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2020 PuppySpot Benefits Guide Final Flipbook PDF
2020 PuppySpot Benefits Guide Final
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2020-2021
GUIDE TO YO U R
BENEFITS UNDERSTANDING YOUR BENEFITS PROGRAM
Table of Contents General Information. . . . . . . . . . . . . . . . . . . . . . . . . . 3 Medical. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Teladoc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Flexible Spending Accounts (FSAs) . . . . . . . . . . . 13 Basic Life and AD&D Insurance . . . . . . . . . . . . . . . 14 Voluntary Life Insurance. . . . . . . . . . . . . . . . . . . . . 14 Disability Insurance. . . . . . . . . . . . . . . . . . . . . . . . . 15 Employee Assistance Program. . . . . . . . . . . . . . . . 16 Voluntary Pet Insurance . . . . . . . . . . . . . . . . . . . . . 16 Cost of Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Voluntary Life Rates. . . . . . . . . . . . . . . . . . . . . . . . . 19 Contact Information. . . . . . . . . . . . . . . . . . . . . . . . . 20 2021 Annual Notices For Group Health Plan Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
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Welcome to the PuppySpot LLC Benefits Program PuppySpot LLC is pleased to present this overview of your employee benefits. We offer a variety of benefits to help you protect your health, your family, and your way of life. Your benefits are a valuable part of your compensation package. Please take the time to review this information carefully, along with the materials provided by the insurance carriers, and keep it handy for future reference. You may also contact the insurance carriers directly if you have any questions; their phone numbers and websites are listed under the Contact Information section.
Guide to Your
2020-2021 Benefits General Information Who Is Eligible You are eligible for benefits if you are a full time employee regularly scheduled to work at least 30 hours per week. You may also enroll your eligible dependents for benefits. Generally, your eligible dependents are: • Your legal spouse, as defined by federal law. • Your same-sex or opposite-sex domestic partner. • Your mentally or physically disabled children over age 26 (if they depend on you for support). You will be required to provide appropriate documentation of their disability.
When Coverage Starts You will be given the information needed to enroll ahead of your eligibility date, so that you do not experience a lapse in coverage. New Employees. Your coverage becomes effective on the first of the month following 60 days. You will be provided your enrollment information on your start date. Open Enrollment. If you sign up for benefits during open enrollment, your coverage becomes effective November 1st.
Changing Your Coverage During the Year Once you enroll for coverage, you may not change or cancel your benefits until the next open enrollment period unless you have a “qualifying event,” such as marriage, divorce, birth or adoption of a child, death of a dependent, or certain events that affect your dependent’s insurance coverage (for example, your spouse losing his or her job). If you experience a qualifying event, you must contact Human Resources to change your coverage within 30 days of the event.
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Medical PuppySpot LLC offers comprehensive medical plan coverage through Allied Benefit Systems. You have your choice of the following plans: • • • •
EPO PPO PPO PPO
Plan 250 4000 6000
How the PPO Plan Works A preferred provider organization (PPO) is a network of doctors and health care facilities that provide services to plan members at discounted rates. You can go to any doctor you like within the Aetna Signature Administrators PPO Network, including specialists, without a referral. In-network preventive care is covered in full. If you go to an out-of-network provider, the plan will pay benefits based on Medicare reimbursement rates for a particular health care service in your geographic area. If your out-of-network provider charges more than the amount covered by the plan, you will have to pay all charges over that amount.
How the EPO Plan Works An Exclusive Provider Organization (EPO) is a network of doctors and health care facilities that closely manage your medical care in an effort to control cost. Under this plan a referral is NOT required to see a specialist. Each visit requires a co-pay. This plan also covers prescription drugs which includes co-pay requirements. (See Chart for details). If you would like to see a listing of in-network physicians you can visit the Allied site at www.alliedbenefit.com, click on “Network Partners” in the above banner and select “Connect” under the PPO section to enter the Aetna search engine tool. This plan utilizes the Aetna Signature Administrators network, this means that medical benefits are covered throughout the majority of the United States. If you go to an out-of-network provider, the plan will pay benefits based on Medicare reimbursement rates for a particular health care service in your geographic area. If your out-of-network provider charges more than the amount covered by the plan, you will have to pay all charges over that amount. The Medical Plan Comparison chart on page 5 shows the key benefits for each of the medical plans.
Availability of Summary Health Information To help you make an informed choice, Allied Benefit Systems makes available a Summary of Benefits and Coverage (SBC), for each plan option. The SBC summarizes important information about the plan’s benefits, limitations and exclusions, in a standard format. It is a great resource as you compare your medical plan options, and is available www. Alliedbenefit.com. You may also request a copy by contacting Human Resources.
See page 9 for a glossary of medical plan terms.
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Guide to Your
2020-2021 Benefits Medical Plan Comparison Plan Name Network Annual Deductible
Deductible Type Coinsurance (your share after deductible) Annual Out-of-Pocket Limit (includes copays, deductible, and coinsurance)
EPO Plan Aetna Signature Administrators Network Only
Aetna Signature Administrators Network
Out-of-Network
$2,000/person $4,000/family
$4,000/person $8,000/family
$6,000/person $12,000/family
Embedded
Embedded
20%
20%
40%
$4,500/person $9,000/family
$6,600/person $13,200/family
$12,000/person $24,000/family
Prescription Drug Out-of-Pocket Limit Preventive Care (includes routine physical exams, well-child care, women’s preventive health services, and routine diagnostic tests)
PPO 400
Prescriptions are applied toward the medical out-of-pocket limit.
Covered in full
Covered Services
40% coinsurance after deductible
Covered in full
What You Pay After Deductible $25 copay
$30 copay
40% coinsurance after deductible
$50 copay
$60 copay
40% coinsurance after deductible
Specialist Referral Required
No
No
No
Inpatient Hospital Services
20% coinsurance after deductible
20% coinsurance after deductible
40% coinsurance after deductible
Outpatient Services
20% coinsurance after deductible
20% coinsurance after deductible
40% coinsurance after deductible
$75 copay
$75 copay
40% coinsurance after deductible
Physician Office Visits
Specialist Office Visits
Urgent Care
Emergency Room Care CVS/Caremark Pharmacy – Retail (up to 30-day supply) • Generic Drugs • Preferred Brand Drugs • Non-Preferred Brand Drugs • Specialty Drugs
CVS/Caremark Pharmacy – Mail Order (up to 90-day supply) • Generic Drugs • Preferred Brand Drugs • Non-Preferred Brand Drugs • Specialty Drugs
$100 copay
$350 copay
$10 copay $35 copay $60 copay Contact CVS Caremark Speciality Pharmacy 1-800-237-2767
$10 copay $35 copay $60 copay Contact CVS Caremark Speciality Pharmacy 1-800-237-2767
$25 copay $35 copay $150 copay Contact CVS Caremark Speciality Pharmacy 1-800-237-2767
$25 copay $35 copay $150 copay Contact CVS Caremark Speciality Pharmacy 1-800-237-2767
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Medical Plan Comparison Plan Name Network Annual Deductible
PPO 6000 Aetna Signature Administrators Network
Out-of-Network
$6,000/person $12,000/family
$8,000/person $16,000/family Embedded
Deductible Type Coinsurance (your share after deductible) Annual Out-of-Pocket Limit (includes copays, deductible, and coinsurance)
0%
50%
$6,250/person $12,500/family
$10,000/person $20,000/family
Prescription Drug Out-of-Pocket Limit
Prescriptions are applied toward the medical out-of-pocket limit.
Preventive Care (includes routine physical exams, well-child care, women’s preventive health services, and routine diagnostic tests)
Covered in full
Covered Services
50% coinsurance What You Pay After Deductible
Physician Office Visits
$40 copay
50% coinsurance after deductible
Specialist Office Visits
$80 copay
50% coinsurance after deductible
Specialist Referral Required
No
No
Inpatient Hospital Services
Covered in full
50% after deductible
Outpatient Services
Covered in full
50% after deductible
$100 copay
50% after deductible
Urgent Care Emergency Room Care
$300 copay
CVS/Caremark Pharmacy – Retail (up to 30-day supply) • Generic Drugs • Preferred Brand Drugs • Non-Preferred Brand Drugs • Specialty Drugs
$10 copay $35 copay $65 copay Contact CVS Caremark Speciality Pharmacy 1-800-237-2767
CVS/Caremark Pharmacy – Mail Order (up to 90-day supply) • Generic Drugs • Preferred Brand Drugs • Non-Preferred Brand Drugs • Specialty Drugs
$25 copay $87.50 copay $150 copay Contact CVS Caremark Speciality Pharmacy 1-800-237-2767
Note: On the $6,000 plan, you must pay the full discounted cost of your medical and prescription drug expenses until you satisfy the annual deductible.
