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2015Benefits Guide
Benefits to Fit Your Style
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Benefits are an important part of your total compensation at Steve Madden. As a Steve Madden employee, you receive a competitive package of benefits offering flexibility, financial protection and a foundation for future security. Your benefits work together to provide you and your family the coverages that best fit your personal situation.
This Benefits Guide describes the details of our benefits as well as the information you need to make your elections. Please be sure to carefully review your Benefits Guide so you have a better understanding of the plans offered and elect the coverages that are right for you and your family.
WELCOME TO STEVE MADDEN’S 2015 BENEFITS PROGRAM
This Benefits Guide provides only a brief summary of the benefits available under the Steve Madden Benefits Program. In the event of a discrepancy between this Guide and the Plan Document, the Plan Document will prevail. Steve Madden retains the right to modify or eliminate these or any other benefits at any time and for any reason.
Steve Madden Benefit Service CenterCall Toll-Free l 877.459.9696
Benefit Specialists are available Monday to Friday, 9:00 a.m. – 5:00 p.m., EST
Email l [email protected]
Send email inquiries anytime; emails received after 5:00 p.m. Monday to Friday will be answered the following business day
Page
Eligibility....................................................................................1
Enrollment...............................................................................2
Wellness
Steve Madden Wellness Tools & Resources .......3
Health Care
Medical......................................................................................4
Dental.........................................................................................6
Vision..........................................................................................7
Financial Protection
Life & Accident Insurance...............................................8
Disability....................................................................................9
Work/Life
Commuter Benefits.........................................................10
Flexible Spending Accounts (FSAs).......................11
Other Benefits.................................................................13
2015 Employee Contributions............................14
Important Contact Information.........................15
Legal Notifications.......................................................16
Domestic Partnership ..............................................28
Affidavit of Marriage...................................................31
1
ELIGIBILITYEligibility
For You. All regular full-time employees are eligible to participate in the Steve Madden medical, dental, vision, life and accidental death/dismemberment and disability plans, commuter, flexible spending, and health savings accounts.
Benefits become effective:
Corporate: 1st of the month following 30 days
Retail (Stores):1st of the month following 60 days
If you are a Variable Hour Employee who averages at least 30 hours worked per week over a 12 month period (and are still employed by Steve Madden at the end of the period), you will be offered health insurance for you and your dependents. If you accept the offer of coverage and pay for the coverage, you may maintain the coverage through a 12-month period, also known as “stability period”.
Eligible Dependents:
l Your legal spouse or domestic partner
l Your unmarried children who depend on you for support, including stepchildren, adopted children, and children of your domestic partner
Dependent Eligibility Through:
lMedical: to the end of the month of their 26th birthday
lDental: to age 20 or 26th birthday if full-time student status
lVision: to age 20 or 26th birthday if full-time student status
l Your disabled child of any age who is dependent on you for support due to a mental or physical handicap that occurs while your child is covered under the plan(s).
Dependent Verification
Steve Madden has a responsibility to ensure that only eligible expenses are paid from the benefit plans. This requirement is consistent with IRS regulations that govern the operation of a qualified plan.
Therefore, in order to complete your dependent enrollment, you will be required to submit verification. If you do not submit the required documentation within 31 days from your benefits effective date, your dependents will not have benefits coverage.
The following are acceptable forms of Dependent Verification:
l Spouse: Marriage certificate or affidavit
l Domestic Partner: Domestic partner affidavit and joint lease/bank account or proof of same residence
l Child(ren): Birth certificate or copy of the first page of the previous year’s tax return or proof of legal guardianship
Making Changes During the Year
The IRS requires that elections for benefits paid for on a before-tax basis remain in effect for the full calendar year. However, the IRS permits mid-year changes within 31 days of a qualifying life event. Examples of qualifying life events are:
l Your marriage, divorce, legal separation or annulment,
l The birth of your baby, or adoption or placement of a child with you for adoption, or another change in the number of your dependents,
l Your dependent’s/dependent of domestic partner’s eligibility or ineligibility for coverage (for example, he or she reaches the plan’s eligibility age limit, becomes or ceases to be a student or becomes married),
l A change in work location or home address for you, your spouse/domestic partner or your dependents/dependent’s of domestic partner,
l A change in coverage of your spouse or your dependent under another employer’s plan. This would include election changes resulting from election cycles that differ from Steve Madden’s,
l Your qualification for a special enrollment under the Health Insurance Portability and Accountability Act of 1996 (HIPAA),
l A court order received by the plan, such as a Qualified Medical Child Support Order (QMCSO), or
l You, your spouse/domestic partner’s or your dependent/dependent of domestic partner’s qualification for Medicare or Medicaid.
It is your responsibility to notify the Steve Madden Benefit Service Center within 31 days of any qualifying event and provide any required documentation as proof of your life status change.
Any change in coverage must be consistent with your life status change. If you need to make an election change during the year or have questions about what constitutes a life status change, contact the Steve Madden Benefit Service Center at 877.459.9696.
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ENROLLMENTThis is your opportunity to choose health and other insurance coverage for you and your family for the year. Before you make any decisions about your benefits, it’s important that you understand all of your options. Be sure to review the remainder of this Guide to learn more about your benefits as well as the information available on the Steve Madden Benefit Portal.
To enroll, you will need to access the Steve Madden Benefit Portal to view the benefits available to you and make your elections. See below for instructions on how to enroll for benefits.
After You EnrollOnce you have completed your online enrollment, you can print or request a confirmation statement. If you need to correct a discrepancy, contact the Steve Madden Benefit Service Center at 877.459.9696 as soon as possible. Generally, you cannot make any changes after your enrollment deadline unless you experience a qualifying life event as described on page 1.
You will receive ID cards in the mail at home.
Your ContributionsYou and Steve Madden share the cost of your benefits. Costs for your 2015 benefit options are shown online when you enroll. Steve Madden helps you save on taxes by deducting your contributions for medical, dental, and vision plans, and flexible spending and health savings accounts from your paycheck on a pre-tax basis.
Contributions for other benefits such as voluntary life and disability are deducted from your paycheck on an after-tax basis.
Coverage Levels
Medical Dental & Visionl Employee onlyl Employee + Spousel Employee + Childl Family
l Employee onlyl Employee + spouse/
domestic partnerl Employee + child(ren)l Family
How to Enrolll Visit: www.crystalconnect.com/stevemadden
l Username: stevemadden
l Password: benefits
Select “Click Here”, you will then be brought to the Steve Madden Benefit Portal login screen
l Create an account
l Make a note of your Username and Password for future use
l Review the benefits information available online and then click “Enroll Now” to make your elections.
Remember! If you are a new hire, you must enroll within 30 days of your benefit effective date. Otherwise, you may not have all of the coverages you need.
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STEVE MADDEN WELLNESS TOOLS & RESOURCESAt Steve Madden, we encourage everyone to take an active role in managing his or her health. Getting an annual physical and health screening as well as eating healthy and staying active help to maintain a healthier lifestyle.
Reduce your Medical Premiums
You can receive a total reduction of $20 bi-weekly on your 2015 medical premiums by completing the steps below.
Non-Tobacco Status. If you are a non-tobacco user, or if you are a tobacco user and will enroll in a tobacco cessation program, you will receive a $10 bi-weekly reduction to your 2015 medical premiums. Complete your attestation at www.stevemadden.hrintouch.com upon benefit enrollment.
