Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Medical, Flexible Spending Account and Health Savings Account, Dental, Vision, Basic and Optional Term Life, Accidental Death and Dismemberment, Short Term and Long Term Disability, and Care24 Services
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For 2013-2014 there will be some changes to your benefits as outlined below. Associates who are scheduled to work at least 30 hours per week and have also attained 60 days of continuous service are eligible to participate in the programs described in this benefits enrollment guide. The effective date of participation will be the 1st of the month following attainment of 60 days of continuous service. Associates scheduled to work less than 30 hours per week and Temporary Associates are ineligible to participate in Mattress Firm benefit plans. 100% preventive coverage for Choice Plus medical plan option High Deductible Health Plan medical option Health Savings Account Employer paid Basic Term Life benefit increased to 1x annual salary, up to $500,000 Employer paid Accidental Death and Dismemberment benefit increased to 1x annual salary, up to $500,000 Short Term Disability 100% employer paid
General Information
Our Benefits program reflects our commitment to providing Benefits that are competitive and are a valuable component of the total compensation package provided to Associates. The Benefits program includes: Medical Insurance Prescription Drugs Dental Insurance Vision Insurance Flexible Spending Account Health Savings Account Term Life Insurance Accidental Death and Dismemberment Long Term Disability Insurance Short Term Disability Insurance Care24 Services
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In addition to your pay, these Benefits, along with personal time and vacation, add substantial value to the overall compensation package provided by Mattress Firm. The comprehensive, low cost Benefits Plans are one of the many rewards of being a part of Mattress Firm. Paying for Your Benefits Your share of the cost for Medical, Dental, and Vision contributions is deducted from your paycheck on a pre-tax basis. That means your taxable income is lower, so you pay less in taxes. When Coverage Begins If you are an existing Associate electing coverage during the Open Enrollment period, coverage is effective on October 1, 2013. If you are a new Associate and are scheduled to work at least 30 hours per week, coverage begins the 1st of the month after 60 days of continuous employment.
Healthcare is an important part of your Benefit package. At Mattress Firm we take pride in the fact that we are able to provide Associates with competitive benefits at a reasonable cost. By utilizing some of the cost-control measures outlined below, you can help minimize costs and maximize benefits. Learn as much as you can about treatments or medications prescribed by your physician. Being an educated and well-informed consumer can help you make the best decisions for you and your family. If you do not fully understand the treatment or why it is being prescribed, ask your doctor. Take all prescribed medication as indicated by your doctor. Not doing so can be harmful to your health and can lead to additional costs. Use the mail order prescription drug service for your maintenance medications it can save you time, and in most cases, money! Maintain an active lifestyle you may want to consult with your doctor on an exercise program that fits your needs.
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Contact information for all of your Benefit providers Overviews of your Medical, Dental, Vision, FSA, Life, Short Term Disability, Long Term Disability, and 401(k) benefits. Employee contributions by Plan
Contact Information
Services Benefits Call Center M F, 7:00 am 6:00 pm CT United Healthcare Carrier 855-232-1849 Medical 800.357.0978 Dental 877.816.3596 Vision 800.638.3120 866.755.2648 800-791-9361 Customer Service 1.800.247.6875 STD Fax 781.304.5599 Evidence of Insurability Fax 781.446.1517 800.249.6269 888.887.4114 Telephone
Flexible Spending Account (FSA) Health Savings Account Term Life Insurance, Accidental Death and Dismemberment, Short Term Disability, and Long Term Disability Benefits
Policy Number 226189
United Healthcare
www.myuhc.com
United Healthcare
www.myuhc.com
www.sunlife.com/us
SunLife
www.mattressfirm401k.com
One America
Coverage begins on the first of the month following 60 days of employment. Temporary Associates are not eligible.