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Guide to Your
2020-2021 Benefits Medical Plan Comparison Plan Name
PPO 250
Network
In-Network
Out-of-Network
Annual Deductible
$250/person $750/family
$500/person $1,500/family Embedded
Deductible Type Coinsurance (your share after deductible) Annual Out-of-Pocket Limit (includes copays, deductible, and coinsurance) Prescription Drug Out-of-Pocket Limit Preventive Care (includes routine physical exams, well-child care, women’s preventive health services, and routine diagnostic tests)
10%
40%
$2,500/person $5,000/family
$5,000/person $10,000/family
Prescriptions are applied toward the medical out-of-pocket limit
Covered in full
Covered Services
40% coinsurance
What You Pay After Deductible
Physician Office Visits
$20 copay
40% coinsurance after deductible
Specialist Office Visits
$35 copay
40% coinsurance after deductible
Specialist Referral Required
No
No
Inpatient Hospital Services
10% coinsurance after deductible
40% coinsurance after deductible
Outpatient Services
10% coinsurance after deductible
40% coinsurance after deductible
$75 copay
40% coinsurance after deductible
Urgent Care Emergency Room Care CVS Caremark Pharmacy – Retail (up to 30-day supply) • Generic Drugs • Preferred Brand Drugs • Non-Preferred Brand Drugs • Specialty Drugs
CVS Caremark Pharmacy – Mail Order (up to 90-day supply) • Generic Drugs • Preferred Brand Drugs • Non-Preferred Brand Drugs • Specialty Drugs
$200 copay
$10 copay $35 copay $65 copay Contact CVS Caremark Speciality Pharmacy 1-800-237-2767
$25 copay $87.50 copay $150 copay Contact CVS Caremark Speciality Pharmacy 1-800-237-2767
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Prescription Drug Benefits To get the most out of your prescription drug benefits, please keep the following in mind. Formulary. CVS Caremark has a formulary or (preferred drug list) that is updated quarterly. We recommend that you review this list on www.cvscaremarkspecialtyrx.com to check the cost of your prescription. Prior Authorization. Some drugs, such as acne antibiotics, steroids, erectile dysfunction drugs, and hepatitis C medications, require prior authorization. That means you or your doctor must contact the insurance company to request approval before the drug is covered under the plan. Step Therapy. Some medications, such as antidepressants, pain management drugs, certain cholesterol drugs, and specialty drugs for conditions like MS and rheumatoid arthritis, are subject to “step therapy.” If your doctor recommends one of these drugs, you must try a “first-line” drug before the plan will cover the step therapy drug. First-line drugs are proven, cost-effective medications that are FDA-approved and treat the same condition. Specialty Pharmacy Program. You are required to use the plan’s specialty pharmacy for specialty drugs, such as injectable and infused therapies used to treat complex medical conditions such as hepatitis C, immune deficiency, hemophilia, multiple sclerosis, and rheumatoid arthritis. No-Cost Contraceptives. Certain contraceptives for women have no member cost-share under the medical plans, as required by health care reform. See www.cvscaremarkspecialtyrx.com for a list of covered contraceptives. HSA Plan Preventive Drugs. Certain preventive drugs are covered for only a copay–you don’t have to meet the annual deductible first. See www.cvscaremarkspecialtyrx.com for a list of these preventive medications. Mandatory Generic. If you choose a brand-name drug when a generic equivalent is available, you will pay the brand copay plus the difference in cost between the brand-name drug and the generic drug. You can also visit www.cvscaremarkspecialtyrx.com, where you can look up covered drugs, calculate their cost and search for generic alternatives. Proton Pump Inhibitors. The plan will not cover brand-name PPIs, such as Nexium. Many over-the-counter PPIs are available. Mail Pharmacy Program. If you take a maintenance medication every day (such as blood pressure medication, contraceptives, or cholesterol medication), you must order your drugs through the mail pharmacy program. To get started, call CVS Caremark customer service or go to www.cvscaremarkspecialtyrx.com. Special Rules for Maintenance Medications. If you’re on a maintenance medication—that is, a drug you take regularly, like blood pressure or cholesterol medication—the plan requires that you order 90-day supplies after you have your prescription filledthree times at the pharmacy. With the CVS/Caremark Maintenance Choice program, you may choose to receive your maintenance medications by mail or at any of the approximately 9,600 CVS pharmacy retail stores nationwide. Either way, you pay the lower mail service prices.
Additional Prescription Savings GoodRX is a free prescription comparison website and application that will show you where to locate the lowest possible prices for the drugs you are prescribed to. GoodRX also generates coupons for certain drugs, simply download the App, or login online, search your drug and pharmacy, and print out the coupon based on the amount of prescribed tablets and milligrams.
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Guide to Your
2020-2021 Benefits Medical Plan Terms You Should Know Deductible
The dollar amount you pay for most services each calendar year before the plan will pay benefits. Please refer to the Medical Plan Comparison chart on pages 5-7 for your plan’s family deductible type.
Coinsurance
The percentage of your medical cost you pay for most covered services. You will begin paying the coinsurance after you have met the applicable deductible.
Copay
The flat dollar amount you may pay for certain services, such as office visits and prescription drugs, when you go to a network provider.
Out-of-Pocket Limit
The maximum share of expenses you may have to pay each calendar year before the plan begins to pay at 100%. The out-of-pocket limit includes what you spend on copays, the deductible, and coinsurance.
Exclusive Provider Organization (EPO)
As a member of an EPO, you can use the doctors and hospitals within the EPO network, but cannot go outside the network for care. There are no outof-network benefits
Preferred Provider Organization (PPO)
A network of doctors and health care facilities that have agreed to provide services to plan members at discounted rates.
Medicare Reimbursement Rates
If you go to an out-of-network provider, the plan will pay benefits based on Medicare reimbursement rates for medical services in your area. Medicare’s fee schedule is a national standard recognized by all providers; it is used to reimburse a significant portion of all medical claims in the United States.
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Teladoc *Teladoc is only available to those enrolled in Puppyspot’s Medical plans. Teladoc gives you 24/7 365 access to U.S. board-certified doctors through the convenience of phone or video consults. Its an affordable alternative to costly urgent care and ER visits when you need care now. Simply call 1-800-Teladoc (835-2362) or visit www.teladoc.com. When can I use Teladoc? Teladoc does not replace your Primary care physician. It is a convenient and affordable option for quality care. When you need immediate care, this benefit will only be available to those members who enroll in the medical plan: • On vacation, on a business trip, or away from home.* • For short-term prescription refills Get the care you need. Teladoc doctors can treat many medical conditions including: • • • • •
Cold & Flu symptoms Allergies UTI’s Sinus Problems Bronchitis
Meet our Doctors. Teladoc is simply a new way to access qualified doctors. All Teladoc doctors: • Are practicing PCP’s pediatricians and family medicine physicians • Average 15 years’ experience • Are U.S. Board certified and licensed in your state. • Are credentialed every 3 years meeting NCQA standards * Teladoc currently only offers U.S. based consultation services. Ex. If you are traveling to Canada for a business trip, you will not be able to access the services from where you are calling from. Calls must be made within the United States and services scheduled in the United States, being that Teladoc only has access to doctors and pharmacies within the United States.
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Allied’s Behavioral Health Enhanced Benefit. Puppyspot understands how work and personal challenges can affect your well-being. This FREE program is designed to help you manage life’s daily challenges. The program refers you to professional counselors and services that can help you and your eligible family members resolve a broad range of personal concerns, such as: • • • • • • • • •
Marriage and relationships Stress and anxiety Depression Substance abuse Anger management Family problems Grief and loss Legal and financial services Dependent care
Mobile App The eConnect mobile app, allows you to talk or chat directly with an Allied Care Solutions counselor or schedule a time for Allied Care Solutions to call you. Legal Services Free telephonic or (30-minute) face-to-face consultation with a local attorney. Web Portal Access thousands of articles, tip sheets, and videos covering a wide array of health, well-being and work-life balance topics. The site also contains child and elder care search engines, reference libraries, legal and financial resources, self-improvement programs and educations training modules. • For more information, Call 1-800-440-1440 • Log in at www.alliedbenefit.com/caresolutions
Guide to Your
2020-2021 Benefits Dental PuppySpot LLC offers dental coverage through Guardian. Under this plan, you are free to go to any licensed dentist you choose—but the plan pays a higher level of benefits if you go to a dentist who is a member of DentalGuard Preferred network. If you go to a dentist outside the network, the plan’s benefits will be based on the R&C for a particular dental service in your area. If the dentist charges more than the R&C, you will have to pay the difference. To find a dental provider please visit https://www.guardiananytime.com/fpapp/FPWeb/search and select the dental tab and network.
Dental Plan Comparison Dental PPO Plan Network
In-Network
Out-of-Network $50/person $150/family
Calendar Year Deductible Calendar Year Maximum Benefit (the most the plan will pay in benefits for each covered person per year)
$1,000/person
Preventive Services* (includes oral exams, cleanings, X-rays, and fluoride treatment)
Plan pays 100%; deductible waived
Plan pays 100% of R&C; deductible waived
Basic Services (includes fillings and extractions)
Plan pays 80% after deductible
Plan pays 80% of R&C after deductible
Major Services (includes bridgework, crowns, dentures, and implants)
Plan pays 50% after deductible
Plan pays 50% of R&C after deductible
Important: If your out-of-network dentist charges more than the approved amount, you will have to pay the difference. The R&C amount is based on what is considered reasonable and customary for a particular dental service, in your area.
Participation in the Guardian Dental Plan also includes a Maximum Rollover benefit. Guardian will roll over a portion of your unused annual maximum into your personal Maximum Rollover Account (MRA). If you reach your Plan Annual Maximum in future years, you can use money from your MRA. To qualify for an MRA, you (1) must have a paid claim during the current calendar year and (2) must not have exceeded the paid claims threshold during the benefit year. Your MRA may not exceed the MRA limit. You can view your annual MRA statement detailing your account and those of your dependents on www.GuardianAnytime.com. Please review the detailed Guardian plan summary for more details. To help you make an informed choice, please refer to the plan summary for more details. The dental summary is available ADP WorkForce Now.