Well Being Assessment. Receive a $10 bi-weekly reduction on your 2015 medical premiums by completing a confidential online well being assessment at www.empireblue.com.
To qualify for the Well Being Assessment (WBA) reduction, you must complete the steps under “How to complete your Well Being Assessment”. Your payroll reduction will become effective 1st of the month following 30 days from the date you complete the WBA. For example; If you complete the WBA on 3/15/15, your reduction will be reflected in your paycheck effective 5/1/15.
Completing an online well being assessment can help you take positive steps to get and stay healthy.
If you have any questions regarding the status of your
www.empireblue.com
As an Empire member, you can log on to Empire’s secure website (www.empireblue.com) and take advantage of:
l Health information. To learn about various diseases and conditions and the ways to prevent theml Insurance information. To become an informed consumerl Personalized tools. To help you better manage your healthl Financial tools. To help you spend your health care dollars more wisely
reductions, please call the Steve Madden Benefit Service Center at 877.459.9696.
How to complete your Well Being Assessment
1. Log in to Empire’s secure member website at www.empireblue.com and select “Register” to complete the registration screens. Once you’ve registered, log in to get started.
2. Click on “Health & Wellness” tab
3. Select “Get Started” under the Healthy Lifestyles section
4. Accept the Healthy Lifestyles terms and conditions and click “Submit”.
5. Select “Well Being Assessment”, and then select “Start”. Answer all of the questions then click “Finish”.
6. Once you have clicked “Finish”, wait for the system to process your answers, then you can view your results. You may also call 877.252.8410 to confirm completion of the assessment.
What You Can Expect
During the well being assessment, you will be asked about your health history — conditions you have and your current weight.
You’ll also see questions about your modifiable health risks. These are the health habits you can change, like eating more fruits and vegetables or wearing SPF when you’re in the sun.
Your answers can help you:
l Understand your health needs and goals
l Pick an online wellness program that fits your needs
l Better manage your health risks
l Identify health concerns to share with your doctor
Important Note: You must wait 15 days after your medical effective date to complete your WBA. If you make your medical election after your medical effective date, you must wait an additional 15 days to complete your WBA. If you attempt to complete the WBA earlier, your record will not be in the Empire system.
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MEDICAL BENEFITS
Filing Claims for Out-of-Network BenefitsWith the Empire medical plans, you may be required to submit claim forms if you use out-of-network providers. Claim forms are available from Empire Member Services. If you have questions about submitting claims, call Empire Member Services at 855.880.0575. Claim forms are also available online at www.empireblue.com.
Steve Madden offers you a choice of three medical plans. All Steve Madden medical plans give you access to the same Empire network in your area. Regardless of the plan you elect, you will have access to a wide range of doctors, hospitals and other health care providers who have agreed to provide services at a discounted rate—a significant savings for you and Steve Madden.
If you do not want to enroll you can choose to waive medical coverage.
Empire Prism PPO Plan and Empire HSA Plan
The Empire PPO Plan and Empire HSA Plan are open access, which gives you the flexibility to go to any doctor or hospital you wish. They do not require you to select a primary care physician (PCP), obtain referrals to see a specialist or go to the hospital. These plans also give you the freedom to go outside the network for care whenever you like. However, you’ll pay more for your care if you use an out-of-network provider.
Please note: Empire HSA Plan members are eligible to enroll in the Health Savings Account.
The following information further explains the differences between in-network and out-of-network coverage in a PPO plan.
Empire PPO Plans: In-Network vs. Out-of-NetworkIn-Network: Out-of-Network:l You can see any network provider without a referral
from a PCP.
l You pay lower out-of-pocket costs.
l There are no claim forms and no surprises with usual, customary and reasonable (UCR) limits.
l The plan pays 100% of most office visits after you pay a modest copay for services; no deductible applies.
l Preventive care services are covered at 100%.
l There is no in-network lifetime maximum.
l You pay a higher percentage of the cost of services.
l The cost of out-of-network services may exceed the usual, customary and reasonable (UCR) limits. The plan pays 70% of the UCR after you meet the annual deductible. You pay the full cost for charges not covered by the plan.
l You must pay the full cost at the time of service and you may be required to submit claim forms to Empire for reimbursement.
l Preventive care services are covered 70% after deductible for adults.
l There is no out-of-network lifetime maximum.
Find a Network ProviderTo find a network provider in your area,
please call Empire at 855.880.0575 or log on to www.empireblue.com.
2015 Medical ContributionsFor monthly and per pay period pre-tax medical contributions, see page 14.
Empire Prism EPO Plan
The Empire EPO Plan is an open access exclusive provider organization, which gives you the flexibility to go to any doctor or hospital you wish. It does not require you to select a primary care physician (PCP), obtain referrals to see a specialist or go to the hospital.
The EPO plan provides for in-network coverage; no out-of-network benefits are covered except in an emergency.
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MEDICAL BENEFITS (cont.)The chart below provides a brief comparison of the coverage levels under each medical plan option available to you.
Empire PPO Plan Empire EPO Plan Empire HSA Plan
In-Network Out-of-Network1 In-Network Only In-Network Out-of-Network1
Annual Deductiblel Individuall Family
N/AN/A
$750$1,875
N/AN/A
$1,500$3,000
$3,000$6,000
Plan Coinsurance 100% 70% 100% 80% 50%
Annual Out-of-Pocket Maximum2
l Individuall Family
(includes Rx cost shares)
$5,250$10,500
$5,250$13,125
(includes Rx cost shares)
$6,350$12,700
(includes Rx cost shares)
$4,000$8,000
$25,000$50,000
Office Visitsl Primary Carel Specialist
$30 copay$30 copay
Covered 70% after ded.Covered 70% after ded.
$30 copay$30 copay
Covered 80% after ded.Covered 80% after ded.
Covered 50% after ded.Covered 50% after ded.
Preventive Carel Child(ren)l Adult
Covered 100%Covered 100%
Covered 100%Covered 70% after ded.
Covered 100%Covered 100%
Covered 100%Covered 100%
Covered 50% after ded.Covered 50% after ded.
Diagnostic Lab & X-Ray (Outpatient)
Covered 100% Covered 70% after ded. Covered 100% Covered 80% after ded. Covered 50% after ded.
Inpatient Hospital Covered 100% Covered 70% after ded. Covered 100% Covered 80% after ded. Covered 50% after ded.
Outpatient Surgery Covered 100% Covered 70% after ded. Covered 100% Covered 80% after ded. Covered 50% after ded.
Emergency Room3 $75 copay $75 copay $75 copay Covered 80% after ded. Covered 50% after ded.
Urgent Care $35 copay Covered 70% after ded. $35 copay Covered 80% after ded. Covered 50% after ded.
Durable Medical Equipment
Covered 100% Covered 70% after ded. Covered 100% Covered 80% after ded. Covered 50% after ded.
Mental Health & Substance Abusel Inpatientl Outpatient
Covered 100%$30 copay
Covered 70% after ded.Covered 70% after ded.
Covered 100%$30 copay
Covered 80% after ded.Covered 80% after ded.
Covered 50% after ded.Covered 50% after ded.
