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Guide to benefitsYour guide to the PSEB associate benefit
programs for June 2020-May 2021
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First things first ..................3
Your health ..........................5Medical ......................................................................... 5
Health Reimbursement Arrangement (HRA) ...... 7
Dental ........................................................................... 11
Vision ........................................................................... 12
Your money ....................... 13Flexible Spending Accounts (FSA) ........................ 13
Life and AD&D insurance ........................................ 14
Disability insurance .................................................. 15
Additional benefit options ...................................... 16
Associate discounts .................................................. 17
Your life ............................. 18Employee Assistance Program (EAP) ..................18
Important contacts ............ 19
Focus on what matters
Everyone who works at PSEB has an impact on our success. And we know that we can’t be the best possible us, unless you are the best possible version of you!
Your health and wellbeing are important, so we’re pleased
to offer a comprehensive benefits package to all eligible
associates.
Our benefits are designed to support you when you need
it most. Some of them are paid for in full by PSEB and will
support you automatically. Others are available for you to
choose from to build a benefits package that suits your needs.
This guide includes detail about all of the benefits available.
Please take the time to read through it and understand the
choices available to you. If you need any more information,
you can visit The Collective at thecollective.psebllc.com or
contact the benefits department using the details on
page 19. When you’re ready to enroll, log into UltiPro.
Peace of mind so you can focus on what matters.
This document is an outline of the coverage proposed by the carrier(s), based on information provided by your company. It does not include all the terms, coverages,
exclusions, limitations, and conditions of the actual contract language. The policies themselves must be read for those details. The intent of this document is to provide you
with general information about your employee benefit plans. It does not necessarily address all the specific issues which may be applicable to you. It should not be construed
as, nor is it intended to provide, legal advice. Questions regarding specific issues should be directed to the Benefits Department.
Content
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First things firstEligibilityActive, full-time associates working at least 30 hours per week are eligible for benefits with PSEB. Associates in Hawaii working at least 20 hours per week are eligible for most benefits.
Some benefits are paid for 100% by PSEB, and coverage is automatic if you are eligible. Other benefits give you choices and require you to enroll.
Eligibility groups• Group 1: Executive Office Team,
Executive Team
• Group 2: District Directors, District Managers, Area Managers, Regional Managers, Distribution Center Managers, Corporate Directors, Corporate Managers
• Group 3: Store Managers, Co-Managers, FT Assistant Store Managers, Stock Leads, Distribution Center Supervisors, Distribution Center Front Office (non-mgt), Distribution Center (non-mgt), Corporate Associates (non-mgt)
• Group 4: PT Assistant Store Managers, Sales Supervisors, Store Associates, Stock Associates, Distribution Center PT Variable Hour Associates, PT Corporate Associates (non-mgt)
Making your benefit selectionsBenefit plans are effective each year from June 1 through May 31. In general, you may make benefit choices as a newly eligible associate, during Open Enrollment and if you have a qualifying life change.
• Newly eligible associates: When you’re first eligible for benefits with PSEB, make your benefit selections within 30 days of your hire or eligibility date. Benefits begin on the first day of the month following 30 days of employment and remain in effect through May 31, 2021 unless you have a qualifying life change. If you are a variable hour associate, the date your benefits begin is based on when your measurement period is satisfied.
• Open Enrollment: Choices you make during Open Enrollment are in effect through May 31, 2021 unless you have a qualifying life change.
• Qualifying life change: Certain events throughout the year such as marriage or divorce, birth or adoption of a child, death of a covered family member, or gain/loss of other coverage can allow you to make changes to your benefit plans consistent with your life change. You have 30 days (31 days for Triple S) from the date of the event to submit this request, and documentation is required. Please review the information in UltiPro or on The Collective for more details.
Enrollment occurs in UltiPro; login instructions are available on The Collective.
Contact the Benefits Department if you have questions about your eligibility or enrollment.
The measurement period is the time the company uses to track hours worked and determine if you have worked an
average of 30 hours per week or more. If it has been determined that you have worked an average of 30 hours or
more during your measurement period, you are eligible to enroll in health benefits and receive coverage for up to
12 months while the company tracks your hours to determine eligibility for the next 12 months.
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Factors that impact your cost for coverage
Spousal surchargeIf your spouse has health coverage available through their own employer but is covered under the PSEB medical plan, a $46 bi-weekly spousal surcharge will apply to your medical coverage. More information is available on The Collective.
Non-tobacco discountIf you and/or your enrolled spouse use tobacco products, a $46 bi-weekly increase will be added to the rates shown on the medical pages. Please contact the benefits department at [email protected] or 1-866-989-6958, #2 to learn about removing the surcharge by completing our tobacco cessation program. More information is available on The Collective.
First things first
Covering your familyIn addition to associates, we extend benefit coverage to eligible dependents.
Your SpouseYou may cover your legal spouse on medical, dental, vision, and additional voluntary life insurance coverage.
Your ChildrenYour natural, adopted, foster, stepchildren, and children in your custody due to a court order are eligible for benefits:
• Medical, Dental, Vision: until the end of the month when they reach age 26 regardless of any other status. Disabled dependents: adult dependent children who became disabled before age 26 and meet carrier requirements are also eligible for coverage. Please contact the benefits department at [email protected] or 1-866-989-6958, #2 if this applies to you.
• Child Life Insurance: from live birth until their 26th birthday if unmarried.
The rates shown on the medical pages are for associates that are non-tobacco users and who do not have a spousal surcharge. If you are a tobacco user and/or if your enrolled spouse has other health coverage available through their own employer, the additional cost(s) above would apply.
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We know the peace of mind that great medical coverage can provide, and we want you to have just that. PSEB offers several medical plans so you can choose the one that suits you best.
Each of our medical plans covers in-network preventive care at 100% when received in a physician’s office. Beyond that, your responsibility depends on the plan you choose, the services you need, and where you receive your care.