Eligible dependents can enroll in Mattress Firms Benefits plans; however, supporting documentation will be required to validate eligibility. Please contact the Benefits Department to determine the required supporting documentation. An eligible dependent includes: Spouse (not fianc, but your legal spouse as determined by applicable law) Common Law Spouse Legal Dependent An Associates child up to age 26 (birth, adoption, or stepchild) Qualified Medical Child Support Order
Due to the pre-taxed status of the health and welfare plans, once you make your final choices for 2013-2014, you cannot change your benefits until the next Open Enrollment Period. Changes during the plan year may only be made due to a qualifying event (listed below), and your benefit changes must be consistent with the qualifying event. Qualifying events: Marriage you may add your new spouse to the plan or cancel your plan to join your spouses plan. Divorce, Legal Separation, Reaching Child Age Limit, Death you may remove your spouse and/or dependents from the plan Birth, Adoption, Court Order/Legal Guardianship, Disability you may add your dependent to the plan Significant Changes in Employment you may add or remove your spouse and/or dependents depending upon an employment change with your spouse (e.g. job loss, employer plan discontinued, significant change in cost of coverage) Loss of Other Group Coverage you may enroll or add spouse and/or dependents to the plan
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Enrollment due to a qualifying event must be received by the Benefits Department within 31 days of the qualifying event. All qualifying events may require proof, e.g. marriage, birth certificate, court order, proof of insurability, HIPAA letter from previous employer or insurance company, etc. If you fail to enroll or choose not to participate in the benefits program within 31 days of eligibility or a qualified life event, you must wait until the next Open Enrollment Period to enroll for coverage.
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Eligible charges are subject to the calendar year deductible unless stated otherwise. See Plan Document for more details.
United Healthcare
Deductible Individual (calendar yr) Family (calendar yr) Out-of-Pocket Maximum Individual Family Co-Insurance Physician Office Visit Lifetime Maximum Preventive Care Hospital Services Urgent Care Copayment Mental Health Care Inpatient/Outpatient Skilled Nursing Facility (60 days limit) Home Health Care (60 days limit) Physician Surgical Services in any setting and Maternity Hospice Care (360 days, lifetime) Pharmacy Benefits Prescription Drugs (Retail) Generic Preferred Brand Name Non-Preferred Brand Name Prescription Drugs (Home Delivery) Generic Preferred Brand Name Non-Preferred Brand Name Associate Only Associate + Spouse Associate + Child(ren) Associate + Family
$4,900 N/A $9,800 N/A 80% after deductible 50% after deductible $30 Office Visit/$60 Specialist No copay deductible applies Unlimited 100% Not covered 80% after copay and deductible $60 copay 80% after copay and deductible 80% after copay and deductible 80% after copay and deductible 80% after copay and deductible 80% after copay and deductible Network 50% after deductible No copay deductible applies 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible Non-Network (Up to 30 Day Supply) $10 $30 $50 $25 $75 $125 $126.00 $335.00 $283.00 $463.00 Page 8
Eligible charges are subject to the calendar year deductible unless stated otherwise. See Plan Document for more details.
United Healthcare
Deductible Individual (calendar yr) Family (calendar yr) Out-of-Pocket Maximum Individual Family Co-Insurance Physician Office Visit Lifetime Maximum Preventive Care Hospital Services Urgent Care Copayment Mental Health Care Inpatient/Outpatient Skilled Nursing Facility Home Health Care Physician Surgical Services
In any setting and Maternity
Network $2,000 $4,000 $5,000 $10,000 80% after deductible 80% after deductible Unlimited 100% 80% after deductible 80% after deductible 80% after deductible 80% after deductible 80% after deductible 80% after deductible
Non-Network $4,000 $8,000 $10,000 $20,000 60% after deductible 60% after deductible Not covered 60% after deductible 60% after deductible 60% after deductible 60% after deductible 60% after deductible 60% after deductible
Hospice Care (unlimited) Pharmacy Benefits Prescription Drugs (Retail) Generic Preferred Brand Name Non-Preferred Brand Name Prescription Drugs (Home Delivery) Generic Preferred Brand Name Non-Preferred Brand Name Associate Only Associate + Spouse Associate + Child(ren) Associate + Family
60% after deductible 80% after deductible Network Non-Network Pharmacy copays do not apply until after Medical deductible (Up to 30 Day Supply) $10 $35 $60 $25 $87.50 $150 $75.00 $232.00 $189.00 $309.00
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Once you have estimated the total cost for each of these expenses, then the total is what you should contribute to your FSA. If needed, contribution planning assistance can be located on the FSA website. When can I start using the money in my FSA? You have immediate access to your entire medical FSA election amount from the first day your benefits become effective. For example, if you set aside $1,000 and during the first week your benefits become effective you incur eligible medical expenses that total $1,000, then you can use your debit card to pay for those expenses. Access to your dependent care FSA amount is limited to the amount contributed to your FSA as of the date of your request for reimbursement. Page 10
What expenses are covered under my FSA? An FSA covers eligible health care expenses that are not paid for by health insurance. Some examples of eligible health expenses include the following: Medical and dental copays and deductibles Orthodontia and/or dental care Physical therapy Hearing care, eye exams, contact lenses and glasses Prescription copays and coinsurance What happens to my contributions if I leave or terminate employment with Mattress Firm? If there is a positive balance in your FSA account you have COBRA rights. If you do not exercise your COBRA rights, you forfeit any of the remaining balance. What is the Use it or Lose it rule? It is important to remember that an FSA is not a savings account. You must use all of your contributions each year or risk losing any unused balance at the end of the plan year. Be sure to base your contributions on what you expect to be able to spend on eligible expenses during the benefit plan year, it is better to be conservative and underestimate.