Prescription Drug Coverage
Retail (30-day supply)l Genericl Formulary
Brand Namel Non-Formulary
Brand Name
$10 copay$25 copay
$50 copay
N/AN/A
N/A
$10 copay$25 copay
$50 copay
(Ded. waived for selective preventative drugs)
Deductible then;$10 copay$25 copay
$50 copay
N/AN/A
N/A
Mail Order (90-day supply)l Genericl Formulary
Brand Namel Non-Formulary
Brand Name
$20 copay$50 copay
$100 copay
N/AN/A
N/A
$20 copay$50 copay
$100 copay
(Ded. waived for preventative drugs)
Deductible then;$20 copay$50 copay
$100 copay
N/AN/A
N/A
1Out-of-network services are subject to usual, customary and reasonable (UCR) limits for similar services in your geographic area. There are no UCR limits for in-network care.2Annual out-of-pocket maximum includes prescription drug cost-share.3No coverage if not a true emergency; copay/deductible waived if admitted to hospital for the PPO and EPO plans only..
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DENTAL BENEFITSSteve Madden offers a dental plan administered by Guardian. You may enroll in dental coverage even if you do not enroll in any other benefits offered through Steve Madden.
If you do not want to enroll in the dental plan, you have the option to waive coverage.
Guardian PPO Plan: In-Network & Out-of-Network
The PPO Plan gives you the freedom to choose any dentist you like, however, you pay less out-of-pocket when you see a participating provider. Dentists participating in the provider network, have agreed to negotiated fees and there is no balance billing.
When using out-of-network providers, claims will be reimbursed at the 90th percentile of Reasonable & Customary, which means you may be balance billed for any amounts over what is considered reasonable and customary for your geographic region.
Guardian Plan Features
In-Network Out-of-Network
Calendar-Year Deductiblel Individuall Family
$50
$150
$50
$150
Calendar-Year Maximum (Basic & Major) $1,500 $1,500
Diagnostic & Preventive Services (e.g., teeth cleanings, fluoride treatments, x-rays)
100% 80%
Basic Restorative Services (e.g., anesthesia, fillings, simple extractions)
80% 80%
Major Restorative Services (e.g., crowns, bridges and dentures, inlays/onlays)
50% 50%
Orthodontia Services Not covered Not covered
Find a Network ProviderTo find a network provider in your area, please
call Guardian at 800.541.7846 or log on to www.guardiananytime.com.
2015 Dental ContributionsFor monthly and per pay period pre-tax dental contributions, see page 14.
The Guardian network dentists charge you only the patient’s share at the time of treatment. You have the freedom to choose a dental provider outside the Guardian network and receive out-of-network benefits.
Note: Non-participating providers may require you to pay the entire amount of the bill in advance. You will then have to submit a claim form for reimbursement. You will receive an ID card
Maximum Rollover ProvisionIf you utilize dental benefits at least once during the calendar year, this plan has a provision to rollover a portion of your unused calendar-year maximum to the following year into a Maximum Rollover Account (MRA) to be used in future years when you reach the plan’s calendar-year maximum.
You can learn more about the maximum rollover provision and view your MRA account when you log on to www.guardiananytime.com.
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VISION BENEFITSSteve Madden offers a vision plan administered by Guardian. You may enroll in vision coverage even if you do not enroll in any other benefits offered through Steve Madden.
If you do not want to enroll in the vision plan, you have the option to waive coverage.
Guardian VSP Plan: In-Network and Out-of-Network
The Steve Madden Vision Service plan (VSP) gives you the freedom to use VSP network providers or to go outside of the VSP network.
l If you use a VSP provider, the vision plan will pay most of your vision expenses and you will not have to submit a claim form.
l If you do not use a VSP provider, you’ll pay your provider in full at the time of service and will submit a claim form to VSP for partial reimbursement.
Guardian Vision Plan Features
In-Network Out-of-Network
Exams(once every 12 months)
100% after $10 copay Plan pays up to $46
Eyeglass Lenses(once every 12 months)Single vision, lined bifocal and lined trifocal lenses; includes scratch-resistant coating
100% after $20 copay Single: Plan pays up to $47Bifocal: Plan pays up to $66Trifocal: Plan pays up to $85
Lenticular: Plan pays up to $125
Frames(once every 24 months)
$115 allowance and a 20% discount above the allowance
Up to $47
Contact Lenses(once every 12 months instead of lenses/frames)l Electivel Medically Necessaryl Evaluation & Fitting
Plan pays up to $105100% after $20 copay
15% off UCR
Plan pays up to $105Plan pays up to $210
No discounts
If you enroll in the vision plan, you’ll also be eligible for discounts and savings on laser vision correction, antireflective coatings and progressive lenses, prescription glasses and sunglasses, and exclusive pricing on annual supplies of popular brand-name contacts.
Note: You will receive a special ID card for vision coverage.
Find a Network ProviderTo find a VSP vision care provider in your area, please call VSP directly at 800.877.7195 or search through Guardian by visiting www.guardiananytime.com.
2015 Vision ContributionsFor monthly and per pay period pre-tax vision contributions, see page 14.
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LIFE INSURANCE BENEFITSLife & Accident Insurance
The Company offers you valuable financial protection for you and your family in the event of death or a serious accident. Steve Madden pays the full cost for your basic life and accidental death and dismemberment insurance coverage; you pay nothing. Life insurance coverage is offered through Guardian.
Basic Life Insurance
As a Steve Madden employee, you receive $50,000 of basic life insurance coverage automatically at no cost to you.
Basic Accidental Death and Dismemberment (AD&D) Insurance
In addition to basic life insurance, you also receive basic accidental death and dismemberment (AD&D) insurance automatically at no cost to you. Your coverage is equal to your basic life insurance amount ($50,000). The amount of the benefit you or your beneficiary receive is based on the severity of your loss.
Voluntary Life Insurance & AD&D
For Yourself. You may elect voluntary life insurance & AD&D coverage for yourself in $10,000 increments up to a maximum of 5x your annual salary or $500,000, whichever is less. If you do not want voluntary life insurance coverage, you may waive it. You may elect up to $250,000 at guaranteed issue. That is, you do not have to provide Evidence of Insurability.
For Your Dependents. In addition to your own life insurance coverage, you may also want protection from the financial burdens that could accompany the death of a spouse/registered domestic partner or a dependent child. You are automatically the beneficiary for this coverage.
l Spouse/registered domestic partner: Benefit in $5,000 increments up to a maximum of 2.5x your annual salary or $250,000, whichever is less, not to exceed 50% of your elected voluntary life amount. Any amount elected over $50,000 is subject to Evidence of Insurability.
l Child(ren) (14 days to age six months): $250
l Child(ren) (age six months to age 19 or age 25 if full-time student): $10,000
Note: In order to elect coverage for your dependents, you must elect voluntary coverage for yourself.
Beneficiary Designation You must designate a beneficiary for company paid life insurance coverage. If you name more than one beneficiary, be sure to indicate the percentage you wish each beneficiary to receive. The percentages must total 100%.
You can update your beneficiary designations anytime during the year.
Note: It is important to keep your beneficiary designations up-to-date. Be sure to review your beneficiary designation elections and make any updates as necessary.
Benefit Reduction at Age 70
If you have reached age 70, your amount of life insurance will be reduced by 35%. Then, reduced by an additional 20% at age 75 and further reduced by 15% at age 80.