Medical
All mainland US associates Anaheim, CA or Bellevue, WA corporate associates only
HRA PPO Plan PPO Plan California HMO
Washington HMO
Network options In- and out-of-network In- and out-of-network In-network only (Kaiser)
Paying for care Mostly deductible then coinsuranceA mix of copays and deductible
then coinsuranceA mix of copays and deductible
then coinsurance
Health account eligibility
Health Reimbursement Arrangement (HRA)
Health Care FSA Health Care FSA Health Care FSA
Plan information
An HRA helps you pay for eligible medical and pharmacy expenses with money contributed by PSEB.
See page 7 for additional information.
The Aetna PPO plan has a higher premium, but with more predictable
costs during the year.
These plans offer in-network care at predictable costs when
you use Kaiser facilities.
Corporate associates in Anaheim, CA or Bellevue, WA have the Kaiser
option in addition to Aetna. See page 8 for more information.Deductibles and out-of-pocket maximums run June - May.
Associates in Puerto Rico and Hawaii have separate plan options; see page 9 for details.
Plan options at-a-glance: Mainland US Associates
Your health
Helpful insurance termsThese terms will help you understand your benefits and coverage options.
Copay – a set fee you pay whenever you use certain medical services, like a doctor visit.
Deductible – the dollar amount you pay before your medical insurance begins paying deductible-eligible claims.
Coinsurance – the percentage of covered medical expenses you continue to pay after you’ve met your deductible and before you reach your out of pocket maximum.
Out-of-pocket maximum – the most you will pay annually / during the year for covered expenses. This includes copays, deductibles, coinsurance, and prescription drugs.
Balance billing – the amount you are billed by your out-of-network provider to make up the difference between what your provider charges and what insurance reimburses. This amount is in addition to, and does not count toward your out-of-pocket maximum.
Plan year – June-May
Calendar year – January-December
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HRA PPO Plan PPO Plan
Network name Aetna Choice POS II (Aetna HealthFund) Aetna Choice POS II (Open Access)
In-network care
Plan year deductible DED $3,000 single coverage; $6,000 with dependents $1,500 per person; $3,000 family maximum
Out-of-pocket maximum $6,000 per person; $12,000 family maximum (plan year) $3,000 per person; $9,000 family maximum (plan year)
Health account: PSEB contribution
HRA (annually) Single coverage: $500 | With dependents: $1,000
Not eligible
Preventive care 100% covered 100% covered
Primary care physician DED then you pay 10% $20 copay
Specialist DED then you pay 10% $40 copay
Virtual doctor (Teladoc) DED then you pay 10% $20 copay
Urgent care DED then you pay 10% $40 copay
Emergency room $250 copay then DED then you pay 10% $250 copay then DED then you pay 20%
Outpatient surgery DED then you pay 10% DED then you pay 20%
Inpatient hospitalization DED then you pay 10% DED then you pay 20%
Prescription drug coverage (CVS Caremark)
30-day fill 90-day fill 30-day fill 90-day fill
Generic You pay 30% (to $25) You pay 30% (to $50) You pay 30% (to $25) You pay 30% (to $50)
Preferred Brand You pay 40% (to $50) You pay 40% (to $100) You pay 40% (to $50) You pay 40% (to $100)
Non-Preferred Brand You pay 50% (to $75) You pay 50% (to $150) You pay 50% (to $75) You pay 50% (to $150)
Specialty You pay 40% (to $200) Not covered – use retail You pay 40% (to $200) Not covered – use retail
After the 3rd fill of long-term maintenance drugs, use CVS Caremark mail or a CVS/Target retail pharmacy to receive a 90-day supply, otherwise you will pay 100% of the drug cost.
Out-of-network cost basics (plus balance billing)
Plan year deductible DED $4,000 single coverage; $8,000 with dependents $3,000 per person; $6,000 family maximum
Coinsurance (you pay) 50% after DED 40% after DED
Out-of-pocket maximum $8,000 per person; $16,000 family maximum $6,000 per person; $18,000 family maximum
Your per-paycheck (bi-weekly) cost for coverageHRA PPO Plan PPO Plan
Associate Only $32.02 $95.05
Associate + Spouse $77.75 $237.48
Associate + Child(ren) $69.98 $212.24
Associate + Family $110.91 $337.81
Medical plan comparisonWhen you need care, your medical plan with Aetna is here for you – regardless of the selection you make. Take a moment to review the options available to you, and head over to The Collective for additional details.
Mainland US - all locations
The Aetna HRA PPO plan does not comply with Massachusetts Minimum Creditable Coverage (MCC) requirements.
Your health
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Health Reimbursement Arrangement (HRA)An HRA is a company-provided allowance to use towards eligible health care expenses.
When you enroll in the HRA PPO Plan, PSEB sets aside money on an annual basis for your medical and pharmacy care.
Paying for careYour eligible medical and pharmacy expenses (deductible and/or copay) are automatically deducted from your HRA allowance first. Once your HRA is depleted, you may pay out of pocket or use your FSA funds.
Unused funds and more Unused funds at the end of the plan year will roll into the next year’s allowance, up to a maximum of $2,250 for individuals or $4,500 if you cover any dependents. Your funds are non-transferable and are forfeited if your employment with PSEB terminates for any reason.
