are covered, those which are excluded or limited, and other terms and conditionsof coverage.

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Dual Option

HNOnly (Core Plan) HNOption H.S.A. (Buy-up)

In-Network non-embedded

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 IncludesDed, coinsurance,

copays & RxDed, coinsurance,

copays & RxLifetime Major Medical Maximum Unlimited Unlimited

Coinsurance 50% 80%Preventive

Wellness 100% 100%Co-pays

Open Access Yes Yes

Office Visits/Consultations for Illness/Injury $35 copay 20% after CYD

Specialist Visits $75 copay 20% after CYDInpatient Hospital 50% after CYD 20% after CYD

Outpatient Surgery 50% after CYD 20% after CYDEmergency Room $300 copay 20% after CYD

Urgent Care $50 copay 20% after CYDOP Major Diagnostics

Complex Diagnostic $300 copay 20% after CYDPrescriptions*

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

N/C

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

Health Savings Accounts(HSA)

Health Savings AccountsA 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 a 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.

HDHPsYou must have coverage under the Baer's Furniture HDHP to open and contribute to an HSA.

HSA ContributionsYou 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: $3,450 in 2018 · Family coverage: $6,900 in 2018

Individuals ages 55 and older can also make additional “catch-up” contributions. The maximum annual catch-up contribution is $1,000.

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Frequently Asked Questions About HSA Plan UsageHow 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.

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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.

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Frequently Asked Questions About HSA Plan Usage - continued

HSA Banking Information

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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 anytime.

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.

Guardian DHMO U30Low Plan

DPPO K7Buy Up Plan

CDT Codes In-Network In-Network Out-of Network

Deductible

Individual No Deductible $50 $100 Family No Deductible $150 $300

Annual Maximum

Individual Unlimited $1,000

Diagnostic & PreventativeDeductible

WaivedDeductible

AppliesExams D0120 No Charge

100% 80%

Cleanings D1110 No ChargeFluoride D1203 No ChargeX-Rays D0272 No Charge

Sealants D1351 No Charge

Regular Restorative Services Deductible AppliesAmalgam Fillings D2150 No Charge

80% 70%Extractions - Single Tooth D7140 No ChargeEndodontics (Root Canal) D3320 $120 - $170Periodontics ( Gum Disease) D4211 No Charge

Major Services Deductible AppliesCrowns D2791 $395.00

50% 40%Bridges D6211 $381 - $575Dentures D5110 $381 - $575

Orthodontics

Lifetime Maximum $2,500-$2,800Not Covered

Age Limitation Child to age 19

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“This document reflects highlights of Baer’s Furniture benefits program. It is not intended to provide complete plan description. In the event of any contradictions or disputes as to the terms contained in this material and the legal plan documents, the legal plan document will govern.”

Vision Insurance

Baer's Furniture offers a vision plan through Guardian. This vision plan provides coverage both in and out of network.The chart below provides a brief overview of the plan.

GuardianVision

In-Network Out-of-Network

Lenses

Single $25 copay $48 allowance

Bifocal $25 copay $67 allowance

Trifocal $25 copay $86 allowance

Contact Lenses 85% of amount over $120 $105 allowance

Frames 80% of amount over $120 $48 allowance

Exams $15 copay $50 allowance

Frequency

Exam Once every 12 months

Lenses or contact lenses Once every 12 months

Frame Once every 24 months

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

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.

Additional PairsCourtesy discount on a second pair of eyeglasses. This discount is available for 12 months after the covered eye exam and available through the DavisVision 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.

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Voluntary Term Life Insurance/AD&D

Baer’s Furniture provides all active employees working 30 or more hours per week the option to purchase lifeinsurance coverage through a group plan. The chart below provides an overview of the plan.

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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 eligibleto enroll. If you do not enroll then and later decide that you would like to enroll, you will be required to complete amedical questionnaire and go through medical underwriting. The insurance carrier reserves the right to declinecoverage based on medical information obtained on the medical questionnaire.