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100% Associate Contributions - Mattress Firm will match your contributions into the Health Savings Account up to specific levels. Associates who enroll in the High Deductible Health Plan (HDHP) are eligible to participate in a Health Savings Account (HSA). The HSA is a tax advantaged account designed to help you save for current and future health care expenses. HSA contributions will be deducted from your paycheck on a pre-tax basis and are subject to annual IRS limits. The maximum annual match from Mattress Firm will be: $240 for Associate only coverage $360 for Associate + Spouse or Associate + Child(ren) coverage $480 for Associate + Family coverage
The contributions will be deposited to your HSA account set-up with an Optum Bank. You can use these funds to pay for qualified medical care expenses. Qualified expenses also count toward your annual deductible. Balances roll over from year to year and the account is portable, which means it stays with you if you change benefit plans or employers. Who is eligible for an HSA? Must be enrolled in an IRS qualified High Deductible Health Plan (HDHP) You must not be covered by another medical plan, unless the other medical plan is a qualified HDHP You must not be enrolled in Medicare coverage Can I participate in a High Deductible Health Plan (HDHP) and another health plan and still be eligible for the HSA? As long as both health plans are HDHPs, you are eligible for an HSA. What is my contribution limit to the HSA? The limits on HSA contributions for 2013 are $3,250 for Individual and $6,450 for Family. You may contribute to the account via pay roll deduction up to the maximums. If you are age 55 and older, you may contribute a catch up contribution in addition to your limit. The catch up contribution in 2013 is $1,000. What expenses may I pay for from my HSA? You may use your HSA for a medical expense that pays for healthcare services, equipment or medications. These include expenses applied to your health plan deductible, dental care services, vision services, prescription services, over-the-counter medications prescribed by your doctor, and certain medical equipment. For a more detailed list of qualified medical expenses, please visit the IRS Publication 502: http://www.irs.gov/publications/p502/index.html OR www.myuhc.com How do I pay for claims through my HSA? Page 12
You will receive your HSA Bank card under a separate mailing from United Healthcare. You can use this card for HSA-eligible expenses at certain qualified locations that accept Visa cards. Save your receipts every time you withdraw money from your HSA - the IRS may ask you to verify an expense should you be audited. Is there a penalty for paying for non-qualified health expenses from my HSA? Yes, you will be subject to your regular income tax rate and a 20% penalty. Do I have to prove my expenses are qualified health expenses? You are responsible for keeping receipts in the event the IRS audits your tax return. If I do not spend all of the money in my HSA, do I lose it? No, you own your HSA. Any unused funds are yours and remain in your HSA. Your account rolls from year to year. You can use the funds in the account for any medical, dental, vision or prescription drugs you need for any of your eligible dependents. If I leave Mattress Firm, do I lose the money in my HSA? No, you own your HSA and the money in it is yours. How do I open an HSA bank account? A link to Optum Bank will be provided on the Mattress Firm benefits site, www.mattressfirmbenefits.com . Click on the link and follow directions to set up your individual account. You can also copy and paste the address below to your web browser: https://enrollhsa.optumbank.com/hsaAppWeb/WelcomeAction.do?is_partner_post=Y&group_num=704140
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Effective 1/1/2011 Over-the-Counter Medications are not eligible expenses for HSAs.