Single coverage With dependents
Plan year allowance $500 $1,000
Plan year allowance The HRA is funded by PSEB; you do not contribute. The amount of your allowance depends on your coverage level:
Your health
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California HMO (Anaheim, CA) Washington HMO (Bellevue, WA)
Network name Kaiser: Core Kaiser: HMO
In-network care
Plan year deductible DED
$750 per person $1,500 family maximum
$750 per person $1,500 family maximum
Plan year out-of-pocket maximum
$3,000 per person $6,000 family maximum
$3,500 per person $7,000 family maximum
Preventive care 100% covered 100% covered
Primary care physician $25 copay $25 copay
Specialist $25 copay $25 copay
Virtual doctor (Kaiser) 100% covered 100% covered
Urgent care $25 copay $25 copay
Emergency room $250 copay (waived if admitted)$250 copay then DED then you pay
20% (waived if admitted)
Outpatient surgery DED then you pay 20% DED then you pay 20%
Inpatient hospitalization DED then you pay 20% DED then you pay 20%
Prescription drug coverage
30-day fill 100-day fill 30-day fill 90-day fill
Preferred Generic $10 copay $20 copay $10 copay $20 copay
Preferred Brand $30 copay $60 copay $20 copay $40 copay
Non-Preferred Brand Not covered Not covered Not covered Not covered
Specialty You pay 20% (to $200) Not covered – use retail You pay 50% (to $150) Not covered – use retail
Out-of-network cost basics (plus balance billing)
Deductible DED
Not covered unless a true emergency. Not covered unless a true emergency.Coinsurance (you pay)
Out-of-pocket maximum
Your per-paycheck (bi-weekly) cost for coverageCalifornia HMO (Anaheim, CA) Washington HMO (Bellevue, WA)
Associate Only $95.05 $95.05
Associate + Spouse $237.48 $237.48
Associate + Child(ren) $212.24 $212.24
Associate + Family $337.81 $337.81
Anaheim, CA and Bellevue, WA corporate locationsAdditional options with Kaiser Permanente are available for associates in the Anaheim and Bellevue corporate locations. These plans require the designation of a Primary Care Physician. Although you do not need to select one at enrollment, be sure to designate one within 90 days or one will be assigned to you.
State registered domestic partner coverage is permitted on Kaiser plans. Spousal surcharge requirements apply to domestic partners as well. Visit The Collective for details.
Your health
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Hawaii Plan (HMAA) Puerto Rico plan (Triple-S Salud)
Network name HWMG Commercial (PPO)
In-network care Calendar year June - May (Plan year)
Annual deductible DED
$100 per person $300 family maximum
$100 per person (major medical) $300 family maximum (major medical)
Out-of-pocket maximumMedical: $2,000 per person; $6,000 family maximum
Prescription: $5,500 per person; $9,000 family maximum
Medical/Hospital/Rx: $6,350 per person $12,700 family max.
Major medical: $2,000 per person | $4,000 family max.
Preventive care 100% covered 100% covered
Primary care physician $15 copay $10 copay
Specialist $15 copay $10 copay
Virtual doctor (page 10) 100% covered $10 copay
Urgent care $25 copay Illness: $50 copay | Accident: no charge
Emergency room You pay 20% Illness: $50 copay | Accident: no charge
Outpatient surgery You pay 20% $100 copay
Inpatient hospitalization You pay 20% $100 copay
Prescription drug coverage
30-day fill 90-day fill 30-day fill 90-day fill
GenericDrug cost over $250:
you pay 20% Otherwise, $12 copay
30-day retail drug cost over $250: you pay 20%
Otherwise, $24 copayYou pay 30% (to $25) You pay 23% (to $50)
Preferred BrandYou pay 20% if drug
cost is over $250 Otherwise, $24 copay
30-day retail drug cost over $250: you pay 20%
Otherwise, $48 copayYou pay 40% (to $50) You pay 30% (to $100)
Non-Preferred BrandYou pay 20% if drug
cost is over $250 Otherwise, $48 copay
30-day retail drug cost over $250: you pay 20%
Otherwise, $96 copayYou pay 50% (to $75) You pay 38% (to $150)
Specialty Not applicable Not covered – use retailYou pay 40% (to $200)
In-network onlyNot covered – use retail
Out-of-network cost basics (plus balance billing)
Annual deductible DED $100 per person; $300 family maximum
Not covered unless a true emergency.Coinsurance (you pay) 20% after DED
Out-of-pocket maximum Single: $2,000 | Family: $6,000
Your per-paycheck (bi-weekly) cost for coverageHawaii Plan (HMAA) Puerto Rico plan (Triple-S Salud)
Associate Only $5.66 $27.82
Associate + Spouse $75.65 $67.82
Associate + Child(ren) $82.52 $59.36
Associate + Family $106.60 $82.97
Hawaii and Puerto Rico locations
Hawaii associates are automatically given the non-tobacco discount.
Your health
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Try virtual visitsDo you have a smart phone or tablet? Virtual visits allow you to get fast, convenient care with a board-certified physician – no matter where you are or what time it is.
Virtual physicians can diagnose symptoms and prescribe medications for minor health concerns. Use it when your primary doctor is not available, if you’re sick while traveling, on nights and weekends, or when it’s inconvenient to leave home.
Use virtual doctor visits for:
• Allergies• Cold and flu• Ear infections• Fever• Headache
• Nausea• Rashes• Sinus infection• And more!
Your source for virtual visits depends on your medical plan:
• Aetna: Teladoc.com/aetna Consider creating an account and providing your medical information once you get your medical ID card so care is available when you need it.
• Kaiser California: Log into your Kaiser account for care or call 1-833-574-2273. website: https://kp.org/getcare
• Kaiser Washington: Log into your Kaiser account for care or call 1-800-297-6877. website: https://kp.org/wa/getcare
• HMAA Hawaii: Visit www.HiDocOnline.com or call 1-844-423-6242.
• Triple-S Salud Puerto Rico: Nurseline available through TeleConsulta at 1-800-255-4375 (not board-certified physicians).
Visit The Collective for more information about Virtual Visits.
Outpatient imagingIn most cases, imaging services (MRI, CT, and X-ray) can be done in outpatient centers that are not attached to a hospital. Smaller buildings generally mean smaller bills – a big savings opportunity if you’re paying a percentage of the cost.
Go generic and saveGeneric drugs are the non-brand-name, FDA-approved versions of their brand-name counterparts. They’re required to have the same active ingredients as the brand-name drug – but at a fraction of the price.
Ask your doctor or pharmacist if a generic is a good option for you.
Save the emergency room for emergenciesUnless loss of life or limb is imminent, consider using Urgent Care or a Virtual Visit to save money, time, and aggravation.