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Vision PuppySpot LLC offers vision coverage through Guardian. Under the Guardian vision care program, you can choose between network and out-of-network providers—but you will receive a higher level of benefits, and enjoy greater convenience, if you go to a vision care provider in the VSP Choice Network network. If you decide to go to an out-of-network provider, you will pay the entire bill up front, then file a claim with Guardian. The plan will reimburse you for your out-of-network services up to the allowances listed below. To find a vision provider please visit https://www.guardiananytime.com/fpapp/FPWeb/search and select the vision tab and network. Guardian Vision Plan Eye Exams: Every 12 Months Lenses: Every 12 Months Frames: Every 24 Months Contacts (instead of glasses): Every 12 Months Network Examination Frames Single Vision Lenses Lined Bifocal Lenses Lined Trifocal Lenses Progressive Lenses Elective Contact Lenses Medically Necessary Contact Lenses
VSP Choice In-Network
Out-of-Network
$10 copay
Plan reimburses up to $39
$130 allowance; 20% discount on balance
Plan reimburses up to $47
$25 Materials Copay Applies, then covered 100%
Plan reimburses up to $23 Plan reimburses up to $37 Plan reimburses up to $49 Plan reimburses up to $64
$130 allowance Covered in full
Plan reimburses up to $100 Plan reimburses up to $210
In addition, Guardian members can receive a number of lens options, such as progressive lenses and special coatings, at a discounted price. Guardian also offers a discount on laser vision correction.
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Guide to Your
2020-2021 Benefits Flexible Spending Accounts (FSAs) FSAs allow you to save money by paying certain health and dependent care expenses on a pre-tax basis. You pay no taxes on the money you put in these accounts, which means more take-home pay for you. The FSAs are administered by Basic Pacific. Health Care FSA. You may contribute up to $2,750 per calendar year to pay for out-of-pocket medical, prescription drug, dental, and vision care expenses for yourself and your eligible family members—even if you do not cover your family members under the PuppySpot LLC health care plans. You can use this FSA to pay expenses like medical and dental plan deductibles and copays; orthodontia expenses not covered by your dental plan, prescription drugs, prescription glasses and contact lenses, and laser eye surgery. Dependent Care FSA. This FSA lets you set aside pre-tax money to pay for eligible dependent care expenses so that you—and your spouse, if you are married—can work. You may contribute up to $5,000 per calendar year in the FSA (if your tax filing status is “married filing jointly” or “head of household”).
Commuter Benefit The commuter benefit lets you save money on your commuting costs by paying for qualified, work-related transportation expenses through pre-tax payroll deductions. • You may contribute up to $270 per month to pay for qualified mass transit (such as bus, subway, or train) or vanpooling in a “commuter highway vehicle” that regularly transports six or more passengers. Any amounts elected over $270 will be deducted from payroll on a post-tax basis. • You may contribute up to $270 per month to pay work-related parking, including parking at or near your workplace, or at or near a location for carpool or vanpool. Any amounts elected over $270 will be deducted from payroll on a post-tax basis. You may start participating in the Commuter Benefits when they are rolled out effective January 1, 2021, and you may change your election every month.
You may carry over up to $500 of unused health care FSA funds from one plan year to the next—but any funds above $500 will be forfeited if you do not spend them on expenses you incur during the plan year (January 1st through Dec 31st ). You will have 90 days after the end of the plan year to submit reimbursement requests.
FSA Debit Card You will receive a debit card that you can use to access your FSA funds for eligible expenses. This card works like a bank debit card—just swipe it when you make your purchase and the money will automatically be deducted from your account. Having your expenses directly debited from your FSA saves you time and improves your cash flow. You may be asked to document your FSA expenses, so be sure to save your receipts!
Special Note for Employees with Domestic Partners The federal government does not recognize domestic partnership; therefore, the IRS does not permit you to use the money in your FSA to pay health care or dependent care expenses incurred by your domestic partner or your domestic partner’s child—unless that person qualifies as your tax dependent under Internal Revenue Code Section 152. A person generally would qualify as a Section 152 tax dependent if you provide more than 50% of that person’s support; the person lives with you for the entire calendar year and is a member of your household; the person is a U.S. citizen or resident; and the person’s relationship with you does not violate any local laws. You are responsible for consulting your tax adviser regarding your domestic partner’s status as your dependent.
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Basic Life and AD&D Insurance All eligible employees are automatically covered by the group life insurance and accidental death and dismemberment (AD&D) insurance plans. PuppySpot LLC pays the full cost of these plans, which are insured by Guardian. Benefits are payable to your designated beneficiary.
Company-Paid Life Insurance Your company-paid life insurance benefit is equal to $15,000.
Company-Paid AD&D Insurance This plan pays an additional benefit if you die as a result of a covered accident. Benefits are also payable if you suffer certain severe injuries in an accident, including loss of limb, sight, or paralysis. Your company-paid AD&D benefit is equal to your life insurance benefit. Your coverage amount will reduce when you get older; see your Certificate of Insurance for details.
Voluntary Life Insurance Employee Voluntary Life Insurance Coverage available in units of $25,000 to a maximum amount of $300,000*. The guaranteed issue amount for employee coverage is $150,000 (EE less than age 65).
Spousal Life Insurance (SP coverage terminates at age 70) Coverage available for your spouse or DP in units of $12,500 to a maximum of $250,000*. The guaranteed issue amount for spousal coverage is $25,000 (SP less than age 65).
Child Life Insurance Coverage available for your children from 14 days to 23 years old at a flat benefit amount of $10,000. One rate covers all enrolled dependent children. *Please Note: If you enroll in the voluntary life insurance plan, you will pay the entire cost of your coverage through payroll deductions on a post-tax basis. Employees must participate with their own voluntary election to make a spousal or child life election. Spousal Life benefit amount is limited to 100% of voluntary employee life election, and spousal life rates are based on employee age and increases in 5-year increments. Age-Based reductions apply: 65% of benefit @ age 65, 40% of benefit @ age 70, 25% of benefit @ age 75, 15% of benefit @ age 80. Evidence of Insurability (EOI) form will be required only for requested amounts of voluntary life insurance above the guarantee issued amounts. Evidence of Insurability is NOT REQUIRED only when you are initially eligible to elect this plan up to the guarantee issue amounts - you can elect up to $150k for yourself and up to $25k for your spouse with NO medical underwriting required. For future elections after initial eligibility, medical underwriting will be required for any election or increase requested.
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Guide to Your
2020-2021 Benefits Disability Insurance Disability insurance protects a portion of your income if you become ill or injured, to help you pay your bills until you can get back to work.
Short-Term Disability (STD) Insurance The STD plan provides a weekly benefit if a non-job-related disability—including pregnancy—prevents you from working. If you enroll in the STD plan, you will pay the entire cost of your coverage through payroll deductions. STD coverage is provided through Guardian. STD Plan Benefit amount:
60% of your weekly earnings
Maximum benefit:
$2,000 per week
Benefit reduced by:
Other disability income benefits, such as state disability insurance, sick leave, or unemployment insurance
Waiting period:
Benefits begin on your 15 day of disability (for an accident) or your15 day of disability (for an illness)
Length of payment period:
Benefits are paid as long as you remain disabled and under a physician’s care, for up to 26 weeks
Pre-existing Condition Limitation. A “pre-existing condition” is any injury or sickness for which your received medical treatment or advice (including diagnostic measures), or had drugs or medicines prescribed or taken in the 3 months prior to the day your STD coverage began. Benefits will not be paid for any disability that begins in the first 12 months you are covered by the STD plan, if that disability is due to or results from a pre-existing condition.
Long-Term Disability (LTD) Insurance The financial consequences of a lengthy disability can be very serious. The LTD plan provides monthly income protection if you become unable to work due to a disabling condition that lasts beyond 181 days. If you enroll in the LTD plan, you will pay the entire cost of your coverage through payroll deductions. LTD coverage is provided through Guardian. LTD Plan Benefit amount:
60% of your monthly earnings
Maximum benefit:
$10,000 per month
Benefit reduced by:
Other disability income benefits, such as State Disability Insurance or Social Security
Waiting period:
Benefits begin after 181 days of continuous disability
Length of payment period:
Benefits are paid as long as you remain disabled and under a physician’s care, or until you reach 65
Pre-existing Condition Limitation. A “pre-existing condition” is any injury or sickness for which your received medical treatment or advice (including diagnostic measures), or had drugs or medicines prescribed or taken in the 3 months prior to the day your LTD coverage began. Benefits will not be paid for any disability that begins in the first 12 months you are covered by the LTD plan, if that disability is due to or results from a pre-existing condition.
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Employee Assistance Program We all need help with life’s challenges now and then. Whether it’s a difficult situation affecting your home life or stress interfering with your work, the employee assistance program (EAP) is there for you and your immediate family members 24 hours a day, seven days a week. The EAP is provided by PuppySpot LLC at no cost to you and is administered by Guardian. The EAP provides free, strictly confidential counseling to help you resolve a wide range of personal issues, including: • • • • • •
Stress and depression Life transitions Grief and loss Parenting and child care Elder care referrals Domestic violence
• • • • •
Workplace conflict Work/life balance Addiction and recovery Financial issues Legal assistance
Call the EAP at 1-800-386-7055 whenever you need help. Your call will be handled confidentially by a professional counselor. The EAP will also cover up to 3 free face-to-face counseling sessions per year for each issue.
Voluntary Pet Insurance Pet Benefit Solutions Enrollment into this voluntary plan option is completed directly though the following Landing Page Link: https://www.petbenefits.com/land/puppyspot. Provided below is a brief outline of the benefits offered; however, it is encouraged to visit the above landing page to get additional details and pricing on the coverage options or to contact Pet Benefit Solutions directly @ 1-800-891-2565 for additional information.
Pets Best Pet Health Insurance
Pet Assure Veterinary Discount Plan
PetPlus Rx Discount Plan
Pets Best is a pet health insurance plan that offers up to 90% reimbursement on accidents and illnesses. Employees can add optional routine care coverage at an additional cost.
Pet Assure is a veterinary discount plan that gives employees an instant 25% discount on in-house medical services at any participating veterinarian.