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United Healthcare
Calendar Year Maximum Orthodontia Lifetime Maximum (per child) Calendar Year Deductible Individual Family Co-Insurance Preventive Basic Major Oral Surgery Orthodontia
(children under the age of 19)
Dental Plan $1,500 $1,000 $50 $150 100%, no deductible 80% after deductible 50% after deductible 80% after deductible 50%, no deductible Covered Services Exams, Bitewing X-rays, All Other X-Rays, Cleaning &Fluoride, Treatments, Sealants, and Palliative Treatment Basic Restorative (Fillings) Simple Extractions Complex Oral Surgery General Anesthesia Resin or Amalgam Fillings Crowns, Dentures Prosthetics (Bridges, Dentures) Implants Monthly Employee Contributions $30.41 $55.93 $59.19 $87.42
Preventive
Basic
Major
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Comprehensive benefits for eye exams, glasses, contacts and a discount on laser vision correction Network and Non-Network options - greater discounts by utilizing Network Providers Find participating network providers at www.myuhcvision.com Vision Plan Network $10 $25 100% 100% 100% 100% 100% Up to $140 100% Up to $130 Plan Frequencies Every 12 months Every 12 months Every 24 months Every 12 months Monthly Employee Contributions $6.50 $12.40 $13.00 $20.00 Non-Network Up to $40 Up to $80 Up to $40 Up to $40 Up to $60 Up to $80 Up to $80 Up to $150 Up to $210 Up to $50
United Healthcare
Copay Exams Hardware Eye Exam Lenses Single Bifocal Trifocal Lenticular Contact Lenses Fitting, follow up & Lenses (in lieu of glasses) Medically Necessary Contacts Frame Retail Value Exam Lenses Frames Contacts Employee Only Employee + Spouse Employee + Child(ren) Employee + Family
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Sun Life
Benefit Amount Guarantee Issue Benefit Reductions
Basic Term Life and AD&D Summary Benefit Schedule 1x annual salary to a maximum of $500,000 All Guarantee Issue To 65% at age 70, 40% at age 75, 25% at age 80, 15% at age 85 and 10% at age 90 or Over
Optional Life insurance is available for you to purchase coverage on yourself and/or your eligible dependents. The premiums are based on the employees age and will be paid by payroll deduction. This coverage is portable and convertible. Optional Term Life Summary Benefit Schedule Increments of $10,000 $10,000 to $500,000 $10,000 to $250,000 (not to exceed 100% of the members amount) To 65% at age 70, 40% at age 75, 25% at age 80, 15% at age 85 and 10% at age 90 or Over $2,000 to $10,000 (increments of $2,000) Guarantee Issue Amount $200,000 $100,000
Sun Life
Associate Spouse Benefit Reductions Child
All
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Optional AD&D insurance is available for you to purchase coverage on yourself and/or your eligible dependents. The premiums are based on the flat rate and will be paid by payroll deduction.
Sun Life
Associate Spouse Child(ren)
Optional AD&D Summary Benefit Schedule Coverage Amounts Starting At: $10,000 increments $10,000 increments $2,000 increments Maximum Benefit Allowed $500,000 $250,000 $10,000
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Sun Life
% of Weekly Salary Maximum Weekly Benefit Max Period Benefit Paid Accident/Sickness Elimination Period
Sun Life
Monthly Benefit Duration Elimination Period Maximum Monthly Benefit
Benefit 60% of monthly salary To Social Security Normal Retirement Age 90 Days $6,000 per month
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CARE 24 SERVICES
Mattress Firm cares about your total health management both physical and emotional. For that reason, we offer a medical benefit through Care24, administered by United Healthcare. The service connects you with the best nurses, mental health, and counseling services to fit your individual needs. With just one phone call, at any hour of the day or night, you can reach a compassionate ear and connect to helpful resources. Services available consist of: 24 hour advice nurse Routine illness Stress and anxiety Relationship worries Coping with grief and loss Questions to ask your doctor Mens, womens, and childrens health Prevention Self-care information Help finding a doctor Information on medications General health information
Care24 provides over-the-phone assistance, you may call toll free 1-888-887-4114. To access the Employee Assistance Program website, log onto www.myuhc.com . Group Number: 704140
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COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a qualifying event. Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a qualified beneficiary. You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you are an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because either one of the following qualifying events happens: Your hours of employment are reduced Your employment ends for any reason other than your gross misconduct If you are the spouse of an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because of any of the following qualifying events: Your spouse dies Your spouses hours of employment are reduced Your spouses employment ends for any reason other than his or her gross misconduct Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both) You become divorced or legally separated from your spouse Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of any of the following qualifying events: The parent-employee dies The parent-employees hours of employment are reduced The parent-employees employment ends for any reason other than his or her gross misconduct The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both) The parents become divorced or legally separated The child stops being eligible for coverage under the plan as a dependent child Page 22
The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. When the qualifying event is the end of employment, reduction of hours of employment, or death of the employee or the employee becomes entitled to Medicare benefits (Part A, Part B, or both); the employer must notify the Plan Administrator of the qualifying event. You must give notice of some qualifying events. For the other qualifying events (divorce or legal separation of the employee and spouse or a dependent child loses eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. You must provide written notice to your employer.
Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouse. Parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage. When the qualifying event is the death of the employee, the employee becomes entitled to Medicare benefits (under Part A, Part B, or both), divorce or legal separation, or a dependent child loses eligibility as a dependent child, COBRA continuation coverage lasts for up to a total of 36 months. When the qualifying event is the end of employment or reduction of the employees hours of employment, and the employee became entitled to Medicare benefits less than 18 months before the qualifying event, COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement. For example, if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates, COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus 8 months). Otherwise, when the qualifying event is the end of employment or reduction of the employees hours of employment, COBRA continuation coverage generally lasts for only up to a total of 18 months. There are two ways in which this 18-month period of COBRA continuation coverage can be extended.
If you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of 29 months. The disability would have to have started before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage. A copy of the Social Security Administration determination notice must be provided within 60 days of the date of the determination and prior to the end of the 18th month on continuation coverage to: benefits@mattressfirm.com
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If your family experiences another qualifying event while receiving 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if notice of the second qualifying event is properly given to the Plan Administrator. This extension may be available to the spouse and any dependent children receiving continuation coverage if the employee or former employee dies, becomes entitled to Medicare benefits (under Part A, Part B, or both), or gets divorced or legally separated, or if the dependent child stops being eligible under the Plan as a dependent child, but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred.
Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labors Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSAs website.)
In order to protect your familys rights, you should keep the Plan Administrator informed of any change in the addresses of family members. You should keep a copy, for your records, of any notices you send to the Plan Administrator.
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Genetic information does not include information about the sex or age of any individual. GINA defines a genetic test as an analysis of human DNA, RNA, chromosomes, proteins, or metabolites that detect genotypes, mutations, or chromosomal changes. Routine tests that do not detect genotypes, mutations, or chromosomal changes, such as complete blood counts, cholesterol tests, and liver enzyme tests, are not considered genetic tests under GINA. Also, under GINA, genetic tests do not include analyses of proteins or metabolites that are directly related to a manifested disease, disorder, or pathological condition that could reasonably be detected by a health care professional with appropriate training and expertise in the field of medicine involved. GINA includes a research exception to the general prohibition against health insurers or group health plans requesting that an individual undergo a genetic test. This exception allows health insurers and group health plans engaged in research to request (but not require) that an individual undergo a genetic test. This exception permits the request to be made but imposes the following requirements: The request must be made pursuant to research that complies with HHS regulations at 45 CFR part 46, or equivalent Federal regulations, and any applicable state or local laws for the protection of human subjects in research No genetic information collected or acquired as part of the research may be used for underwriting purposes The health insurer or group health plan must notify the Federal government in writing that it is conducting activities pursuant to this research exception and provide a description of the activities conducted The health insurer or group health plan must comply with any future conditions that Federal government may require for activities conducted under this research exception
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GINAs provisions prohibiting discrimination in health coverage based on genetic information do not extend to life insurance, disability insurance, or long-term care insurance. For example, GINA does not make it illegal for a life insurance company to discriminate based on genetic information. In addition, GINAs provisions prohibiting discrimination by employers based on genetic information generally do not apply to employers with fewer than 15 employees. For health coverage provided by a health insurer to individuals, GINA does not prohibit the health insurer from determining eligibility or premium rates for an individual based on the manifestation of a disease or disorder in that individual. For employment-based health coverage provided by group health plans, GINA permits the overall premium rate for an employer to be increased because of the manifestation of a disease or disorder of an individual enrolled in the plan, but the manifested disease or disorder of one individual cannot be used as genetic information about other group members to further increase the premium. GINA also does not prohibit health insurers or health plan administrators from obtaining and using genetic test results in making payment determinations.