If you have a true emergency – head injury, severe trauma, chest pain, allergic reaction, etc. – get care from your nearest emergency room as quickly as possible. Coverage is the same in- and out-of-network for true emergencies
Choices for health careMaking smart healthcare choices helps you – and your wallet – feel healthy, secure, and supported.
Your health
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DentalDental coverage is a highly valued benefit, and for good reason! Good oral health has been shown to enhance your mental and overall wellbeing, and knowing that you’re covered should you need to see a dentist or specialist for a big-ticket procedure is a big relief.
We offer you dental insurance through Aetna. This coverage is optional (like flossing!), so you must actively elect the plan when you make your benefit selections in order to be covered.
For more information on dental coverage, visit the dental page on The Collective.
Tip: If you choose to use a dentist who doesn’t participate in the Aetna dental network, your out-of-pocket costs will be higher and you will be subject to balance billing.
Coverage summary
Basic PPO Enhanced PPO
In-network Out-of-Network In-Network Out-of-Network
Plan year Deductible June - May
$100 per person $300 max per family
$100 per person $300 max per family
$50 per person $150 max per family
$50 per person $150 max per family
Plan year Maximum Benefit June - May
$1,000 per person $1,000 per person $2,000 per person $2,000 per person
Dental network name Dental PPO/PDN with PPO II Dental PPO/PDN with PPO II
Preventive Services Exams, cleanings, and X-rays
100% covered100% covered (plus
balance billing)100% covered
100% covered (plus balance billing)
Basic Services Fillings, root canals, extractions, oral surgery, endodontics, periodontics
You pay 40% after deductible
You pay 40% after deductible (plus balance billing)
You pay 20% after deductible
You pay 20% after deductible (plus balance billing)
Major Services Crowns, inlays/onlays, bridges and dentures
You pay 60% after deductible
You pay 60% after deductible (plus balance billing)
You pay 50% after deductible
You pay 50% after deductible (plus balance billing)
Implants Not covered Covered as a Major Service
Orthodontics Child and adult
Not covered$50 lifetime deductible, then 50% coverage
$1,500 lifetime benefit maximum
Your per-paycheck (bi-weekly) cost for coveragePSEB contributes to the cost of your dental coverage.
Basic PPO Enhanced PPO
Associate Only $11.11 $20.01
Associate + Spouse $22.23 $40.04
Associate + Child(ren) $20.00 $36.04
Associate + Family $33.34 $60.07
Your health
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VisionRegular eye exams are an important part of health maintenance, no matter your age. And if you or your family members wear glasses or contact lenses, you already know that the cost of vision care can quickly add up. Not only that, but regular eye examinations can detect general health problems at their earliest stages.
We offer comprehensive vision coverage through VSP which provides you and your family with access to great eye doctors, quality eyewear and affordable eye care. This plan is also optional; you’ll need to elect it at enrollment to be covered.
Your costs will depend on the services you require and whether it is received in the Choice network.
Coverage summary In-Network Out-of-Network
Exam available once every 12 months
$10 copay (exam + materials)
$10 copay, then up to $45 reimbursement
Lenses available once every 12 months
No charge after copay for basic lenses (add-ons may incur a charge)
Up to $30 - $65 reimbursement (based on lens type)
Frames available once every 12 months
Plan pays up to $200 retail, 20% discount amounts over $200
$110 allowance at CostcoUp to $70 reimbursement
Contact lenses available once every 12 months in lieu of lenses & frames
Fitting & Evaluation: up to $60 copay $200 allowance for lenses
Up to $105 reimbursement for services and materials
Suncare benefit in lieu of contacts or glasses
$200 allowance for ready-made non-prescription sunglasses after $10 copay
For more information on vision coverage, visit the vision page on The Collective. To find an in-network provider in your area, search the Choice network at vsp.com.
Your per-paycheck (bi-weekly) cost for coverage
Associate Only $3.87
Associate + Spouse $6.33
Associate + Child(ren) $5.70
Associate + Family $12.64
Your health
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Our Flexible Spending Accounts (FSA) allow you to pay for eligible out-of-pocket expenses with pre-tax dollars.
Flexible Spending Accounts (FSA)
Health and Dependent CareOur Health and Dependent Care FSA options are administered through Navia Benefit Solutions. FSA elections must be made on the Navia website.
Health Care FSA Dependent Care FSA
Pay for qualified medical, pharmacy, dental, and vision expenses.
Pay for qualified child or elder care expenses.
All contributions to your FSA are tax free. If you don’t spend the money in your account during the plan year (June - May), you will lose it. You cannot transfer money from one FSA to another.
Contribution limits
You tell us how much you want to save each pay check into your FSA, adding up to no more than the limits shown below. PSEB will not make contributions into your FSA.
Maximum plan year contributions
Health Care FSA $2,750
Dependent Care FSA $5,000; $2,500 if married and filing separately
FSA elections do not roll over and must be made each plan year.
Commuter & ParkingYou can pay for eligible parking and transit expenses through our Commuter Plan, administered through Navia Benefit Solutions. This plan runs on a monthly basis so you can stop, start, or change your contributions from month to month. Visit the Navia website for more information.
Maximum monthly contribution
$270 per month
New for 2020: manage your commuter plan enrollment on the Navia website.
Bellevue associates are eligible to either participate in the Commuter FSA or receive an ORCA Pass/on-site parking subsidy.
For more information on the FSA options available to you, visit the FSA page on The Collective or the Navia website.
Your money
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Life and AD&D insurance
Basic coveragePSEB provides you with life insurance and AD&D coverage through Cigna. Not sure what group you’re in? Click the group numbers for definitions.
Group 1 Groups 2 and 3
$1,000,000 1x annual salary up to $250,000
This benefit is automatic for all eligible associates and provided at no cost to you. Be sure to verify your beneficiary designation.
Additional life insuranceYou have the option to purchase additional life insurance through Cigna for yourself, your spouse, and dependent child(ren). This year only, elect up to the medical question limit with no medical questions or underwriting required (unless previously declined by Cigna).