Evidence of Insurability
If you elect voluntary life insurance coverage over the guaranteed issue amount or elect for it the first time at the next open enrollment period, you will need to provide Evidence of Insurability. For any voluntary coverage that is subject to Evidence of Insurability, your contributions will take effect once your application is received and approved by Guardian.
Voluntary Life/AD&D Insurance Monthly Rates for Employee/Spouse
Age of Employee
Rates per $1,000
Age of Employee
Rates per $1,000
Under 29 $0.067 55-59 $0.677
30-34 $0.077 60-64 $0.73735-39 $0.107 65-69 $1.33740-44 $0.157 70-74 $2.71745-49 $0.237 75-79 $7.74750-54 $0.437 80+ $17.097
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DISABILITY BENEFITS
How the LTD Plan Works
After 180 days of disability, you become eligible for LTD benefits if the claims administrator certifies that you cannot perform the duties of your regular job because of illness or injury. After 24 months of disability payments, you are eligible for continued LTD benefits if the claims administrator determines that you are unable to work at any job for which you are reasonably qualified, based on training, education and experience.
Your LTD benefit is reduced by any disability income payable from the following sources:
l Social Security (that you or your family receives),
l Workers’ Compensation or a similar law,
l Any Steve Madden-sponsored pension plan or group insurance plan providing benefits for loss of work because of disability, and
l State-mandated disability programs.
However, LTD benefits are not reduced by federal, state, local income taxes or FICA. In addition, LTD benefits are not reduced by any private disability coverage that you have purchased. There is a 24-month limit on mental health and self-reported claims (such as a sore back that cannot be substantiated by a doctor).
Disability Benefits
Steve Madden provides you with disability benefits in the event you are out of work for a period of time due to a non-work related injury or illness. Disability coverage is offered through Guardian.
Short-Term Disability (STD)
Should you be absent from work due to an extended illness or injury, you may be eligible for Short Term Disability. You must be disabled and out of work for eight days (14 days for manager) before benefits may begin. Steve Madden pays the full cost of your basic short-term disability insurance coverage; you pay nothing. The plan pays:
50 % of your weekly earnings up to $1,000 per week while you are disabled for up to 26 weeks.
Long-Term Disability (LTD)
The LTD Plan provides a source of income if you are totally disabled for more than 180 days and you are unable to return to work. The LTD plan pays a continuing monthly income as follows:
Class 1: Manager
60% of your average monthly earnings up to $10,000 per month
Class 2: Non-Manager
60% of your average monthly earnings up to $5,000 per month
Voluntary Short-Term Disability (STD)
You can elect to increase, or “buy-up”, your weekly STD benefit if your current annual salary is higher than $52,001. If Eligible and you enroll, the plan pays:
50% of your weekly earnings up to $500 per week while you are disabled for up to 26 weeks.
Voluntary Short Term Disability Contributions$0.16 per $10 of weekly benefit
Steve Madden contributes 75% of the cost for LTD coverage; you pay the remaining 25%.
Voluntary Long Term Disability Contributions$0.19 per $100 of monthly covered payroll
New! Effective 01/01/2015
Steve Madden added a paid leave policy! If you have an FMLA qualified reason, you may be eligible for paid leave. Benefits are based on seniority and supporting medical documentation will be required. For more information contact [email protected].
You have the Option to choose “Tax Free” or “Taxable”
l If you choose the “Tax-Free” option, the cost of the LTD premium will be included in your W-2 as taxable income. By doing so, the monthly benefit – should you file an LTD claim – will convert to a tax-free benefit.
lIf you choose “taxable” – should you file an LTD claim – you will be required to pay taxes on benefit monies received. Should you file an LTD claim, the monthly benefit would be taxed.
10
COMMUTER BENEFITSCommuter benefits, available through Benefit Resource Inc., allow you to pay for eligible transportation expenses incurred when commuting to and from work with tax-free money. Thismeans you can receive an eTrac card to purchase passes and tickets for all major public transportation (e.g., subway, train, bus, ferry), nationwide. You can even pay for parking expenses.
Contribution Amount
You may contribute up to the following monthly maximums determined by the IRS:
Transportation Amount Per MonthTransit expenses $130*Parking expenses $250*
* Monthly amounts subject to change by the IRS* The full elected contibution will be taken on the second
paycheck of the month.
Like premiums for your health care benefits and contributions to an FSA, all commuter benefit contributions are deducted from your paycheck on a pre-tax basis up to the monthly IRS limits. This means your contributions are deducted from your paycheck before Social Security, Federal and State income taxes are withheld, further lowering your income for tax purposes. You can also elect to contribute above the pre-tax monthly amounts above. Any election above the pre-tax amounts will be deducted post-tax. You should only elect Post-Tax Transit and Post-Tax Parking plans if you’ve elected the pre-tax maximum in the Pre-Tax Transit and Pre-Tax Parking plans.
Enrolling or Changing Your ElectionIf you need to enroll in or change your CommuterBenefit election, you may do so throughout the year. You may enroll or change your transit or parking plan elections during the first seven days of each month. All enrollments or election changes are effective the 1st of a calendar month subsequent to the close of the monthly election period. For example, if you enroll on January 3rd, you will receive your eTrac card at the end of February and available to use for March expenses.
You can make your Commuter Benefit elections and changes by visiting the Steve Madden Benefit Portal at www.stevemadden.hrintouch.com and click on “Employee Login.”
Any available balances you have for transit and parking are rolled over from month to month automatically. There is no restriction on the amount you can carry over.
Keep in mind that if you leave the company, your account will be transferred to an individual plan and you will receive a new Beniversal Card. The new card will be loaded with the remaining funds directly from Benefit Resource Inc.
Register for your commuter benefits through The Steve Madden Benefit Portal
11
FLEXIBLE SPENDING ACCOUNTSThere are two separate Flexible Spending Account choices: Health Care and Dependent Care. Both are offered through Benefit Resource Inc. By participating in a Flexible Spending Account, you can experience valuable tax savings while guaranteeing money is available for important expenditures.
The Health Care FSA enables you to set aside money for covered health-related, out-of-pocket medical expenses, such as physician or prescription copays, insulin, first aid supplies, prescription eyeglasses, contact lens solutions and supplies and out-of-pocket dental expenses.
If you are enrolled in the Empire HSA plan, you can set money aside tax-free under a Limited Purpose FSA which allows you to reimburse dental and vision expenses only.
FSA Feature Health Care FSA/Limited Purpose Health Care FSA Dependent Care FSAHow much you can contribute each plan year
Up to $2,550. Up to $5,000.(Up to $2,500 if you file taxes as “married, filing sep-arately.” Your contribution cannot be greater than your spouse’s annual salary.)
Eligible dependents
Eligible dependents include: l Your children for whom you are a legal guardian and
who depend on you for financial support and you claim as dependents on your income tax return; and
l Your legal spouse.
Eligible dependents include: l Your children under age 13; l Your spouse, if physically or mentally incapa-
ble of self-care; and l Any other person residing in your household
and considered a dependent for tax purposes who is physically or mentally incapable of self-care, regardless of age.
How much you’re reimbursed
Up to the total amount you elected for the calendar year. Up to the amount of the current contributions in your account; if your expense is greater than your account balance, you’ll be reimbursed once you’ve contributed enough to pay for the expense.