PetPlus is a prescription discount plan that provides employees with members-only pricing (up to 50% off) on Rx’s, preventatives, food and more.
Varies based on breed/age/zip code
Single Pet = $3.69 Unlimited Pets = $5.08
Single Pet = $1.73 Unlimited Pets = $3.46
Pre-existing conditions
None
None
Dogs and cats
All pets are covered, including dogs, cats, horses, birds, ferrets, pigs and more
Dogs and cats
Participating Veterinarians
Any licensed veterinarian in the US or Canada
Participating veterinarians in all 50 states + Puerto Rico
N/A
Additional Benefits
24/7 Pet Help Line powered by whiskerDocs
Lost Pet Recovery Service
24/7 Pet Help Line powered by whiskerDocs
Description
Employee Per Pay Cost:
Exclusions Types of Pets
16
Guide to Your
2020-2021 Benefits Cost of Coverage Medical Contributions per Paycheck EPO Plan Employee Only
$106.74
Employee + Spouse/Domestic Partner
$299.22
Employee + Child(ren)
$222.60
Employee + Family
$421.86 PPO 4000
Employee Only
$83.46
Employee + Spouse/Domestic Partner
$234.03
Employee + Child(ren)
$208.27
Employee + Family
$338.89 PPO 6000
Employee Only
$63.10
Employee + Spouse/Domestic Partner
$225.00
Employee + Child(ren)
$200.00
Employee + Family
$325.00 PPO 250
Employee Only
$137.68
Employee + Spouse/Domestic Partner
$403.55
Employee + Child(ren)
$301.32
Employee + Family
$529.02
Dental Contributions per Paycheck Guardian Dental PPO Plan Employee Only
$7.35
Employee + Spouse/Domestic Partner
$19.29
Employee + Child(ren)
$17.49
Employee + Family
$29.26
Vision Contributions per Paycheck Guardian VSP Plan Employee Only
$2.86
Employee + Spouse/Domestic Partner
$4.82
Employee + Child(ren)
$4.92
Employee + Family
$7.78
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STD Rates Your Age
Rate Per $100 of Weekly Pay
15 - 24
$0.51
25 - 29
$0.68
30 - 34
$1.00
35 - 39
$0.78
40 - 44
$0.56
45 - 49
$0.59
50 - 54
$0.73
55 - 59
$0.86
60+
$1.15
How to Calculate Your STD Insurance Contribution 1. Divide your annual income by 52 to determine your weekly pay, 2. Divide your weekly pay by 100. 3. Multiply this amount by the rate in the chart to get your weekly cost. Example. Rebecca is 40 years old and makes $43,500 per year. Here’s how she would figure her monthly STD cost: 1. $43,500 annual salary ÷ 12 = $3,625 monthly salary 2. $3,625 ÷ $100 = $36.25 3. $36.25 = per month* *Multiply this monthly rate by 12 and divide by the number of pay periods to get your cost per pay period.
LTD Rates Your Age
Rate Per $1,000 of Monthly Pay
15 - 24
$0.19
25 - 29
$0.25
30 - 34
$0.48
35 - 39
$0.77
40 - 44
$1.19
45 - 49
$1.81
50 - 54
$2.32
55 - 59
$2.46
60+
$2.58
How to Calculate Your LTD Insurance Contribution 1. Divide your annual income by 12 to determine your monthly pay. 2. Divide your monthly pay by 1,000. 3. Multiply this amount by the rate in the chart to get your monthly cost. Example. Rebecca is 40 years old and makes $43,500 per year. Here’s how she would figure her monthly LTD cost: 1. $43,500 annual salary ÷ 12 = $3,625 monthly salary 2. $3,625 ÷ 1,000 = 3.625 3. 3.625 x = per month* *Multiply this monthly rate by 12 and divide by the number of pay periods to get your cost per pay period.
18
Guide to Your
2020-2021 Benefits Voluntary Life Rates Age Bracket
Monthly Rate per $1,000
Less than 30
$0.104
30 - 34
$0.110
35 - 39
Voluntary Employee Life Insurance - Per-Pay (26 deductions) Employee Contribution $25,000
$50,000
$75,000
$100,000
$125,000
$150,000
$1.20
$2.40
$3.60
$4.80
$6.00
$7.20
$1.27
$2.54
$3.81
$5.08
$6.35
$7.62
$0.149
$1.72
$3.44
$5.16
$6.88
$8.60
$10.32
40 - 44
$0.222
$2.56
$5.12
$7.68
$10.25
$12.81
45 - 49
$0.356
$4.11
$8.22
$12.32
$16.43
$20.54
$175,000
$200,000
$225,000
$8.40
$9.60
$10.80
$8.88
$10.15
$11.42
$12.03
$13.75
$15.47
$15.37
$17.93
$20.49
$24.65
$28.75
$32.86
$250,000
$275,000
$300,000
$12.00
$13.20
$14.40
$12.69
$13.96
$15.23
$17.19
$18.91
$20.63
$23.05
$25.62
$28.18
$30.74
$36.97
$41.08
$45.18
$49.29
50 - 54
$0.590
$6.81
$13.62
$20.42
$27.23
$34.04
$40.85
$47.65
$54.46
$61.27
$68.08
$74.88
$81.69
55 - 59
$0.960
$11.08
$22.15
$33.23
$44.31
$55.38
$66.46
$77.54
$88.62
$99.69
$110.77
$121.85
$132.92
60 - 64
$1.558
$17.98
$35.95
$53.93
$71.91
$89.88
$107.86
$125.84
$143.82
$161.79
$179.77
$197.75
$215.72
65 - 69
$3.261
$37.63
$75.25
$112.88
$150.51
$188.13
$225.76
$263.39
$301.02
$338.64
$376.27
$413.90
$451.52
Age Bracket
Monthly Rate per $1,000
Voluntary Spousal Life Insurance - Per-Pay (26 deductions) Employee Contribution $12,500
$25,000
$37,500
$50,000
$62,500
$75,000
$87,500
$100,000
$112,500
Less than 30
$0.104
$0.60
$1.20
$1.80
$2.40
$3.00
$3.60
$4.20
$4.80
$5.40
$6.00
30 - 34
$0.110
$0.63
$1.27
$1.90
$2.54
$3.17
$3.81
$4.44
$5.08
$5.71
$6.35
35 - 39
$0.149
$0.86
$1.72
$2.58
$3.44
$4.30
$5.16
$6.02
$6.88
$7.74
$8.60
40 - 44
$0.222
$1.28
$2.56
$3.84
$5.12
$6.40
$7.68
$8.97
$10.25
$11.53
$12.81
$125,000
45 - 49
$0.356
$2.05
$4.11
$6.16
$8.22
$10.27
$12.32
$14.38
$16.43
$18.48
$20.54
50 - 54
$0.590
$3.40
$6.81
$10.21
$13.62
$17.02
$20.42
$23.83
$27.23
$30.63
$34.04
55 - 59
$0.960
$5.54
$11.08
$16.62
$22.15
$27.69
$33.23
$38.77
$44.31
$49.85
$55.38
60 - 64
$1.558
$8.99
$17.98
$26.97
$35.95
$44.94
$53.93
$62.92
$71.91
$80.90
$89.88
65 - 69
$3.261
$18.81
$37.63
$56.44
$75.25
$94.07
$112.88
$131.69
$150.51
$169.32
$188.13
Age Bracket
Monthly Rate per $1,000
$137,500
$150,000
$162,500
$175,000
$187,500
$200,000
$212,500
$225,000
$237,500
$250,000
Less than 30
$0.104
$6.60
$7.20
$7.80
$8.40
$9.00
$9.60
$10.20
$10.80
$11.40
$12.00 $12.69
Voluntary Spousal Life Insurance - Per-Pay (26 deductions) Employee Contribution
30 - 34
$0.110
$6.98
$7.62
$8.25
$8.88
$9.52
$10.15
$10.79
$11.42
$12.06
35 - 39
$0.149
$9.46
$10.32
$11.18
$12.03
$12.89
$13.75
$14.61
$15.47
$16.33
$17.19
40 - 44
$0.222
$14.09
$15.37
$16.65
$17.93
$19.21
$20.49
$21.77
$23.05
$24.33
$25.62
45 - 49
$0.356
$22.59
$24.65
$26.70
$28.75
$30.81
$32.86
$34.92
$36.97
$39.02
$41.08
50 - 54
$0.590
$37.44
$40.85
$44.25
$47.65
$51.06
$54.46
$57.87
$61.27
$64.67
$68.08 $110.77
55 - 59
$0.960
$60.92
$66.46
$72.00
$77.54
$83.08
$88.62
$94.15
$99.69
$105.23
60 - 64
$1.558
$98.87
$107.86
$116.85
$125.84
$134.83
$143.82
$152.80
$161.79
$170.78
$179.77
65 - 69
$3.261
$206.95
$225.76
$244.58
$263.39
$282.20
$301.02
$319.83
$338.64
$357.46
$376.27
Age Bracket
Monthly Rate per $1,000
14 days to 26
$0.167
Voluntary Child(ren) Life Insurance - Per-Pay (26 deductions) Employee Contribution Flat Benefit Amount of $10,000 $0.77
19
Contact Information Benefit Plan
Carrier/Administrator
Group Number
Phone
Website
EPO Plan
Allied Benefit Systems
A18196
866-455-8727
www.alliedbenefit.com
PPO 4000
Allied Benefit Systems
A18196
866-455-8727
www.alliedbenefit.com
PPO 6000
Allied Benefit Systems
A18196
866-455-8727
www.alliedbenefit.com
PPO 250
Allied Benefit Systems
A18196
866-455-8727
www.alliedbenefit.com
Pharmacy Benefit Manager
CVS/Caremark
A18196
877-860-6415
www.caremark.com
Specialty Pharmacy
CVS/Caremark
A18196
800-237-2767
www.cvscaremarkspecialtyrx.com
DentalGuard Preferred Dental Plan PPO
Guardian
555394
888-600-1600
www.guardiananytime.com
Vision Plan
Guardian
555394
888-600-1600
www.guardiananytime.com
Basic Pacific
PuppySpot Group LLC
916-303-7090
www.basicpacific.com [email protected]
Basic Life and AD&D Insurance
Guardian
555394
888-600-1600
www.guardiananytime.com
Voluntary or Optional Life and AD&D Insurance
Guardian
555394
888-600-1600
www.guardiananytime.com
Disability Insurance
Guardian
555394
888-600-1600
www.guardiananytime.com
Employee Assistance Program
Guardian
555394
800-386-7055
www.ibhworklife.com User Name: Matters Password: wlm70101
Voluntary Pet Benefit Solutions
Pet Benefit Solutions
n/a
800-891-2566
www.petbenefits.com/land/puppyspot
Human Resources
PuppySpot
866-706-7337
[email protected]
Flexible Spending Account
HR Contact
Most insurance companies now offer free mobile apps to help manage your care on the go. Visit their website for details. Log onto your ADP WorkForce Now profile page to make benefit elections. The website is https://my.adp.com/static/redbox/login.html.