Associate Spouse Child
Increments Increments of $10,000
Elect a flat dollar amount:
• $10,000• $25,000• $50,000
• $75,000• $100,000• 125,000
$5,000 or $10,000 Coverage ends at age 26
Under 6 months of age: $500
Coverage maximum $500,000100% of associate election to
a maximum of $125,000$10,000
(under 6 months: $500)
Medical question limit $250,000 $50,000 Not applicable
Your cost for coverage is dependent on your age and your coverage amount, and is paid through post-tax payroll deductions. You can review your cost when you elect your coverage.
Additional AD&D insuranceAdditional AD&D insurance is also available through Cigna. You can enroll yourself in the associate only plan or you can choose to enroll yourself, your spouse and/or your dependent children.
Associate Spouse Child
Coverage options Increments of $100,000 Increments of $50,000 $5,000 or $10,000
Coverage maximum5x annual salary to a
maximum of $500,000100% of associate election to
a maximum of $250,000$10,000
While nothing can take away the pain of losing a loved one, life insurance can help to ease the financial pressure on your family should something happen to you. Accidental Death and Dismemberment (AD&D) insurance provides additional financial support if you are killed or seriously injured as the result of an accident.
Your money
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Disability insuranceSometimes life throws you a curve ball and you may be unable to work due to illness or injury. Disability insurance is available to help meet your financial needs.
Disability benefits are available to eligible associates on the first day of the
month following 180 days of eligibility.
Short-term disability insurance Applies to Groups 1, 2 and 3 PSEB provides you with short-term disability insurance through Cigna at no cost to you.
• Benefits begin after 7 days of inability to work due to a covered illness or injury
• May pay 60% of your base pay, up to $1,500 per week
• Up to 12 weeks of pay continuation
Depending on where you live/work, you may be entitled to a state disability benefit. Benefits under this plan would be reduced by the benefit you receive from your state.
Long-term disability insuranceGroups 1, 2, and Store Managers PSEB provides you with long-term disability insurance through Cigna at no cost to you.
• Benefits begin after 90 days of inability to work due a covered disability.
• May pay 60% of your base pay, up to:
Group 1 Group 2 and Store Managers
$20,000 per month $12,000 per month
Payments may continue until you reach your Social Security Disability Retirement Age if you remain unable to work. Certain exclusions, along with any pre-existing condition limitations, may apply.
Group 3 (excluding Store Managers) You may purchase long-term disability insurance through Cigna to provide lasting income support if you are unable to work for an extended period of time.
• Benefits begin after 90 days of inability to work due to illness or injury
• May pay 60% of your base pay, up to $5,000 per month
• Payments may continue until you reach your Social Security Disability Retirement Age if you remain unable to work.
Certain limitations and exclusions, along with pre-existing condition limitations, may apply.
For more information on the disability options available to you, and what you’re eligible for, visit the disability insurance page on The Collective.
Your money
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Additional benefit options401(k) Retirement Plan
PSEB continues to offer 401(k) to eligible associates. For more information, please visit The Collective.
Critical illness insurance
The expenses associated with a critical illness, such as a heart attack, stroke or cancer, can be overwhelming. Even with a comprehensive medical plan you may be hit with significant out-of-pocket expenses at an already stressful time.
Critical illness insurance through Aetna pays out a cash benefit which you can use to help cover costs that your medical plan doesn’t cover, like your deductible or out-of-pocket maximum, if you or a covered family member experiences a covered critical illness such as heart attack, stroke, major organ failure, or cancer.
The cash benefit amount is $10,000 for you (associate). You may also elect to cover your spouse and child(ren) – the available benefit is $5,000.
The insurance premiums are paid through post-tax payroll deductions; and are available when you enroll. Your cost depends on the plan you choose, your age, your tobacco status, and who you cover.
Hospital indemnity insurance
PSEB offers access to hospital indemnity insurance through Aetna to help you cover the costs of hospital admission, whether for planned or unplanned reasons.
Hospital indemnity insurance pays you a cash benefit for medical and non-medical expenses related to a covered inpatient hospital stay. You have two plan options; the difference is the admission benefit.
Plan one Plan two
Hospital admission $500 benefit $1,000 benefit
Hospital stay $100 benefit per day $100 benefit per day
Hospital stay (ICU) $200 benefit per day $200 benefit per day
Newborn routine care $100 benefit $100 benefit
The insurance premiums are paid through post-tax payroll deductions; and are available when you enroll. Your cost depends on the plan you choose and who you cover.
Your money
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Accident insurance
Accidents happen and can cause huge financial strain. Accident insurance helps you cover the costs of an injury, giving you an extra level of financial protection when you need it most.
The accidental injury insurance is provided through Aetna. In the event of an injury, this coverage will pay out a cash benefit you can use to help cover your deductible, copays, emergency medical transportation and more.
Plan one Plan two
Ground ambulance $300 benefit $300 benefit
Initial treatment (ER/Urgent Care/Office Visit)
$100 benefit $150 benefit
Fracture Up to $2,750 benefit Up to $4,125 benefit
Surgery Up to $1,000 benefit Up to $1,500 benefit
The insurance premiums are paid through post-tax payroll deductions; and are available when you enroll. Your cost depends on the plan you choose and who you cover.
Identity theft protection
Identity theft is a leading cause of financial loss. Protection through InfoArmor can help you monitor your personal information and protect your financial wellbeing.
PrivacyArmor, a service of InfoArmor, can monitor everything from your credit inquiries to your social media accounts. This service is available for purchase with premiums paid through post-tax payroll deductions.
Cost information is available at enrollment.
Legal services
Access to quality, prepaid legal services can give you peace of mind.
In-network providers who contract with MetLife Legal can provide you with legal advice and consultation without additional costs. Available topics include money matters, home and real estate, personal issues, estate planning, civil lawsuits, family or elder-care issues, and vehicle and driving matters.
Cost information is available at enrollment.