Effect on future benefits
The amount of your future Social Security benefits may be slightly reduced because neither you nor the Company will pay Social Security taxes on your FSA contributions. Your Social Security benefit will not be re-duced at all if your earnings after your FSA deductions are more than the Social Security Wage Base ($115,500 for 2014).
With the Dependent Care FSA, you can pay for nursery schools, summer day camps, daycare and other similar expenses.
For the FSAs, pre-tax dollars are deducted from your pay before federal income taxes and Social Security taxes are calculated. That means you pay for eligible expenses with dollars that have not already been subject to these taxes.
The chart below highlights the features of each account — how much you can contribute, who’s eligible and how you’re reimbursed.
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Do the Math: Example of How a Health Care and Dependent Care FSA Can Save You Money
Cindy is married and filing jointly with a household income of $60,000. Cindy anticipates that her family will have $5,000 in eligible health care and dependent care expenses:
Without FSA With FSACombined Annual Income $60,000 $60,000
Pre-Tax Health Care & Dependent Care Contributions $0 $5,000
Taxable Income $60,000 $55,000
Federal Income Tax and Social Security Taxes $21,390 $19,608
After-Tax Health Care & Dependent Care Contributions $5,000 $0
Take Home Pay $33,610 $35,392Cindy saves $1,782 annually in taxes by participating
in a Health Care and Dependent Care FSA.
Note: Above example assumes 28% federal tax rate and 7.65% for Social Security; example has not taken into account any state or local taxes.
Plan Carefully: Use It or Lose It for Balances Over $500
Although there’s no way to completely predict what the future will bring, it’s a good idea to take a few minutes to review your current health care and dependent care expenses and estimate what your expenses will be for 2015.
Monies must be used within the plan year. You can carry forward up to $500 of unused funds which can be used after April of the following year. Any balances above $500 will be forfeited.
For a complete listing of reimbursable health care and dependent care expenses, you may call the IRS at 800.829.3676 and request Publications #502 (health care) or #503 (dependent care). You may also access these publications through the Internet at: www.irs.gov or the Steve Madden Benefit Portal.
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OTHER BENEFITSEmployee Assistance Program (EAP)
Steve Madden has teamed up with Guardian to provide assistance to you when you need it most. EAP offers you guidance with personal issues and concerns from balancing a career and life to obtaining legal guidance. The WorkLifeMatters program, through a dedicated team of counselors and service professionals, is able to help provide help and support with issues such as:
• Emotional Well‐being
• Relationship Issues
• Workplace Challenges
• Legal and Financial Concerns
• Health and Wellness
• Community Resources
• Manager Resources
• Assist with resolving claims and billing issues
If you would like to contact the EAP Support Center, please call 800.386.7055 or log on www.ibhworklife.com.
TravelAid Services
This benefit provides you and your dependents with a safety net for both personal and business travel. No matter if you are 100 miles or over 5,000 miles away from home, TravelAid is available around the clock and around the world to ensure assistance when you need help the most - whether it’s a medical emergency or simply replacing travel documents. For more information, visit www.guardiananytime.com.
College Tuition Reimbursement
Earn free Tuition Rewards for participation in the Guardian Dental Plan. Your participation in the Guardian Dental Plan will earn you Tuition Rewards that can be used to pay for up to one year’s tuition at a SAGE Scholar college.
Following your dental plan enrollment, you will receive a Welcome email. Check your spam folder. If you do not receive a welcome email contact [email protected]. The welcome email is notification that an online account is established. You can log in to see the points posted to your account, and add additional students as you wish. One Tuition Reward point = $1. If you do not log in to your account in the first 6 months, your Tuition Reward may be reduced.
For more information, visit www.collegetuitionbenefit.com.
This benefit is being provided to you by Steve Madden at no cost to you.
Health Advocate
Steve Madden has teamed up with Health Advocate to assist employees with questions during enrollment, as well as provide Clinical Services, Administrative Services, Health Coaching, and Information & Service Support. Health Advocate can also research provider quality information to assist employees in making informed decisions about where to have elective tests and surgeries performed.
The first time you call, you will be assigned a Personal Health Advocate who will help you:
• Find the best doctors
• Assist with eldercare
• Save money on healthcare
• Help Members better understand their condition
• Assist with resolving claims and billing issues
• Untangle insurance claims
• Save money on healthcare
• Locate and research treatments for medical condition
• Secure second opinions
If you have any questions, please contact Health Advocate at 866.695.8622.
Gym Reimbursement
If you participate in the Empire Medical Plans, you have the oppurtinuty to be reimbursed up to $600 per benefit plan year for your fitness center’s membership dues.
1. Work out 50 times at a qualifying fitness center for each 6-month period within your beenfit plan year.
2. Track your workout sessions. You can use your fitness center’s computer printout or the fitness log sheet on the back of the Gym Reimbursment form.
3. Once you have met the visit requirements, send in a Gym Reimbursement form with a copy of the Fitness Facility Member Verification (FFMV) Form, proof of your fitness center membership payment and record of you workout sessions.
For each 6-month period, you will get up to one-half the yearly max reimbursement amount, or your membership dues for the 6-month period, whichever is less.
For more information, visit www.empireblue.com.
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2015 EMPLOYEE CONTRIBUTIONSMedical Plan Pre-Tax Contributions
Empire PPO Empire EPOEmpire EPO
Base Salary Less than $50,000
Empire HSAEmpire HSA
Base Salary Less than $50,000
Per Pay Period
Per Pay Period
Per Pay Period Per Pay Period Per Pay Period
Employee only $74.58 $58.64 $50.91 $41.04 $34.73Employee + Spouse $167.37 $143.01 $89.19 $102.05 $56.92Employee + Child $167.37 $143.01 $89.19 $102.05 $56.92Family $251.34 $208.66 $128.63 $148.13 $81.01
Dental Plan Pre-Tax Contributions
Guardian Dental PPO
Per Pay Period
Employee only $3.16Employee + spouse $6.14Employee + children $5.67Family $8.65
Vision Plan Pre-Tax Contributions
VSP PlanPer Pay Period
Employee only $0.67Employee + spouse $1.13Employee + children $1.15Family $1.83
Below are the monthly and per pay period employee pre-tax contributions for medical, dental and vision coverage.
Contributions for any Voluntary coverages (Short Term Disability, Long Term Disability, Life, Health Savings Account, Flexible Spending Accounts and Commuter Benefit) will depend on specific election amounts and/or annual salary. Please refer to each benefit page to see rates for your voluntary benefits.
Reduce your medical premiums by $10 or $20 bi-weekly!See page 3 for details on how to obtain your medical premium reductions.
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IMPORTANT CONTACT INFORMATIONIf you have questions regarding your eligibility or have general benefit questions, please call the Steve Madden Benefit Service Center by phone at 877.459.9696 or send an email to [email protected]. You may also contact the carrier directly. See below for carrier contact information.