20
Guide to Your
2020-2021 Benefits 2021 Annual Notices For Group Health Plan Benefits The following notices are not intended to be a description of the benefits offered under the Plan. For more information about specific benefits, refer to the Summary Plan Descriptions for the Plan, which are available by contacting the Human Resources Department.
Women’s Health and Cancer Rights Act (WHCRA) Notice Enrollment Notice: 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. Therefore, the following deductibles and coinsurance apply for the: • EPO Plan • $4,000 PPO Plan • $6,000 PPO Plan • $250 PPO Plan If you would like more information on WHCRA benefits, call your plan administrator Lauren Sobel at 866-706-7337.
Annual Notice: Do you know that your plan, as required by the Women’s Health and Cancer Rights Act of 1998, provides benefits for mastectomy-related services including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy, including lymphedema? Call your plan administrator Lauren Sobel at 866-706-7337 for more information.
Newborns’ and Mother’s Health Protection Act
Michelle’s Law When a dependent child over the age of 26 loses student status under the eligibility policy of PuppySpot Group group health plan coverage, as a result of a medically necessary leave of absence from a post-secondary educational institution, the PuppySpot Group group health plan will continue to provide coverage during the leave of absence for the earlier end date of up to one year, or until coverage would otherwise terminate under the PuppySpot Group group health plan. To maintain eligibility continue coverage as a dependent during such leave of absence: • The PuppySpot Group group health plan must receive written certification by a treating physician of the dependent child which states that the child is suffering from a serious illness or injury and that the leave of absence (or other change of enrollment) is medically necessary; and • For any additional permissible conditions, please refer to the plan’s SPD. To access your SPDs, visit ADP WorkForce Now. To obtain additional information, please contact: Lauren Sobel at HR@ puppyspot.com.
Notice of HIPAA Special Enrollment Rights This notice is being provided to ensure that you understand your right to apply for group health insurance coverage. You should read this notice even if you plan to waive coverage at this time.
Loss of Other Coverage If you are declining coverage 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 n 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.
Medicaid or CHIP If you or your dependents lose eligibility for coverage under Medicaid or the Children’s Health Insurance Program (CHIP) or become eligible for a premium assistance subsidy under Medicaid or CHIP, you may be able to enroll yourself and your dependents. You must request enrollment within 60 days of the loss of Medicaid or CHIP coverage or the determination of eligibility for a premium assistance subsidy.
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).
To request special enrollment or obtain more information, please contact:
Medical Loss Ratio (MLR) Rule Notice
Important Notice from PuppySpot LLC about Your Prescription Drug Coverage and Medicare
The Affordable Care Act requires health insurers in the individual and small group markets to spend at least 80 percent of the premiums they receive on health care services and activities to improve health care quality (in the large group market, this amount is 85 percent). This is referred to as the Medical Loss Ratio (MLR) rule or the 80/20 rule. If a health insurer does not spend at least 80 percent of the premiums it receives on health care services and activities to improve health care quality, the insurer must rebate the difference.
Lauren Sobel 7261 Sheridan Street Suite 300A Hollywood, FL 33024 866-706-7337
Note Regarding “Pre-Existing Condition Exclusions” Effective for plan years beginning on or after January 1, 2014, a group health plan may NOT impose a pre-existing condition exclusion (PCE) with respect to any individual.
Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with PuppySpot LLC 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.
21
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. PuppySpot LLC has determined that the prescription drug coverage offered by the PuppySpot LLC Employee Benefit Plans are, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and are therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.
When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.
What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current coverage may be affected. If you do decide to join a Medicare drug plan and drop your current coverage, be aware that you and your dependents will not be able to get this coverage back until the next open enrollment period.
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 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 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.
22
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: Name of Entity/Sender: Contact/Office: Address: 33024 Phone Number:
11/1/2020 PuppySpot LLC Lauren Sobel/Human Resources 7261 Sheridan Street Suite 300A Hollywood, FL 866-706-7337
Continuation Coverage Rights Under COBRA Introduction You’re getting this notice because you recently gained coverage under a group health plan (the Plan). This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator. You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.
What is COBRA continuation coverage? COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • Your hours of employment are reduced, or • Your employment ends for any reason other than your gross misconduct. If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • Your spouse dies; • Your spouse’s hours of employment are reduced; • Your spouse’s employment ends for any reason other than his or her gross misconduct; • Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or • You become divorced or legally separated from your spouse.
Guide to Your
2020-2021 Benefits Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events: • The parent-employee dies; • The parent-employee’s hours of employment are reduced; • The parent-employee’s employment ends for any reason other than his or her gross misconduct; • The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); • The parents become divorced or legally separated; or • The child stops being eligible for coverage under the Plan as a “dependent child.”
When is COBRA continuation coverage available? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events: • The end of employment or reduction of hours of employment; • Death of the employee; • The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both). For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs.
How is COBRA continuation coverage provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage. There are also ways in which this 18-month period of COBRA continuation coverage can be extended:
Disability extension of 18-month period of COBRA continuation coverage If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage.
Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred.
Are there other coverage options besides COBRA Continuation Coverage? Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov.
If you have questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.HealthCare.gov.
Keep your Plan informed of address changes To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator.
Plan contact information Lauren Sobel Human Resources Department PuppySpot LLC 7261 Sheridan Street Suite 300A Hollywood, FL 33024 866-706-7337 [email protected] Effective: 11/1/2020
Notice of HIPAA Privacy Practices 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. This notice is intended to inform you of the privacy practices followed by the PuppySpot LLC Health Plan and the Plan’s legal obligations regarding your protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The notice also explains the privacy rights you and your family members have as participants of the Plan. It is effective on 11/1/2020. The Plan often needs access to your protected health information in order to provide payment for health services and perform plan administrative functions. We want to assure the plan participants covered under the Plan that we comply with federal privacy laws and respect your right to privacy. PuppySpot LLC requires all members of our workforce and third parties that are provided access to protected health information to comply with the privacy practices outlined below.
Protected Health Information Your protected health information is protected by the HIPAA Privacy Rule. Generally, protected health information is information that identifies an individual created or received by a health care provider, health plan or an employer on behalf of a group health plan that relates to physical or mental health conditions, provision of health care, or payment for health care, whether past, present or future.
How We May Use Your Protected Health Information Under the HIPAA Privacy Rule, we may use or disclose your protected health information for certain purposes without your permission. This section describes the ways we can use and disclose your protected health information.
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Payment. We use or disclose your protected health information without your written authorization in order to determine eligibility for benefits, seek reimbursement from a third party, or coordinate benefits with another health plan under which you are covered. For example, a health care provider that provided treatment to you will provide us with your health information. We use that information in order to determine whether those services are eligible for payment under our group health plan.
Right to an Accounting of Disclosures. You have the right to receive an accounting of certain disclosures of your protected health information. The accounting will not include disclosures that were made (1) for purposes of treatment, payment or health care operations; (2) to you; (3) pursuant to your authorization; (4) to your friends or family in your presence or because of an emergency; (5) for national security purposes; or (6) incidental to otherwise permissible disclosures.
Health Care Operations. We use and disclose your protected health information in order to perform plan administration functions such as quality assurance activities, resolution of internal grievances, and evaluating plan performance. For example, we review claims experience in order to understand participant utilization and to make plan design changes that are intended to control health care costs.
Your request for an accounting must be submitted in writing to the person listed below. You may request an accounting of disclosures made within the last six years. You may request one accounting free of charge within a 12-month period.
Treatment. Although the law allows use and disclosure of your protected health information for purposes of treatment, as a health plan we generally do not need to disclose your information for treatment purposes. Your physician or health care provider is required to provide you with an explanation of how they use and share your health information for purposes of treatment, payment, and health care operations. As permitted or required by law. We may also use or disclose your protected health information without your written authorization for other reasons as permitted by law. We are permitted by law to share information, subject to certain requirements, in order to communicate information on health-related benefits or services that may be of interest to you, respond to a court order, or provide information to further public health activities (e.g., preventing the spread of disease) without your written authorization. We are also permitted to share protected health information during a corporate restructuring such as a merger, sale, or acquisition. We will also disclose health information about you when required by law, for example, in order to prevent serious harm to you or others. Pursuant to Your Authorization. When required by law, we will ask for your written authorization before using or disclosing your protected health information. If you choose to sign an authorization to disclose information, you can later revoke that authorization to prevent any future uses or disclosures. To Business Associates. We may enter into contracts with entities known as Business Associates that provide services to or perform functions on behalf of the Plan. We may disclose protected health information to Business Associates once they have agreed in writing to safeguard the protected health information. For example, we may disclose your protected health information to a Business Associate to administer claims. Business Associates are also required by law to protect protected health information. To the Plan Sponsor. We may disclose protected health information to certain employees of PuppySpot LLC for the purpose of administering the Plan. These employees will use or disclose the protected health information only as necessary to perform plan administration functions or as otherwise required by HIPAA, unless you have authorized additional disclosures. Your protected health information cannot be used for employment purposes without your specific authorization.