Associate discountsAs an associate of PSEB, you and your eligible dependents receive a discount of 30%-50% off full-priced products at PacSun and Eddie Bauer. Log into the UltiPro homepage for up-to-date information.
Your money
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Employee Assistance Program (EAP)Balancing the demands of work, home, family, finances, health and wellbeing can be challenging at times. We want to make sure that when issues do arise, you won’t have to face them alone.
As a member of Group 1, Group 2, or Group 3, you have access to our Employee Assistance Program (EAP) run by Cigna. Our EAP is a confidential service, paid for by PSEB, offering you access to experienced counselors who can help with stress, anxiety, drug and alcohol dependence, grief, loss and more.
The Cigna EAP won’t cost you anything to use and any calls you make are confidential; no one at PSEB will be informed of your call.
You or your family can reach a counselor by visiting www.cignalap.com or dialing 1-800-538-3543 – any time of day or night. If necessary, you are provided with up to 3 face-to-face visits at no cost to you.
Our EAP can support you with
• Family or relationship issues
• Stress
• Substance abuse
• Identity theft
• Adoption
• Child and elder care
• Education or work/life support
• Legal or financial questions
Highlights
• Confidential
• Unlimited telephonic consultations
• Up to 3 face-to-face visits at no cost
• Available 24/7
Your life
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Benefit Benefit
Health
Main
lan
d U
S
MedicalAetna
www.Aetna.com 1-877-204-9186
Pharmacy Aetna plans
CVS Caremark Specialty Rx: www.aetnaspecialtyrx.com
1-800-238-6279
Health Reimbursement Arrangement (HRA)
Aetna www.Aetna.com 1-877-204-9186
Virtual Doctor Aetna plans
Teladoc www.Teladoc.com/aetna
1-855-835-2362
Medical Anaheim, CA Corporate
Kaiser (California) www.kp.org
1-800-464-4000
Medical Bellevue, WA Corporate
Kaiser (Washington) www.kp.org/wa 1-888-901-4636
Virtual Doctor Kaiser California
www.kp.org/getcare 1-833-574-2273
Virtual Doctor Kaiser Washington
www.kp.org/wa/getcare 1-800-297-6877
Haw
aii &
Pu
erto
Ric
o
Medical Hawaii
HMAA www.hmaa.com 1-800-621-6998
Medical Puerto Rico
Triple-S Salud www.ssspr.com 1-800-981-3241
Pharmacy Hawaii
Optum Rx www.hmaa.com/healthplans/
prescription-plan-info/ 1-808-941-4622
Pharmacy Puerto Rico
Abarca www.ssspr.com 1-800-981-3241
Virtual Doctor Hawaii
www.HiDocOnline.com 1-844-423-6242
Virtual Visit (Nurseline) Puerto Rico
Nurseline through TeleConsulta 1-800-255-4375
DentalAetna
www.Aetna.com 1-877-204-9186
VisionVSP
www.VSP.com 1-800-877-7195
Money
Flexible Spending Accounts
Navia www.naviabenefits.com
1-800-669-3539
Life and AD&D insurance
Cigna www.cigna.com 1-800-362-4462
Disability insuranceCigna
www.cigna.com 1-800-362-4462
Critical illness Hospital indemnity Accident
Aetna www.aetna.com 1-800-607-3366
Identity theft protection
InfoArmor www.myprivacyarmor.com
1-800-789-2720Legal Plan
MetLife Legal www.legalplans.com
1-800-821-6400
Life
Employee Assistance Program (EAP)
Cigna www.cignaLAP.com
1-800-538-3543
PSEB Benefits Department
PSEB [email protected] 1-866-989-6958, #2
Important contacts
Legal Notices
SUMMARY OF BENEFITS & COVERAGE (SBC) DOCUMENTS
SBC DOCUMENTS ARE AVAILABLE ONLINE
Required Summary of Benefits & Coverage documents may be found online at https://TheCollective.psebllc.com. Paper copies are also available, free of charge, by contacting the Benefits Team at [email protected] or 1-86-989-958, option #2.
CERTIFICATE OF CREDITABLE PRESCRIPTION DRUG COVERAGE
IMPORTANT NOTICE FROM PSEB LLC 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 PSEB 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. 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. Your company has determined that the prescription drug coverage offered by Aetna, Kaiser Permanente, HMAA, and Triple S is on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.
WHEN CAN YOU JOIN A MEDICARE DRUG PLAN?
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th through 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.
CERTIFICATE OF CREDITABLE PRESCRIPTION DRUG COVERAGE 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. Your current coverage pays for other health expenses in addition to prescription drugs. If you enroll in a Medicare prescription drug plan, you and your eligible dependents may still be eligible to receive all of your current health and prescription drug benefits. If you do decide to join a Medicare drug plan and drop your current company coverage, be aware that you and your dependents may be able to get this coverage back by enrolling back into the company benefit plan during the Open Enrollment period under the company benefit plan.
WHEN WILL YOU PAY A HIGHER PREMIUM (PENALTY) TO JOIN A MEDICARE DRUG PLAN?
You should also know that if you drop or lose your current coverage with the company and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.
FOR MORE INFORMATION ABOUT THIS NOTICE OR YOUR CURRENT PRESCRIPTION DRUG COVERAGE…
Contact the person listed below for further information. Note: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through the company 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 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). • Date: June 1, 2020 • Name of Entity/Sender: PSEB LLC • Contact - Position/Office: Benefits Team • Address: 3450 E. Miraloma Avenue Anaheim, CA 92806 • Phone Number: 1.866.989.6958, option #2
Legal Notices
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 are not already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1.866.444.EBSA (3272).
If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of January 31, 2020. Contact your State for more information on eligibility.