Benefit Provider Telephone WebsiteMedical & Prescription Drug Plans
Empire 855.880.0575 www.empireblue.com
Dental Plan Guardian 800.541.7846 www.guardiananytime.comVision Plan Guardian
(Vision Service Plan (VSP) Signature network)
800.877.7195 www.vsp.com
Flexible Spending Accounts (FSAs)
Benefit Resource Inc. 800.473.9595 www.benefitresource.com
Commuter Benefits Benefit Resource Inc. 800.473.9595 www.benefitresource.comLife & AD&D Insurance Guardian 800.538.4583 www.guardiananytime.comShort Term Disability Guardian 888.262.5670 www.guardiananytime.comLong Term Disability Guardian 800.538.4583 www.guardiananytime.comHealth Advocate Health Advocate 866.695.8622 www.healthadvocate.com/
stevemaddenEmployee Assistance Plan (EAP)
Guardian 800.386.7055 www.ibhworklife.comUsername: Matters
Password: Wlm70101
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LEGAL DISCLOSURESCoordination of BenefitsYour medical and dental options contain a coordination of benefits provision that is designed to prevent the duplication of coverage and overpayment of benefits when you or your eligible dependents are covered by more than one plan. Here is how coordination of benefits works:
If you are the patient, the Steve Madden plan will pay benefits first. The other plan will pay benefits according to its own coordination of benefits rule after you submit a claim.
l If your spouse is the patient and has coverage through another plan, his or her plan will pay benefits first. The Steve Madden plan will pay its normal benefits minus any benefits paid by the first plan. This means that your spouse will not receive any benefit from the Steve Madden plan if your spouse’s plan pays benefits that are equal to or greater than the benefits Steve Madden would pay.
l If your child is the patient and he or she is covered by the Steve Madden plan and your spouse’s plan, the decision about which plan pays first is covered by the “birthday rule.” This means that the Steve Madden plan pays first if your birthday (month/day) comes before your spouse’s in the calendar year. For example, if your birthday is March 1 and your spouse’s is April 1, Steve Madden benefits pay first. Otherwise, your spouse’s plan pays first. If the Steve Madden plan pays second, it will reduce its normal benefit by the amount paid by the other plan.
Continuing Coverage Through COBRAThe Consolidated Omnibus Budget Reconciliation Act (COBRA) allows you to temporarily extend you and your dependents’ medical, dental and vision benefits and Health Care FSA in certain situations where coverage would otherwise end (like at your termination of employment). If you elect COBRA coverage, your medical, dental and vision benefits will continue for a defined period of time. Your spouse and dependent children can also continue coverage under COBRA. You will be required to pay the premiums for this continued coverage, which will be the full cost of the plan plus a 2% administrative fee. For more information about continuing coverage through COBRA, please call the Steve Madden Benefit Service Center at 877.459.9696.
Mental Health ParityThe Mental Health Parity and Addiction Equity Act of 2008 requires plans to provide mental health and substance abuse benefits at the same level that benefits for medical and surgical related benefits are offered. Key changes that will affect most group health plans include:
l Group health plans are prohibited from having annual or lifetime maximum dollar limits for mental health benefits that are lower than medical or surgical benefits.
l The new law expands mental health benefits to include substance use disorder benefits.
l Cost-sharing provisions, such as deductibles and copays, or a plan’s terms regarding the amount, duration and scope of mental health benefits are no longer restricted from the plan.
Privacy Rights Under HIPAAA federal law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), requires that health plans protect the confidentiality of your private health information.
This Plan, the Plan Administrator and the Plan Sponsor will not use or disclose information that is protected by HIPAA (protected health information) except as necessary for treatment, payment, and other health care operations of the Plan, or as permitted or required by law. In particular, the Plan will not, without authorization, use or disclose protected health information for employment-related actions and decisions, or in connection with any other benefit or employee benefit plan of your Employer.
The Plan also requires all of its business associates (as that term is defined by HIPAA) to observe HIPAA’s privacy requirements.
Protected health information may be used by and disclosed to Human Resources, and Benefits and Finance/Accounting employees of your Employer who are responsible for carrying out administrative functions for the Plan (such as enrollment/disenrollment, determinations of eligibility and benefits due, provider payments, participant reimbursements and audits).
However, these employees will only have access to the information on a “need to know” basis and will use only the minimum necessary protected health information to accomplish the intended Plan administration purpose.
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Women’s Health and Cancer Rights ActThe Women’s Health and Cancer Rights Act of 1998 requires that all health insurance plans that cover mastectomy also cover the following medical care:
l Reconstruction of the breast on which the mastectomy was performed;
l Surgery and reconstruction of the other breast to produce symmetrical appearance;
l Treatment of physical complications in all stages of mastectomy, including lymphedema; and
l Mastectomy bras and external prostheses limited to the lowest cost alternative available that meets the patient’s physical needs.
If you have questions about your benefits under the Empire medical plans, please call the member services number on your medical ID card or contact the Steve Madden Benefit Service Center.
Newborns’ and Mothers’ Health Protection ActFederal law (Newborns’ and Mothers’ Health Protection Act of 1996) prohibits the plan from limiting a mother’s or newborn’s length of hospital stay to less than 48 hours for a normal delivery or 96 hours for a Cesarean delivery or from requiring the provider to obtain preauthorization for a stay of 48 or 96 hours, as appropriate. However, federal law generally does not prohibit the attending provider, after consultation with the mother, from discharging the mother or her newborn earlier than 48 hours for normal delivery or 96 hours for Cesarean delivery.
Summary of Benefits and Coverage (SBC)As required by law, across the US, insurance companies and group health plans like ours are providing plan participants with a consumer-friendly SBC as a way to help understand and compare medical benefits. Each SBC contains concise medical plan information, in plain language, about benefits and coverage, including, what is covered, what you need to pay for various benefits, what is not covered and where to go for more information or to get answers to questions. SBC documents are updated when there is a change to the benefits information displayed on an SBC.
Government regulations are very specific about the information that can and cannot be included in each SBC. Plans are not allowed to customize very much of the SBC documents. There are detailed instructions the Plan had to follow about how the SBCs look, how many pages the SBC should be (maximum 4-pages), the font size, the colors used when printing the SBC and even which words were to be bold.
The SBC for our Empire medical plans are available from Steve Madden Benefit Service Center. To get a copy of the most current Summary of Benefits and Coverage (SBC) documents for our medical plans, contact the Benefit Service Center at 877.459.9696.