Your Rights Right to Inspect and Copy. In most cases, you have the right to inspect and copy the protected health information we maintain about you. If you request copies, we will charge you a reasonable fee to cover the costs of copying, mailing, or other expenses associated with your request. Your request to inspect or review your health information must be submitted in writing to the person listed below. In some circumstances, we may deny your request to inspect and copy your health information. To the extent your information is held in an electronic health record, you may be able to receive the information in an electronic format. Right to Amend. If you believe that information within your records is incorrect or if important information is missing, you have the right to request that we correct the existing information or add the missing information. Your request to amend your health information must be submitted in writing to the person listed below. In some circumstances, we may deny your request to amend your health information. If we deny your request, you may file a statement of disagreement with us for inclusion in any future disclosures of the disputed information.
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Right to Request Restrictions. You have the right to request that we not use or disclose information for treatment, payment, or other administrative purposes except when specifically authorized by you, when required by law, or in emergency circumstances. You also have the right to request that we limit the protected health information that we disclose to someone involved in your care or the payment for your care, such as a family member or friend. Your request for restrictions must be submitted in writing to the person listed below. We will consider your request, but in most cases are not legally obligated to agree to those restrictions. However, we will comply with any restriction request if the disclosure is to a health plan for purposes of payment or health care operations (not for treatment) and the protected health information pertains solely to a health care item or service that has been paid for out-of-pocket and in full. Right to Request Confidential Communications. You have the right to receive confidential communications containing your health information. Your request for restrictions must be submitted in writing to the person listed below. We are required to accommodate reasonable requests. For example, you may ask that we contact you at your place of employment or send communications regarding treatment to an alternate address. Right to be Notified of a Breach. You have the right to be notified in the event that we (or one of our Business Associates) discover a breach of your unsecured protected health information. Notice of any such breach will be made in accordance with federal requirements. Right to Receive a Paper Copy of this Notice. If you have agreed to accept this notice electronically, you also have a right to obtain a paper copy of this notice from us upon request. To obtain a paper copy of this notice, please contact the person listed below. Our Legal Responsibilities. We are required by law to protect the privacy of your protected health information, provide you with certain rights with respect to your protected health information, provide you with this notice about our privacy practices, and follow the information practices that are described in this notice. We may change our policies at any time. In the event that we make a significant change in our policies, we will provide you with a revised copy of this notice. You can also request a copy of our notice at any time. For more information about our privacy practices, contact the person listed below. If you have any questions or complaints, please contact: Lauren Sobel Human Resources PuppySpot LLC 7261 Sheridan Street Suite 300A Hollywood, FL 33024 866-706-7337 [email protected]
Complaints If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact the person listed above. You also may send a written complaint to the U.S. Department of Health and Human Services — Office of Civil Rights. The person listed above can provide you with the appropriate address upon request or you may visit www.hhs.gov/ocr for further information. You will not be penalized or retaliated against for filing a complaint with the Office of Civil Rights or with us.
Guide to Your
2020-2021 Benefits 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 July 31, 2020. Contact your State for more information on eligibility –
ALABAMA – Medicaid Website: http://myalhipp.com/ Phone: 1-855-692-5447
COLORADO – Health First Colorado (Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+) Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711 CHP+: https://www.colorado.gov/pacific/hcpf/child-health-plan-plus CHP+ Customer Service: 1-800-359-1991/ State Relay 711 Health Insurance Buy-In Program (HIBI): https://www.colorado.gov/pacific/hcpf/ health-insurance-buy-program HIBI Customer Service: 1-855-692-6442
ALASKA – 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
FLORIDA – Medicaid Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplrecovery.com/ hipp/index.html Phone: 1-877-357-3268
ARKANSAS – Medicaid Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)
GEORGIA – Medicaid Website: https://medicaid.georgia.gov/health-insurance-premiumpayment-program-hipp Phone: 678-564-1162 ext 2131
CALIFORNIA – Medicaid Website: https://www.dhcs.ca.gov/services/Pages/TPLRD_CAU_cont.aspx Phone: 916-440-5676
INDIANA – Medicaid 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: https://www.in.gov/medicaid/ Phone 1-800-457-4584
IOWA – Medicaid and CHIP (Hawki) Medicaid Website: https://dhs.iowa.gov/ime/members Medicaid Phone: 1-800-338-8366 Hawki Website: http://dhs.iowa.gov/Hawki Hawki Phone: 1-800-257-8563
MONTANA – Medicaid Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084
KANSAS – Medicaid Website: http://www.kdheks.gov/hcf/default.htm Phone: 1-800-792-4884