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A Medically Necessary Leave of Absence is a leave of absence or change in enrollment status that: Commences while an individual is suffering from serious illness or injury Is medically necessary Causes the individual to lose student status for purposes of the plan
The individuals treating physician must certify that he or she is suffering from a serious illness or injury and that the leave of absence is medically necessary.
Requirements
To qualify for continued coverage under Michelles Law, an individual must: Be qualified as a dependent child under the terms of the group health plan or coverage Have been enrolled in the group health plan or coverage, based on his or her status as a student at a post-secondary educational institution, immediately before the first day of the Medically Necessary Leave of Absence
Under Michelles Law, coverage must be continued until the earlier of: One year after the first day of the Medically Necessary Leave of Absence The date on which the coverage would otherwise terminate (e.g., the dependent child reaches the plans limiting age)
The dependent child is entitled to the same benefits during a Medically Necessary Leave of Absence as those benefits in which he/she was enrolled immediately before the leave.
Continuation Process
If you feel that this law applies to your situation, please contact Human Resources.
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COLORADO Medicaid
Medicaid Website: http://www.colorado.gov/ Medicaid Phone (In state): 1-800-866-3513 Medicaid Phone (Out of state): 1-800-221-3943
ALASKA Medicaid
Website: http://health.hss.state.ak.us/dpa/programs/medicaid/ Phone (Outside of Anchorage): 1-888-318-8890 Phone (Anchorage): 907-269-6529
FLORIDA Medicaid
Website: https://www.flmedicaidtplrecovery.com/ Phone: 1-877-357-3268
ARIZONA CHIP
Website: http://www.azahcccs.gov/applicants Phone (Outside of Maricopa County): 1-877-764-5437 Phone (Maricopa County): 602-417-5437
GEORGIA Medicaid
Website: http://dch.georgia.gov/ Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP) Phone: 1-800-869-1150
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INDIANA Medicaid
Website: http://www.in.gov/fssa Phone: 1-800-889-9949
MINNESOTA Medicaid
Website: http://www.dhs.state.mn.us/ Click on Health Care, then Medical Assistance Phone: 1-800-657-3629
IOWA Medicaid
Website: www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562
MISSOURI Medicaid
Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005
KANSAS Medicaid
Website: http://www.kdheks.gov/hcf/ Phone: 1-800-792-4884
MONTANA - Medicaid
Website: http://medicaidprovider.hhs.mt.gov/clientpages/ clientindex.shtml Phone: 1-800-694-3084
KENTUCKY Medicaid
Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570
NEBRASKA Medicaid
Website: www.ACCESSNebraska.ne.gov Phone: 1-800-383-4278
LOUISIANA Medicaid
Website: http://www.lahipp.dhh.louisiana.gov Phone: 1-888-695-2447
NEVADA Medicaid
Medicaid Website: http://dwss.nv.gov/ Medicaid Phone: 1-800-992-0900
MAINE Medicaid
Website: http://www.maine.gov/dhhs/ofi/publicassistance/index.html Phone: 1-800-977-6740 TTY 1-800-977-6741
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TEXAS Medicaid Website: https://www.gethipptexas.com/ Phone: 1-800-440-0493 UTAH Medicaid and CHIP
Website: http://health.utah.gov/upp Phone: 1-866-435-7414
VERMONT Medicaid
Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427
PENNSYLVANIA Medicaid
Website: http://www.dpw.state.pa.us/hipp Phone: 1-800-692-7462
WASHINGTON Medicaid
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WISCONSIN Medicaid
Website: http://www.badgercareplus.org/pubs/p-10095.htm Phone: 1-800-362-3002
WYOMING Medicaid
Website: http://health.wyo.gov/healthcarefin/equalitycare Phone: 307-777-7531
To see if any more States have added a premium assistance program since January 31, 2013, or for more information on special enrollment rights, you can contact either: U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/ebsa 1-866-444-EBSA (3272) U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, Ext. 61565