Mutual of Omaha Voluntary Term Life/AD&D

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

Employee MinimumMaximum

$10,000 5x annual salary, up to $300,000

SpouseMinimumMaximum

$5,000100% of employee’s benefit, up to $150,000

Dependent LifeMinimumMaximum

$10,000100% of employee benefit, up to $10,000

Employee Guarantee Issue 5 times annual salary, up to $200,000

Spouse Guarantee Issue 100% of employee’s benefit, up to $30,000

Dependent Guarantee Issue 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 ReductionAt 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.


Voluntary Disability Insurance

Baer’s Furniture provides all active employees working 30 or more hours per week the option to purchase Short Termand Long Term Disability coverage through a group plan. When you enroll in short term or long term disability you paythe full cost through payroll deductions.

In the event you become disabled from a non work-related injury or sickness, disability benefits are provided as asource of income. You are not eligible to receive short-term disability benefits if you are receiving workers’compensation benefits.

The only time you can enroll in guaranteed issue Short Term or Long Term Disability is at the date you first becomeeligible to enroll. If you do not enroll then and later decide that you would like to enroll, you will be required to a completea medical questionnaire and go through medical underwriting. The insurance carrier reserves the right to decline coveragebased on medical information obtained on the medical questionnaire.

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Mutual of Omaha Voluntary Long Term Disability

Employee Definition All Full-Time, 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 ConditionsAny 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.

Mutual of Omaha Voluntary Short-Term Disability

Employee Definition All Full-Time, 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 LimitationAny 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


Voluntary Critical Illness

Baer’s Furniture provides all active employees working 30 or more hours per week the option to purchase VoluntaryCritical Illness Insurance through a group plan. When you enroll in Critical Illness coverage you pay the full cost through payroll deductions.

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Mutual of Omaha Voluntary Critical Illness

Benefit Category and Condition % of Critical Illness Principal Sum

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%

CancerCancer (Invasive)Bone Marrow TransplantCarcinoma in Situ, Benign Brain Tumor

100%50%25%

Coverage Minimum Guarantee Issue Maximum

For YouAvailable as a flat benefit

$10,000 $10,000 $10,000

SpouseAvailable as a flat benefit

$10,000 $10,000 $10,000

Child(ren)Benefit for each child

$3,000 $3,000 $3,000


Payroll Deductions

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

Medical

AetnaHSA HN Option

w/o wellnessHSA HN Option

w/ wellnessHN Only

w/o wellnessHN Only

w/ wellness

Employee Only $87.00 $63.00 $57.00 $38.00

Employee + Spouse $387.00 $339.00 $345.00 $293.00

Employee + Child(ren) $325.00 $281.00 $283.00 $239.00

Family $627.00 $560.00 $576.00 $495.00

Dental

Guardian DHMO U30 DPPO K7

Employee Only $5.40 $15.96

Employee + Spouse $10.81 $33.40

Employee + Child(ren) $12.03 $40.02

Family $17.44 $53.44

Vision

Guardian Vision

Employee Only $2.75

Employee + Spouse $4.63

Employee + Child(ren) $4.72

Family $7.47

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*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

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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.

Accident and Universal LifeCustomer Service: 800-918-8877Claims: 877-201-9373

*For questions on claims or benefits contact applicable carrier above for the supplemental benefits.

Group Hospital Indemnity Insurance Customer Service & Claims: 1-800-256-8606

Trustmark Employee Employee &

SpouseEmployee &

ChildrenFamily

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.

Bi-Weekly Rates Employee Employee &

SpouseEmployee &

ChildrenFamily

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.

Gap Insurance

Baer’s Furniture provides Supplemental Limited Benefit Group Hospital Indemnity insurance through American Public Life. This benefits helpscover out-of-pocket expenses related to Hospital Confinement and/or medically necessary Outpatient Treatment related to an injury or sickness.

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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.

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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