ALABAMA – Medicaid Website: http://myalhipp.com/ Phone: 1.855.692.5447 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 ARKANSAS – Medicaid Website: http://myarhipp.com/ Phone: 1.855.MyARHIPP (855.692.7447) California – Medicaid Website: https://www.dhcs.ca.gov/services/Pages/TPLRD_CAU_co nt.aspx Phone: 1-800-541-5555 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+: Colorado.gov/HCPF/Child-Health-Plan-Plus CHP+ Customer Service: 1.800.359.1991/State Relay 711 FLORIDA – Medicaid Website: http://flmedicaidtplrecovery.com/hipp/ Phone: 1.877.357.3268 GEORGIA – Medicaid Website: https://medicaid.georgia.gov/health-insurance-premium-payment-program-hipp Phone: 678-564-1162 ext 2131
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: http://www.indianamedicaid.com Phone 1.800.403.0864 IOWA – Medicaid 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 KANSAS – Medicaid Website: http://www.kdheks.gov/hcf/default.htm Phone: 1-800-792-4884 KENTUCKY – Medicaid Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website: https://chfs. 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 LOUISIANA – Medicaid Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-6185488 (LaHIPP) MAINE – Medicaid Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1.800.442.6003 TTY: Maine relay 711 MASSACHUSETTS – Medicaid and CHIP Website: http://www.mass.gov/eohhs/gov/departments/masshealth/ Phone: 1.800.862.4840
Legal Notices
PREMIUM ASSISTANCE UNDER MEDICAID AND THE CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) - CONTINUED
MINNESOTA – Medicaid Websitehttps://mn.gov/dhs/people-we-serve/children-andfamilies/health-care/health-care-programs/programs-andservices/medical-assistance.jsp Phone: 1.800.657.3739 MISSOURI – Medicaid Website: https://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573.751.2005 MONTANA – Medicaid Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1.800.694.3084 NEBRASKA – Medicaid Website: http://www.ACCESSNebraska.ne.gov Phone: 1-855-632-7633 Lincoln: 402-473-7000 Omaha: 402-595-1178 NEVADA – Medicaid Medicaid Website: https://dhcfp.nv.gov Medicaid Phone: 1.800.992.0900 NEW HAMPSHIRE – Medicaid Website: https://www.dhhs.nh.gov/oii/hipp.htm Phone: 603.271.5218 Toll-Free: 1-800-852-3345, ext 5218 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 NEW YORK – Medicaid Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1.800.541.2831 NORTH CAROLINA – Medicaid Website: https://dma.ncdhhs.gov/ Phone: 919.855.4100 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 OREGON – Medicaid Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1.800.699.9075
PENNSYLVANIA – Medicaid Website: https://www.dhs.pa.gov/providers/Providers/Pages/Medical /HIPP-Program.aspx Phone: 1-800-692-7462 RHODE ISLAND – Medicaid and CHIP Website: http://www.eohhs.ri.gov/ Phone: 855.697.4347 , or 401-462-0311 (Direct RIte Share Line) SOUTH CAROLINA – Medicaid Website: https://www.scdhhs.gov Phone: 1.888.549.0820 SOUTH DAKOTA - Medicaid Website: http://dss.sd.gov Phone: 1.888.828.0059 TEXAS – Medicaid Website: http://gethipptexas.com/ Phone: 1.800.440.0493 UTAH – Medicaid and CHIP Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1.877.543.7669 VERMONT– Medicaid Website: http://www.greenmountaincare.org/ Phone: 1.800.250.8427 VIRGINIA – Medicaid and CHIP Medicaid Website: http://www.coverva.org/hipp/ Medicaid Phone: 1.800.432.5924 CHIP Phone: 1.855.242.8282 WASHINGTON – Medicaid Website: https://www.hca.wa.gov/ Phone: 1.800.562.3022 WEST VIRGINIA – Medicaid Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf Phone: 1-800-362-3002 WISCONSIN – Medicaid and CHIP Website: https://health.wyo.gov/healthcarefin/medicaid/ Phone: 1.800.362.3002 WYOMING – Medicaid Website: https://wyequalitycare.acs-inc.com/ Phone: 307.777.7531
Legal Notices
PREMIUM ASSISTANCE UNDER MEDICAID AND THE CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) - CONTINUED
To see if any other states have added a premium assistance program since January 31, 2020, or for more information on special enrollment rights, contact either:
U.S. Department of Labor Associate Benefits Security Administration dol.gov/agencies/ebsa 866.444.EBSA (3272)
U.S. Department of Health & Human Services Centers for Medicare & Medicaid Services cms.hhs.gov 877.267.2323 (Menu Option 4, Ext. 61565)
Legal Notices
WOMEN’S HEALTH & CANCER RIGHTS ACT NOTICES If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (“WHCRA”). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:
• All states 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 the plan. Therefore, the following deductibles and coinsurance apply:
If you would like more information on WHCRA benefits, call your plan administrator at 1-800-599-9393.
Federal law (Newborns’ and Mothers’ Health Protection Act of 1996) prohibits the plan from limiting a mother’s or newborn’s length of stay to less than 48 hours for a normal delivery or 96 hours for a cesarean delivery or from requiring the provider to obtain pre-authorization for a stay of 48 hours 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.
HEALTHCARE REFORM & YOUR BENEFITS PSEB LLC offers a medical plan option that provides valuable comprehensive coverage that meets the requirements of the healthcare reform law and is intended to be affordable as defined by the law. Also note, it’s unlikely that you are eligible for financial help from the government to help you pay for insurance purchased through a Marketplace because you have access to an employer plan that complies with the affordability standard.
PATIENT PROTECTION DISCLOSURE NOTICE (Applies to
Kaiser plans only) Kaiser Permanente generally allows the designation of a primary care provider. You have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members. For information on how to select a primary care provider, and for a list of the participating primary care providers, contact Kaiser Permanente. For children, you may designate a pediatrician as the primary care provider. You do not need prior authorization from Kaiser Permanente or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a healthcare professional in our network who specializes in obstetrics or gynecology. The healthcare professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating healthcare professionals who specialize in obstetrics or gynecology, contact the Kaiser Permanente.