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This Notice is effective as of January 1, 2010 and shall remain in effect until you are notified of any changes, modifications or amendments. This Notice applies to health information the Mattress Firm Employee Benefit Plans (referred to herein as the Plan OR collectively referred to herein as the Plan) creates or receives about you. You may receive notices about your medical information and how it is handled by other plans or insurers. The Health Insurance Portability and Accountability Act of 1996, as amended (HIPAA), mandated the issuance of regulations to protect the privacy of individually identifiable health information, which were issued at 45 CFR Parts 160 through 164 (the Privacy Regulations). As a participant or beneficiary of the Plan, you are entitled to receive a notice of the Plans privacy procedures with respect to your health information that is created or received by the Plan (your Protected Health Information or PHI). This Notice is intended to inform you about how the Plan will use or disclose your PHI, your privacy rights with respect to the PHI, the Plans duties with respect to your PHI, your right to file a complaint with the Plan or with the Secretary of the U.S. Department of Health and Human Services (HHS) and the office to contact for further information about the Plans privacy practices.
Other than the uses or disclosures discussed below, any use or disclosure of your PHI will be made only with your written authorization. Any authorization by you must be in writing. You will receive a copy of any authorization you sign. You may revoke your authorization in writing, except your revocation cannot be effective to the extent the Plan has taken any action relying on your authorization for disclosure. Your authorization may not be revoked if your authorization was obtained as a condition for obtaining insurance coverage and any law provides the insurer with the right to contest a claim under the policy or the policy itself provides such right. When using or disclosing PHI or when requesting PHI from another covered entity, the Plan will make reasonable efforts not to use, disclose or request more than the minimum amount of PHI necessary to accomplish the intended purpose of the use, disclosure or request, taking into consideration practical and technological limitations. However, the minimum necessary standard will not apply in the following situations: disclosures to or requests by a health care provider for treatment uses or disclosures made to the individual disclosures made to HHS uses or disclosures that are required by law uses or disclosures that are required for the Plans compliance with legal regulations uses and disclosures made pursuant to a valid authorization
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The following uses and disclosures of your PHI may be made by the Plan: For Payment. Your PHI may be used or disclosed to obtain payment, including disclosures for coordination of benefits paid with other plans and medical payment coverages, disclosures for subrogation in order for the Plan to pursue recovery of benefits paid from parties who caused or contributed to the injury or illness, disclosures to determine if the claim for benefits are covered under the Plan, are medically necessary, experimental or investigational, and disclosures to obtain reimbursement under insurance, reinsurance, stop loss or excessive loss policies providing reimbursement for the benefits paid under the Plan on your behalf. Your PHI may be disclosed to other health plans maintained by the Plan sponsor for any of the purposes described above. For Treatment. Your PHI may be used or disclosed by the Plan for purposes of treating you. One example would be if your doctor requests information on what other drugs you are currently receiving during the course of treating you. For the Plans Operations. Your PHI may be used as part of the Plans health care operations. Health care operations include quality assurance, underwriting and premium rating to obtain renewal coverage, and other activities that are related to creating, renewing, or replacing the contract of health insurance or health benefits or securing or placing a contract for reinsurance of risk, including stop loss insurance, reviewing the competence and qualification of health care providers and conducting cost management and quality improvement activities, and customer service and resolution of internal grievances. The Plan is prohibited from using or disclosing your PHI that is genetic information for underwriting purposes. The following use and disclosure of your PHI may only be made by the Plan with your written authorization or by providing you with an opportunity to agree or object to the disclosure: To Individuals Involved in Your Care. The Plan is permitted to disclose your PHI to your family members, other relatives and your close personal friends if: the information is directly relevant to the family or friends involvement with your care or payment for that care; and you have either agreed to the disclosure or have been given an opportunity to object and have not objected.