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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-KIDSNOW 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, 2014. Contact your State for more information on eligibility–
ALABAMA – MedicaidWebsite: http://www.medicaid.alabama.govPhone: 1-855-692-5447
COLORADO – MedicaidMedicaid Website: http://www.colorado.gov/Medicaid Phone (Instate): 1-800-866-3513Medicaid Phone (Out of state): 1-800-221-3943ALASKA – Medicaid
Website: http://health.hss.state.ak.us/dpa/programs/medicaid/Phone (Outside of Anchorage): 1-888-318-8890Phone (Anchorage): 907-269-6529ARIZONA – CHIPWebsite: http://www.azahcccs.gov/applicantsPhone (Outside of Maricopa County): 1-877-764-5437Phone (Maricopa County): 602-417-5437
FLORIDA – MedicaidWebsite: https://www.flmedicaidtplrecovery.com/Phone: 1-877-357-3268GEORGIA – MedicaidWebsite: http://dch.georgia.gov/-Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP)PPhone: 1-800-869-1150
IDAHO – MedicaidMedicaid Website: http://healthandwelfare.idaho.gov/Medical/Medicaid/PremiumAssistance/tabid/1510/Default.aspxMedicaidPhone:1-800-926-2588
MONTANA – MedicaidWebsite: http://medicaidprovider.hhs.mt.gov/clientpages/cli-entindex.shtmlPhone: 1-800-694-3084
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INDIANA – MedicaidWebsite: http://www.in.gov/fssaPhone: 1-800-889-9949
NEBRASKA– MedicaidWebsite: www.ACCESSNebraska.ne.govPhone: 1-855-632-7633
IOWA – MedicaidWebsite: www.dhs.state.ia.us/hipp/Phone: 1-888-346-9562
PENNSYLVANIA – MedicaidWebsite: http://www.dpw.state.pa.us/hipPhone: 1-800-692-7462
KANSAS – MedicaidWebsite: http://www.kdheks.gov/hcf/Phone: 1-800-792-4884
NEVADA – MedicaidMedicaid Website: http://dwss.nv.gov/MedicaidPhone: 1-800-992-0900
KENTUCKY – MedicaidWebsite: http://chfs.ky.gov/dms/default.htmPhone: 1-800-635-2570
NEW HAMPSHIRE – MedicaidWebsite: http://www.dhhs.nh.gov/oii/documents/hippapp.pdfPhone: 603-271-5218
LOUISIANA – MedicaidWebsite: http://www.lahipp.dhh.louisiana.govPhone: 1-888-695-2447
NEW JERSEY – Medicaid and CHIPMedicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/medicaid/Medicaid Phone: 609-631-2392CHIP Website: http://www.njfamilycare.org/index.htmlCHIP-Phone: 1-800-701-0710
MAINE – MedicaidWebsite: http://www.maine.gov/dhhs/ofi/public-assistance/index.htmlPhone:1-800-977-6740TTY1-800-977-6741
NEW YORK – MedicaidWebsite: http://www.nyhealth.gov/health_care/medicaid/Phone: 1-800-541-2831
MASSACHUSETTS – Medicaid and CHIPWebsite: http://www.mass.gov/MassHealthPhone: 1-800-462-1120
NORTH CAROLINA – MedicaidWebsite: http://www.ncdhhs.gov/dmaPhone: 919-855-4100
MINNESOTA – MedicaidWebsite: http://www.dhs.state.mn.us/-Click on Health Care, then Medical AssistancePhone: 1-800-657-3629
NORTH DAKOTA – MedicaidWebsite: http://www.nd.gov/dhs/services/medicalserv/med-icaid/Phone: 1-800-755-2604
MISSOURI – MedicaidWebsite: http://www.dss.mo.gov/mhd/participants/pages/hipp.htmPhone: 573-751-2005
UTAH – Medicaid and CHIPWebsite: http://health.utah.gov/uppPhone: 1-866-435-7414
OKLAHOMA – Medicaid and CHIPWebsite: http://www.insureoklahoma.orgPhone: 1-888-365-3742
VERMONT – MedicaidWebsite: http://www.greenmountaincare.org/Phone: 1-800-250-8427
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OREGON – MedicaidWebsite: http://www.oregonhealthykids.gohttp://www.hijossaludablesoregon.govPhone: 1-800-699-9075
VIRGINIA – Medicaid and CHIPMedicaid Website: http://www.coverva.org/programs_pre-mium_assistance.cfmMedicaid Phone: 1-800-432-5924CHIP Website: http://www.coverva.org/programs_premium_assistance.cfmCHIP Phone: 1-855-242-8282
To see if any other states have added a premium assistance program since July 31, 2014, or for more information on special enrollment rights, contact either:
U.S. Department of LaborSecurity Administrationwww.dol.gov/ebsa1-866-444-EBSA(3272)OMB Control Number1210-0137 (expires10/31/2016)
U.S. Department of Health and Human Services Employee BenefitsCenters for Medicare & Medicaid Serviceswww.cms.hhs.gov1-877-267-2323, Menu Option 4, Ext. 61565
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Medicare Part D Notice of Creditable Coverage
Important Notice from the Company About Your Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with the Company 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.
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. The Company has determined that the prescription drug coverage offered by the Company’s Benefit Program is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is considered Creditable Coverage.
Because your existing coverage is, on average, at least as good as standard Medicare prescription drug coverage (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.
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th through December 7th. However, if you lose creditable prescription drug coverage, through no fault of your own, you will also be eligible for a 60-day Special Enrollment Period (SEP) to join a Medicare drug plan.
If you decide to join a Medicare drug plan, your current coverage with the Company will not be affected. See the Company’s Benefit Summaries for more information about what happens to your current coverage if you join a Medicare drug plan.
If you do decide to join a Medicare drug plan and drop your current prescription drug coverage with the Company, be aware that you and your dependents may not be able to get this coverage back.
You should also know that if you drop or lose your coverage with the Company and do not 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 prescription drug coverage that is at least as good as Medicare’s prescription drug coverage, your monthly premium may go up by at least 1% of the base beneficiary premium per month for every month that you did not have that coverage. For example, if you go 19 months without coverage, your premium may consistently be at least 19% higher than the 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 Benefit Service Center for further information at 877.459.9696. Note: You will get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through the Company changes. You also may request a copy of this notice at any time.
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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 will 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:
l Visit www.medicare.gov
l Call your State Health Insurance Assistance Program for personalized help,
l Call 800.MEDICARE (800.633.4227). TTY users should call 877.486.2048.
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 800.772.1213 (TTY 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 whether or not you are required to pay a higher premium (a penalty).
Date: January 1, 2015
Name of Entity/Sender: Steve Madden
Contact - Position/Office: Human Resources
Address: 52-16 Barnett Avenue Long Island City, NY 11104
Phone Number: 8 7 7 . 4 5 9 . 9 6 9 6 (Steve Madden Benefit
Service Center)
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NOTICE OF PRIVACY PRACTICESThis 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.
Our Company’s Pledge to You
This notice is intended to inform you of the privacy practices followed by Steve Madden (the 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 September 18, 2012.
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. Steve Madden 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.
• 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.
• 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.
• 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.
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• 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 Steve Madden 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.
• 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.
Your request to 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.
• 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.
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• 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 to the right.
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:
Date: January 1, 2015
Name of Entity/Sender: Steve Madden
Contact - Position/Office: Human Resources
Address: 52-16 Barnett Ave
Long Island City, NY 11104
Phone Number: 718.446.1800
ComplaintsIf 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.
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EVALUATING YOUR HEALTH INSURANCE OPTIONS
What You Need to Know
This letter has been created to help you understand your health insurance options. The recently passed health care reform law (called the Patient Protection & Affordable Care Act) requires most Americans to carry health insurance coverage or pay a penalty.You can:
• Elect employer-provided health insurance (if offered).
• Purchase health insurance through the Marketplace.
You have likely heard about the Marketplace (formerly known as the health insurance exchange) in the news and around the water cooler. The Marketplace, which started on October 1, 2013, is designed to help you find health insurance plans that fit minimum standards for coverage and family budget.
• You may be able to save money on premiums if your employer does not offer coverage, or offers coverage that does not meet government standards. Your potential savings on health insurance premiums would be dependent on household size and income. If you are offered employer-provided health insurance that meets those government standards, you may not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. If the cost of your employer’s plan to cover yourself only (and not other members of your family) is more than 9.5% of your annual household income, you may be eligible for a tax credit.
Open enrollment for health insurance coverage through the Marketplace began on October 1, 2014, and coverage takes effect as early as January 1, 2014. Visit www.healthcare.gov to learn more about your options, or to request assistance.