Legal Notices
STATEMENT OF ERISA RIGHTS
As a participant in the Plan, you are entitled to certain rights and protections under the Associate Retirement Income Security Act of 1974 (“ERISA”). ERISA provides that all participants shall be entitled to:
• Examine, without charge, at the Plan Administrator’s office
and at other specified locations, the documents governing the plan, including the insurance contract and a copy of the latest annual report (Form 5500 Series) if any filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Associate Benefits Security Administration.
• Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the plan, including insurance contracts, and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The Plan Administrator may make a reasonable charge for the copies.
• Receive a summary of the Plan’s annual financial report, if any. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report, if any.
You have a right to continue healthcare coverage for yourself, spouse, or dependents if there is a loss of coverage under the plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review the summary plan description and the documents governing the Plan on the rules governing your COBRA continuation coverage rights.
In addition to creating rights for participants, ERISA imposes duties upon the people who are responsible for operation of the Plan. These people, called “fiduciaries” of the Plan, have a duty to operate the Plan prudently and in the interest of you and other Plan participants and beneficiaries. Fiduciaries who violate ERISA may be removed and required to make good any losses they have caused the Plan.
No one, including the Company or any other person, may fire you or discriminate against you in any way to prevent you from obtaining welfare benefits or exercising your rights under ERISA.
If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.
Under ERISA, there are steps you can take to enforce these rights. For instance, if you request a copy of plan documents or the latest annual report from the Plan Administrator and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to
$110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the Plan Administrator. If you have a claim for benefits, which is denied or ignored, in whole or in part, and you have exhausted the claims procedures available to you under the Plan (see your plan document or summary plan description for more detail), you may file suit in a state or Federal court. In addition, if you disagree with the plan’s decision or lack thereof concerning the qualified status of a domestic relations order or a medical child support order, you may file suit in Federal court. If it should happen that Plan fiduciaries misuse the Plan’s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous.
If you have any questions about your Plan, you should contact the Plan Administrator. If you have any questions about this statement, or your rights under ERISA, or if you need assistance or information regarding your rights under HIPAA, you should contact the nearest office of the Associate Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Associate Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Associate Benefits Security Administration.
Legal Notices
HIPAA NOTICE OF PRIVACY PRACTICES
Protecting Your Health Information Privacy Rights
PSEB LLC is committed to the privacy of your health information. The administrators of the PSEB Health and Welfare Plan (the “Plan”) use strict privacy standards to protect your health information from unauthorized use or disclosure.
The Plan’s policies protecting your privacy rights and your rights under the law are described in the Plan’s Notice of Privacy Practices. You may receive a copy of the Notice of Privacy Practices by contacting [email protected] or 1-800-599-9393. The notice also is available on-line at http://associates.eddiebauer.com/benefits/sbc/.
HIPAA SPECIAL ENROLLMENT RIGHTS – Aetna, HMAA, Kaiser Permanente Notice of Your HIPAA Special Enrollment Rights
A federal law called HIPAA requires that we notify you about an important provision in the plan - your right to enroll in the plan under its “special enrollment provision” if you acquire a new dependent, or if you decline coverage under this plan for yourself or an eligible dependent while other coverage is in effect and later lose that other coverage for certain qualifying reasons.
Loss of Other Coverage (Excluding Medicaid or a State Children’s Health Insurance Program)
If you decline enrollment for yourself or for an eligible dependent (including your spouse) while other health insurance or group health plan coverage is in effect, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 31 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).
Loss of Coverage for Medicaid or a State Children’s Health Insurance Program
If you decline enrollment for yourself or for an eligible dependent (including your spouse) while Medicaid coverage or coverage under a state children’s health insurance program is in effect, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage. However, you must request enrollment within 60 days after your or your dependents’ coverage ends under Medicaid or a state children’s health insurance program.
New Dependent by Marriage, Birth, Adoption, or Placement for Adoption
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 new dependents. However, you must request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption.
Eligibility for Medicaid or a State Children’s Health Insurance Program
If you or your dependents (including your spouse) become eligible for a state premium assistance subsidy from Medicaid or through a state children’s health insurance program with respect to coverage under this plan, you may be able to enroll yourself and your dependents in this plan. However, you must request enrollment within 60 days after your or your dependents’ determination of eligibility for such assistance.
To request special enrollment or to obtain more information about the plan’s special enrollment provisions, contact the Benefits Team at benefits@ sebllc.com or 1-800-599-9393.
Legal Notices
HIPAA SPECIAL ENROLLMENT RIGHTS – Triple S Notice of Your HIPAA Special Enrollment Rights
A federal law called HIPAA requires that we notify you about an important provision in the plan - your right to enroll in the plan under its “special enrollment provision” if you acquire a new dependent, or if you decline coverage under this plan for yourself or an eligible dependent while other coverage is in effect and later lose that other coverage for certain qualifying reasons.
Loss of Other Coverage (Excluding Medicaid or a State Children’s Health Insurance Program)
If you decline enrollment for yourself or for an eligible dependent (including your spouse) while other health insurance or group health plan coverage is in effect, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).
Loss of Coverage for Medicaid or a State Children’s Health Insurance Program
If you decline enrollment for yourself or for an eligible dependent (including your spouse) while Medicaid coverage or coverage under a state children’s health insurance program is in effect, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage. However, you must request enrollment within 60 days after your or your dependents’ coverage ends under Medicaid or a state children’s health insurance program.
New Dependent by Marriage, Birth, Adoption, or Placement for Adoption
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 new dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.
Eligibility for Medicaid or a State Children’s Health Insurance Program
If you or your dependents (including your spouse) become eligible for a state premium assistance subsidy from Medicaid or through a state children’s health insurance program with respect to coverage under this plan, you may be able to enroll yourself and your dependents in this plan. However, you must request enrollment within 60 days after your or your dependents’ determination of eligibility for such assistance.
To request special enrollment or to obtain more information about the plan’s special enrollment provisions, contact the Benefits Team at benefits@ sebllc.com or 1-800-599-9393.
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Explore your new benefits
2021 Open Enrollment Guide