NEBRASKA – Medicaid Website: http://www.ACCESSNebraska.ne.gov Phone: 1-855-632-7633 Lincoln: 402-473-7000 Omaha: 402-595-1178
KENTUCKY – Medicaid Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website:https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx Phone: 1-855-459-6328 Email: [email protected] KCHIP Website: https://kidshealth.ky.gov/Pages/index.aspx Phone: 1-877-524-4718 Kentucky Medicaid Website: https://chfs.ky.gov
NEVADA – Medicaid Medicaid Website: http://dhcfp.nv.gov Medicaid Phone: 1-800-992-0900
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LOUISIANA – Medicaid Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-618-5488 (LaHIPP)
NEW HAMPSHIRE – Medicaid Website: https://www.dhhs.nh.gov/oii/hipp.htm Phone: 603-271-5218 Toll free number for the HIPP program: 1-800-852-3345, ext 5218
MAINE – Medicaid Enrollment Website: https://www.maine.gov/dhhs/ofi/applications-forms Phone: 1-800-442-6003 TTY: Maine relay 711 Private Health Insurance Premium Webpage: https://www.maine.gov/dhhs/ofi/applications-forms Phone: -800-977-6740. TTY: Maine relay 711
NEW JERSEY – Medicaid and CHIP 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
MASSACHUSETTS – Medicaid and CHIP Website: http://www.mass.gov/eohhs/gov/departments/masshealth/ Phone: 1-800-862-4840
NEW YORK – Medicaid Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831
MINNESOTA – Medicaid Website: https://mn.gov/dhs/people-we-serve/children-and-families/health-care/ health-care-programs/programs-and-services/other-insurance.jsp Phone: 1-800-657-3739
NORTH CAROLINA – Medicaid Website: https://medicaid.ncdhhs.gov/ Phone: 919-855-4100
MISSOURI – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005
NORTH DAKOTA – Medicaid Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825
OKLAHOMA – Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1-888-365-3742
UTAH – Medicaid and CHIP Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669
OREGON – Medicaid Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075
VERMONT– Medicaid Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427
PENNSYLVANIA – Medicaid Website: https://www.dhs.pa.gov/providers/Providers/Pages/Medical/ HIPP-Program.aspx Phone: 1-800-692-7462
VIRGINIA – Medicaid and CHIP Website: https://www.coverva.org/hipp/ Medicaid Phone: 1-800-432-5924 CHIP Phone: 1-855-242-8282
RHODE ISLAND – Medicaid and CHIP Website: http://www.eohhs.ri.gov/ Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line)
WASHINGTON – Medicaid Website: https://www.hca.wa.gov/ Phone: 1-800-562-3022
SOUTH CAROLINA – Medicaid Website: https://www.scdhhs.gov Phone: 1-888-549-0820
WEST VIRGINIA – Medicaid Website: http://mywvhipp.com/ Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)
SOUTH DAKOTA - Medicaid Website: http://dss.sd.gov Phone: 1-888-828-0059
WISCONSIN – Medicaid and CHIP Website: https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm Phone: 1-800-362-3002
TEXAS – Medicaid Website: http://gethipptexas.com/ Phone: 1-800-440-0493
WYOMING – Medicaid Website: https://health.wyo.gov/healthcarefin/medicaid/programs-and-eligibility/ Phone: 1-800-251-1269
To see if any other states have added a premium assistance program since July 31, 2020, or for more information on special enrollment rights, contact either: U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/agencies/ebsa 1-866-444-EBSA (3272)
U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, Menu Option 4, Ext. 61565
Paperwork Reduction Act Statement 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 1/31/2023)
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Guide to Your
2020-2021 Benefits
New Health Insurance Marketplace Coverage Options and Your Health Coverage
Form Approved OMB No. 1210-0149 H[SLUHV5312020
PART A: General Information ΈΙΖΟ͑ΜΖΪ͑ΡΒΣΥΤ͑ΠΗ͑ΥΙΖ͑ΙΖΒΝΥΙ͑ΔΒΣΖ͑ΝΒΨ͑ΥΒΜΖ͑ΖΗΗΖΔΥ͑ΚΟ͑ͣͥ͑͢͡͝ΥΙΖΣΖ͑ΨΚΝΝ͑ΓΖ͑Β͑ΟΖΨ͑ΨΒΪ͑ΥΠ͑ΓΦΪ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ:͑ΥΙΖ͑ΖΒΝΥΙ͑ ͺΟΤΦΣΒΟΔΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͟΅Π͑ΒΤΤΚΤΥ͑ΪΠΦ͑ΒΤ͑ΪΠΦ͑ΖΧΒΝΦΒΥΖ͑ΠΡΥΚΠΟΤ͑ΗΠΣ͑ΪΠΦ͑ΒΟΕ͑ΪΠΦΣ͑ΗΒΞΚΝΪ͑͝ΥΙΚΤ͑ΟΠΥΚΔΖ͑ΡΣΠΧΚΕΖΤ͑ΤΠΞΖ͑ΓΒΤΚΔ͑ ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΥΙΖ͑ΟΖΨ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΟΕ͑ΖΞΡΝΠΪΞΖΟΥνΓΒΤΖΕ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͟ ͑
What is the Health Insurance Marketplace? ΅ΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΚΤ͑ΕΖΤΚΘΟΖΕ͑ΥΠ͑ΙΖΝΡ͑ΪΠΦ͑ΗΚΟΕ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ͑ΥΙΒΥ͑ΞΖΖΥΤ͑ΪΠΦΣ͑ΟΖΖΕΤ͑ΒΟΕ͑ΗΚΥΤ͑ΪΠΦΣ͑ΓΦΕΘΖΥ͑͟΅ΙΖ͑ ;ΒΣΜΖΥΡΝΒΔΖ͑ΠΗΗΖΣΤ͓͑ΠΟΖ͞ΤΥΠΡ͑ΤΙΠΡΡΚΟΘ͓͑ΥΠ͑ΗΚΟΕ͑ΒΟΕ͑ΔΠΞΡΒΣΖ͑ΡΣΚΧΒΥΖ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ͑ΠΡΥΚΠΟΤ͑͟ΊΠΦ͑ΞΒΪ͑ΒΝΤΠ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ ΗΠΣ͑Β͑ΟΖΨ͑ΜΚΟΕ͑ΠΗ͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΙΒΥ͑ΝΠΨΖΣΤ͑ΪΠΦΣ͑ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞ͑ΣΚΘΙΥ͑ΒΨΒΪ͑͟ΡΖΟ͑ΖΟΣΠΝΝΞΖΟΥ͑ΗΠΣ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ͑ ΔΠΧΖΣΒΘΖ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΓΖΘΚΟΤ͑ΚΟ͑ΔΥΠΓΖΣ͑ͣͤ͑͢͡ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΤΥΒΣΥΚΟΘ͑ΒΤ͑ΖΒΣΝΪ͑ΒΤ͑ͻΒΟΦΒΣΪ͑͑ͣͥ͑͢͢͟͝͡
Can I Save Money on my Health Insurance Premiums in the Marketplace? ΊΠΦ͑ΞΒΪ͑ΦΒΝΚΗΪ͑ΥΠ͑ΤΒΧΖ͑ΞΠΟΖΪ͑ΒΟΕ͑ΝΠΨΖΣ͑ΪΠΦΣ͑ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞ͑͝ΓΦΥ͑ΠΟΝΪ͑ΚΗ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΕΠΖΤ͑ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑͝ΠΣ͑ ΠΗΗΖΣΤ͑ΔΠΧΖΣΒΘΖ͑ΥΙΒΥ͑ΕΠΖΤΟ͘Υ͑ΞΖΖΥ͑ΔΖΣΥΒΚΟ͑ΤΥΒΟΕΒΣΕΤ͑͟΅ΙΖ͑ΤΒΧΚΟΘΤ͑ΠΟ͑ΪΠΦΣ͑ΡΣΖΞΚΦΞ͑ΥΙΒΥ͑ΪΠΦ͘ΣΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑ΕΖΡΖΟΕΤ͑ΠΟ͑ ΪΠΦΣ͑ΙΠΦΤΖΙΠΝΕ͑ΚΟΔΠΞΖ͑͟