Want to Buy on the Marketplace? Start with This Information
STEP 1. Visit www.healthcare.gov and begin the application processSTEP 2. You will need the information below to apply. (Numbers correspond directly to numbers on actual application.)
3. Employer Name: Steven Madden Ltd
4. Employer Identification Number (EIN) Whl-133588231/Rtl-133850272
5. Employer Address: 52-16 Barnett Avenue
6. Employer Phone Number: 718.446.1800
7. Employer City: Long Island City
8. Employer State NY
9. Who can we contact about employee health coverage at this job?
Benefit Service Center
10. Employer Contact Phone Number (If different from above) 877.459.9696
11. Email Address [email protected]
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Basic Information About Steve Madden’s Health Coverage
As your employer, we offer medical plans to full-time employees scheduled to work 30 or more hours per week. We also extend cov-erage to eligible dependents as follows:
• Your spouse
• Your domestic partner (Person with whom the employee lives together and share a common domestic life but are neither joined by marriage nor a civil union; same sex as the employee)
• Your married or unmarried child(ren) up to age 20 or 26 including:
• A newborn, biological child or a child placed with you for adoption
• A stepchild who receives more than one-half of his or her support from you; or
• Any other child for whom you have legal guardianship or court-ordered custody, provided that the child receives more than one-half of his or her support from you
• Your unmarried child who is beyond the age limit at the initial enrollment if you provide proof of handicap and de-pendence at the time of enrollment
• Child(ren) of a domestic partner who meet the age requirements above
Our health coverage meets the minimum value standard, and the cost of our coverage to you is intended to be affordable (based on wages).
Note: Although our coverage is intended to be affordable, you may still be eligible for a premium discount through the Marketplace. The Marketplace will use your household income, along with other factors, to determine whether you may be eligible for a premium discount. If, for example, your wages vary from week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly employed mid-year, or if you have other income losses, you may still qualify for a premium discount.If you decide to shop for coverage in the Marketplace, healthcare.gov will guide you through the process.
The Impact of Purchasing Coverage Through the MarketplaceIf you choose to purchase health insurance through the Marketplace instead of electing the health insurance provided by your em-ployer:
• You may lose your employer’s contribution to your health insurance.
• You may also lose any tax deductions from your employer contribution — in addition to your employee contributions to employer-sponsored coverage — on your Federal and State income taxes.
• Payments to the Marketplace are made on an after-tax basis.
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DOMESTIC PARTNERSHIPMedical, dental, and vision coverage is available for domestic partners meeting the definitions and criteria as described below assuming adequate documentation is presented. Carefully review the information and consider each section as it relates to you, especially the tax ramifications.
Along with your online enrollment, you and your partner will be asked to complete a Declaration of Domestic Partnership and provide several items documenting your relationship and cohabitation. All information submitted to Benefit Service Center will be held in the strictest of confidence.
Domestic Partners as defined as:
• Who are both at least (18) years of age and mentally competent to sign the required affidavit;
• Who share a common residence for at least twelve (12) consecutive months, be jointly responsible for each other’s common welfare as evidenced by either joint financial arrangements or joint ownership of real estate or personal property for at least twelve (12) consecutive months;
• Who have had an emotional and financial commitment to one another for a minimum of twelve (12) consecutive months; and
Documentation Required:
• Completion, by both partners, of the enclosed Declaration of Domestic Partnership The Declaration of Domestic Partnership must be notarized.
And Either:
• Joint-tenancy lease and jointly-held mortgage with both partner’s signature or,
• Two (2) additional forms of documentation as evidence that the partners are committed to one another.
Examples:
• Joint checking account, bills or driver’s licenses showing the same address, an insurance policy or will indicating partner as beneficiary or a copy of a registration certificate filed with those cities or states recognizing domestic partnerships.
TAX ISSUES:
In a private letter ruling (PLR 9603011), the IRS ruled that benefits paid under a group health plan for a domestic partner who would not qualify as a spouse under state law or as a dependent under the IRC caused the employee to receive additional compensation taxable as wages. In other words, the employee is required to declare as taxable income the value of the domestic partner’s health coverage.
The above is predicated on applicable state law where the taxpayer resides and determines whether or not domestic partners are “spouses.” Since very few states recognize domestic partnerships, it is extremely difficult for a domestic partner to qualify as a spouse and receive benefits tax-free. Therefore, in this case, employers extending coverage to an employee’s domestic partner must include the value of the coverage provided to the domestic partner in the employee’s wages. The amount to be included is the “fair market value” of the coverage minus any after tax employee’s contributions toward coverage.
OTHER ISSUES TO NOTE:
• Termination of the partnership and thus benefits for the partner will need to be communicated in writing. The completed Declaration of Termination of Domestic Partnership needs to be submitted to the Benefits Coordinator within 31 days of the status change.
• An employee will be eligible to seek benefits for another domestic partner one (1) year from the date indicated on the Declaration of Termination.
• Termination of coverage for domestic partners DOES NOT qualify that person for continuation of coverage under Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA).
• At present, the Family and Medial Leave Act (FMLA) of 1993 does not include unmarried domestic partners within its definition of “spouse.”
• The domestic partner will NOT be recognized as an eligible dependent under Flexible Spending Program.
• If the partnership is, at any time, found to be invalid, coverage for the partner will be terminated retroactively. Steve Madden is entitled to seek reimbursement for any claims and/or premium paid on the partner’s behalf.
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Declaration of Domesic Partnership
We declare, under penalty or perjury, under the laws of the State of _____________________that the assertions in this Declaration are true to the best of our knowledge. We understand that this form is not an application for dental and or health insurance coverage and that the purpose for this form is to establish the eligibility of persons named herein for the coverage provided under Steve Madden’s dental and or health insurance program.
Employee’s Name
Employee’s Signature
Social Security Number
Date of Birth Date
Domestic Partner’s Name
Domestic Partner’s Signature
Social Security Number
Date of Birth Date
Employee & Domestic Partner Home Address:
Street Address
City ST Zip
Notary Public
My Commission expires: _______________
Date
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Domestic Partner Statement
Please check each statement that applies to you. If both statements are checked, you will not have any imputed income.
____ My domestic partner is a member of my household and lives with me the entire year.
____ I provide more than 50% of my domestic partner’s and partner’s child(ren) (if applicable)
support for the year.
By signing below, I certify that my domestic partner and my partner’s child(ren) (if applicable) qualify as eligible tax dependents for employer sponsored benefit purposes under Section 152 of the Internal Revenue Code for the entire current tax year. I agree to notify Human Resources at Steve Madden if there is a change in my situation that disqualifies my domestic partner or my partner’s child(ren) as an eligible IRS dependent for employer sponsored benefits.
_________________________________ __________________
Signature Date
__________________________________
Print Name
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Affidavit of Marriage
This is to confirm that I, ________________________________________, am currently
legally married to ________________________________________, who is listed as a dependent on my employer
sponsored health insurance plan(s).
________________________________________ ____________________
Signature of Employee Date
STATE OF ___________________ )
) ss.:
COUNTY OF _________________)
On this _____ day of _______________ 20__, before me personally came ________________________________________ to be known and known to me to be the person described and who executed the foregoing Agreement, and (s)he duly acknowledged to me that (s)he executed the same.
________________________________________
Notary Public
My Commission expires: _______________
(print employee name)
(print employee name)
AFFIDAVIT OF MARRIAGE
November 2014