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? ΊΖΤ͑͟ͺΗ͑ΪΠΦ͑ΙΒΧΖ͑ΒΟ͑ΠΗΗΖΣ͑ΠΗ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΗΣΠΞ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΥΙΒΥ͑ΞΖΖΥΤ͑ΔΖΣΥΒΚΟ͑ΤΥΒΟΕΒΣΕΤ͑͝ΪΠΦ͑ΨΚΝΝ͑ΟΠΥ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ ΗΠΣ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΟΕ͑ΞΒΪ͑ΨΚΤΙ͑ΥΠ͑ΖΟΣΠΝΝ͑ΚΟ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͘Τ͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑͟ΠΨΖΧΖΣ͑͝ΪΠΦ͑ΞΒΪ͑ΓΖ͑ ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΙΒΥ͑ΝΠΨΖΣΤ͑ΪΠΦΣ͑ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞ͑͝ΠΣ͑Β͑ΣΖΕΦΔΥΚΠΟ͑ΚΟ͑ΔΖΣΥΒΚΟ͑ΔΠΤΥ͞ΤΙΒΣΚΟΘ͑ΚΗ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΕΠΖΤ͑ ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑ΥΠ͑ΪΠΦ͑ΒΥ͑ΒΝΝ͑ΠΣ͑ΕΠΖΤ͑ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑ΥΙΒΥ͑ΞΖΖΥΤ͑ΔΖΣΥΒΚΟ͑ΤΥΒΟΕΒΣΕΤ͑͟ͺΗ͑ΥΙΖ͑ΔΠΤΥ͑ΠΗ͑Β͑ΡΝΒΟ͑ΗΣΠΞ͑ΪΠΦΣ͑ ΖΞΡΝΠΪΖΣ͑ΥΙΒΥ͑ΨΠΦΝΕ͑ΔΠΧΖΣ͑ΪΠΦ͙͑ΒΟΕ͑ΟΠΥ͑ΒΟΪ͑ΠΥΙΖΣ͑ΞΖΞΓΖΣΤ͑ΠΗ͑ΪΠΦΣ͑ΗΒΞΚΝΪ͚͑ΚΤ͑ΞΠΣΖ͑ΥΙΒΟ͖͑ͪͦ͑͟ΠΗ͑ΪΠΦΣ͑ΙΠΦΤΖΙΠΝΕ͑ ΚΟΔΠΞΖ͑ΗΠΣ͑ΥΙΖ͑ΪΖΒΣ͑͝ΠΣ͑ΚΗ͑ΥΙΖ͑ΔΠΧΖΣΒΘΖ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΡΣΠΧΚΕΖΤ͑ΕΠΖΤ͑ΟΠΥ͑ΞΖΖΥ͑ΥΙΖ͓͑ΞΚΟΚΞΦΞ͑ΧΒΝΦΖ͓͑ΤΥΒΟΕΒΣΕ͑ΤΖΥ͑ΓΪ͑ΥΙΖ͑ ͲΗΗΠΣΕΒΓΝΖ͑ʹΒΣΖ͑ͲΔΥ͑͝ΪΠΦ͑ΞΒΪ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑͟͢ ͑ ͿΠΥΖͫ͑ͺΗ͑ΪΠΦ͑ΡΦΣΔΙΒΤΖ͑Β͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΚΟΤΥΖΒΕ͑ΠΗ͑ΒΔΔΖΡΥΚΟΘ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑ ΖΞΡΝΠΪΖΣ͑͝ΥΙΖΟ͑ΪΠΦ͑ΞΒΪ͑ΝΠΤΖ͑ΥΙΖ͑ΖΞΡΝΠΪΖΣ͑ΔΠΟΥΣΚΓΦΥΚΠΟ͙͑ΚΗ͑ΒΟΪ͚͑ΥΠ͑ΥΙΖ͑ΖΞΡΝΠΪΖΣ͞ΠΗΗΖΣΖΕ͑ΔΠΧΖΣΒΘΖ͑͟ͲΝΤΠ͑͝ΥΙΚΤ͑ΖΞΡΝΠΪΖΣ͑ ΔΠΟΥΣΚΓΦΥΚΠΟ͑͞ΒΤ͑ΨΖΝΝ͑ΒΤ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΖ͑ΔΠΟΥΣΚΓΦΥΚΠΟ͑ΥΠ͑ΖΞΡΝΠΪΖΣ͞ΠΗΗΖΣΖΕ͑ΔΠΧΖΣΒΘΖ͑͞ΚΤ͑ΠΗΥΖΟ͑ΖΩΔΝΦΕΖΕ͑ΗΣΠΞ͑ΚΟΔΠΞΖ͑ΗΠΣ͑ ͷΖΕΖΣΒΝ͑ΒΟΕ͑΄ΥΒΥΖ͑ΚΟΔΠΞΖ͑ΥΒΩ͑ΡΦΣΡΠΤΖΤ͑͟ΊΠΦΣ͑ΡΒΪΞΖΟΥΤ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΣΖ͑ΞΒΕΖ͑ΠΟ͑ΒΟ͑ΒΗΥΖΣ͞ ΥΒΩ͑ΓΒΤΚΤ͑͟
͑ How Can I Get More Information? ͷΠΣ͑ΞΠΣΖ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΪΠΦΣ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͝ΡΝΖΒΤΖ͑ΔΙΖΔΜ͑ΪΠΦΣ͑ΤΦΞΞΒΣΪ͑ΡΝΒΟ͑ΕΖΤΔΣΚΡΥΚΠΟ͑ΠΣ͑ ΔΠΟΥΒΔΥ͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͟ [email protected] ͑ ΅ΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΔΒΟ͑ΙΖΝΡ͑ΪΠΦ͑ΖΧΒΝΦΒΥΖ͑ΪΠΦΣ͑ΔΠΧΖΣΒΘΖ͑ΠΡΥΚΠΟΤ͑͝ΚΟΔΝΦΕΚΟΘ͑ΪΠΦΣ͑ΖΝΚΘΚΓΚΝΚΥΪ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑ ΖΒΝΥΙʹΒΣΖ͟ΘΠΧ͑ΗΠΣ͑ΞΠΣΖ͑ΚΟΗΠΣΞΒΥΚΠΟ͑͝ΚΟΔΝΦΕΚΟΘ͑ΒΟ͑ΠΟΝΚΟΖ͑ΒΡΡΝΚΔΒΥΚΠΟ͑ΗΠΣ͑ΙΖΒΝΥΙ͑ ;ΒΣΜΖΥΡΝΒΔΖ͑ΒΟΕ͑ΚΥΤ͑ΔΠΤΥ͑͟ΝΖΒΤΖ͑ΧΚΤΚΥ͑ ΚΟΤΦΣΒΟΔΖ͑ΔΠΧΖΣΒΘΖ͑ΒΟΕ͑ΔΠΟΥΒΔΥ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΗΠΣ͑Β͑ΖΒΝΥΙ͑ͺΟΤΦΣΒΟΔΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΚΟ͑ΪΠΦΣ͑ΒΣΖΒ͑͟
͑͢ͲΟ͑ ΖΞΡΝΠΪΖΣ͞ΤΡΠΟΤΠΣΖΕ͑ ΙΖΒΝΥΙ͑ΡΝΒΟ͑ΞΖΖΥΤ͑ΥΙΖ͑ ͓ΞΚΟΚΞΦΞ͑ ΧΒΝΦΖ͑ΤΥΒΟΕΒΣΕ͓͑ ΚΗ͑ ΥΙΖ͑ΡΝΒΟ͘Τ͑ΤΙΒΣΖ͑ΠΗ͑ ΥΙΖ͑ΥΠΥΒΝ͑ΒΝΝΠΨΖΕ͑ΓΖΟΖΗΚΥ͑ΔΠΤΥΤ͑ΔΠΧΖΣΖΕ͑ ΓΪ͑ ΥΙΖ͑ΡΝΒΟ͑ΚΤ͑ ΟΠ͑ ΝΖΤΤ͑ΥΙΒΟ͑ͧ͑͡ΡΖΣΔΖΟΥ͑ΠΗ͑ ΤΦΔΙ͑ΔΠΤΥΤ͑͟
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PART B: Information About Health Coverage Offered by Your Employer ΅ΙΚΤ͑ΤΖΔΥΚΠΟ͑ΔΠΟΥΒΚΟΤ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΒΟΪ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͟ͺΗ͑ΪΠΦ͑ΕΖΔΚΕΖ͑ΥΠ͑ΔΠΞΡΝΖΥΖ͑ΒΟ͑ ΒΡΡΝΚΔΒΥΚΠΟ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΚΟ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͝ΪΠΦ͑ΨΚΝΝ͑ΓΖ͑ΒΤΜΖΕ͑ΥΠ͑ΡΣΠΧΚΕΖ͑ΥΙΚΤ͑ΚΟΗΠΣΞΒΥΚΠΟ͑͟΅ΙΚΤ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΚΤ͑ΟΦΞΓΖΣΖΕ͑ ΥΠ͑ΔΠΣΣΖΤΡΠΟΕ͑ΥΠ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΡΡΝΚΔΒΥΚΠΟ͑͟ 3. Employer name
4. Employer Identification Number (EIN)
5. Employer address
6. Employer phone number
PuppySpot LLC
75-3203646
7261 Sheridan Street Suite 300A
866-706-7337
7. City
8. State
Hollywood
10. Who can we contact about employee health coverage at this job?
FL
9. ZIP code
33024
Lauren Sobel
11. Phone number (if different from above)
͑
12. Email address
[email protected]
ΖΣΖ͑ΚΤ͑ΤΠΞΖ͑ΓΒΤΚΔ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΥΙΚΤ͑ΖΞΡΝΠΪΖΣͫ͑ x ͲΤ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͝ΨΖ͑ΠΗΗΖΣ͑Β͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑ΥΠͫ͑ �
ͲΝΝ͑ΖΞΡΝΠΪΖΖΤ͑͑͟ͶΝΚΘΚΓΝΖ͑ΖΞΡΝΠΪΖΖΤ͑ΒΣΖͫ͑ ͑ Full Time Employees who have completed the waiting period, coverage beginning first of the month following 60 ͑ days. ͑ ͑ ͑
΄ΠΞΖ͑ΖΞΡΝΠΪΖΖΤ͑͟ͶΝΚΘΚΓΝΖ͑ΖΞΡΝΠΪΖΖΤ͑ΒΣΖͫ͑͑ ͑ ͑ ͑ ͑ ͑ x ΈΚΥΙ͑ΣΖΤΡΖΔΥ͑ΥΠ͑ΕΖΡΖΟΕΖΟΥΤͫ͑
ΈΖ͑ΕΠ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑͟ͶΝΚΘΚΓΝΖ͑ΕΖΡΖΟΕΖΟΥΤ͑ΒΣΖͫ͑ ͑ ͑ ͑ ͑
ΈΖ͑ΕΠ͑ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑͟ ͑
ͺΗ͑ΔΙΖΔΜΖΕ͑͝ΥΙΚΤ͑ΔΠΧΖΣΒΘΖ͑ΞΖΖΥΤ͑ΥΙΖ͑ΞΚΟΚΞΦΞ͑ΧΒΝΦΖ͑ΤΥΒΟΕΒΣΕ͑͝ΒΟΕ͑ΥΙΖ͑ΔΠΤΥ͑ΠΗ͑ΥΙΚΤ͑ΔΠΧΖΣΒΘΖ͑ΥΠ͑ΪΠΦ͑ΚΤ͑ΚΟΥΖΟΕΖΕ͑ ΥΠ͑ΓΖ͑ΒΗΗΠΣΕΒΓΝΖ͑͝ΓΒΤΖΕ͑ΠΟ͑ΖΞΡΝΠΪΖΖ͑ΨΒΘΖΤ͑͟ ͑ ͛͛͑ ͶΧΖΟ͑ΚΗ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΚΟΥΖΟΕΤ͑ΪΠΦΣ͑ΔΠΧΖΣΒΘΖ͑ΥΠ͑ΓΖ͑ΒΗΗΠΣΕΒΓΝΖ͑͝ΪΠΦ͑ΞΒΪ͑ΤΥΚΝΝ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΡΣΖΞΚΦΞ͑ ΕΚΤΔΠΦΟΥ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͟΅ΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΨΚΝΝ͑ΦΤΖ͑ΪΠΦΣ͑ΙΠΦΤΖΙΠΝΕ͑ΚΟΔΠΞΖ͑͝ΒΝΠΟΘ͑ΨΚΥΙ͑ΠΥΙΖΣ͑ΗΒΔΥΠΣΤ͑͝ ΥΠ͑ΕΖΥΖΣΞΚΟΖ͑ΨΙΖΥΙΖΣ͑ΪΠΦ͑ΞΒΪ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΡΣΖΞΚΦΞ͑ΕΚΤΔΠΦΟΥ͑͟ͺΗ͑͝ΗΠΣ͑ΖΩΒΞΡΝΖ͑͝ΪΠΦΣ͑ΨΒΘΖΤ͑ΧΒΣΪ͑ΗΣΠΞ͑ ΨΖΖΜ͑ΥΠ͑ΨΖΖΜ͙͑ΡΖΣΙΒΡΤ͑ΪΠΦ͑ΒΣΖ͑ΒΟ͑ΙΠΦΣΝΪ͑ΖΞΡΝΠΪΖΖ͑ΠΣ͑ΪΠΦ͑ΨΠΣΜ͑ΠΟ͑Β͑ΔΠΞΞΚΤΤΚΠΟ͑ΓΒΤΚΤ͚͑͝ΚΗ͑ΪΠΦ͑ΒΣΖ͑ΟΖΨΝΪ͑ ΖΞΡΝΠΪΖΕ͑ΞΚΕ͞ΪΖΒΣ͑͝ΠΣ͑ΚΗ͑ΪΠΦ͑ΙΒΧΖ͑ΠΥΙΖΣ͑ΚΟΔΠΞΖ͑ΝΠΤΤΖΤ͑͝ΪΠΦ͑ΞΒΪ͑ΤΥΚΝΝ͑ΦΒΝΚΗΪ͑ΗΠΣ͑Β͑ΡΣΖΞΚΦΞ͑ΕΚΤΔΠΦΟΥ͑͟ ͑ ΖΒΝΥΙʹΒΣΖ͟ΘΠΧ ΨΚΝΝ͑ΘΦΚΕΖ͑ΪΠΦ͑ΥΙΣΠΦΘΙ͑ΥΙΖ ΡΣΠΔΖΤΤ͑͟ΖΣΖ͘Τ͑ΥΙΖ͑ ͺΗ͑ΪΠΦ͑ΕΖΔΚΕΖ͑ΥΠ͑ΤΙΠΡ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΚΟ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͝ ΖΒΝΥΙʹΒΣΖ͟ΘΠΧ͑ΥΠ͑ΗΚΟΕ͑ΠΦΥ͑ΚΗ͑ΪΠΦ͑ΔΒΟ͑ΘΖΥ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΠ͑ΝΠΨΖΣ͑ΪΠΦΣ͑ ΖΞΡΝΠΪΖΣ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΪΠΦ͘ΝΝ͑ΖΟΥΖΣ͑ΨΙΖΟ͑ΪΠΦ͑ΧΚΤΚΥ͑ ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞΤ͑͟ ͑
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Guide to Your
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Guide to Your
2020-2021 Benefits Notes ——————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————
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This booklet is intended to provide only the highlights of your benefits; see your plan documents for full details. If any conflict ever arises between this booklet and the actual plan document, the terms of the plan document will govern in all cases. PuppySpot LLC reserves the right to change, modify, or terminate the benefit plans at any time. This booklet is not a contract for purposes of employment or payment of benefits.