The following uses and disclosures of your PHI may be made by the Plan without your authorization or without providing you with an opportunity to agree or object to the disclosure: For Appointment Reminders. Your PHI may be used so that the Plan, or one of its contracted service providers, may contact you to provide appointment reminders, information on treatment alternatives, or other health related benefits and services that may be of interest to you, such as case management, disease management, wellness programs, or employee assistance programs. To the Plan Sponsor. PHI may be provided to the sponsor of the Plan provided that the sponsor has certified that this PHI will not be used for any other benefits, employee benefit plans or employment-related activities.
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When Required by Law. The Plan may also be required to use or disclose your PHI as required by law. For example, the law may require reporting of certain types of wounds or a disclosure to comply with a court order, a warrant, a subpoena, a summons, or a grand jury subpoena received by the Plan. For Workers Compensation. The Plan may disclose your PHI as authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs, established by law, that provide benefits for work-related injuries or illnesses without regard to fault. For Public Health Activities. When permitted for purposes of public health activities, including when necessary to report product defects, to permit product recalls and to conduct post-marketing surveillance. Your PHI may also be used or disclosed if you have been exposed to a communicable disease or are at risk of spreading a disease or condition, if authorized or required by law. To Report Abuse, Neglect or Domestic Violence. When authorized or required by law to report information about abuse, neglect or domestic violence to public authorities if there exists a reasonable belief that you may be a victim of abuse, neglect or domestic violence. In such case, the Plan will promptly inform you that such a disclosure has been or will be made unless that notice would cause a risk of serious harm. For the purpose of reporting child abuse or neglect, the Plan is not required to inform the minor that such a disclosure has been or will be made. Disclosure may generally be made to the minors parents or other representatives, although there may be circumstances under federal or state law when the parents or other representatives may not be given access to a minors PHI. For Public Health Oversight Activities. The Plan may disclose your PHI to a public health oversight agency for oversight activities authorized or required by law. This includes uses or disclosures in civil, administrative or criminal investigations; inspections; licensure or disciplinary actions (for example, to investigate complaints against providers); and other activities necessary for appropriate oversight of government benefit programs (for example, to investigate Medicare or Medicaid fraud). For Judicial or Administrative Proceedings. The Plan may disclose your PHI when required for judicial or administrative proceedings. For example, your PHI may be disclosed in response to a subpoena or discovery request provided certain conditions are met. One of those conditions is that satisfactory assurances must be given to the Plan that the requesting party has made a good faith attempt to provide written notice to you, and the notice provided sufficient information about the proceeding to permit you to raise an objection and no objections were raised or any raised were resolved in favor of disclosure by the court or tribunal. For Other Law Enforcement Purposes. The Plan may disclose your PHI for other law enforcement purposes, including for the purpose of identifying or locating a suspect, fugitive, material witness or missing person. Disclosures for law enforcement purposes include disclosing information about an individual who is or is suspected to be a victim of a crime, but only if the individual agrees to the disclosure, or the Plan is unable to obtain the individuals agreement because of emergency circumstances. Furthermore, the law enforcement official must represent that the information is not intended to be used against the individual, the immediate law enforcement activity would be materially and adversely affected by waiting to obtain the individuals agreement, and disclosure is in the best interest of the individual as determined by the exercise of the Plans best judgment.
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To a Coroner or Medical Examiner. When required to be given to a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death or other duties as authorized or required by law. Also, disclosure is permitted to funeral directors, consistent with applicable law, as necessary to carry out their duties with respect to the decedent. For Research. The Plan may use or disclose PHI for research, subject to certain conditions. To Prevent or Lessen a Serious and Imminent Threat. When consistent with applicable law and standards of ethical conduct, if the Plan, in good faith, believes the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and the disclosure is to a person reasonably able to prevent or lessen the threat, including the target of the threat. State Privacy Laws. Some of the uses or disclosures described in this Notice may be prohibited or materially limited by other applicable state laws to the extent such laws are more stringent than the Privacy Regulations. The Plan shall comply with any applicable state laws that are more stringent when using or disclosing your PHI for any purposes described by this Notice. Article I.
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Right to Inspect and Copy PHI (continued) Information used for quality control or peer review analyses and not used to make decisions about individuals is not in the designated record set. You or your personal representative will be required to complete a form to request access to the PHI in your designated record set. If access is denied, you or your personal representative will be provided with a written denial setting forth the basis for the denial, a statement of your review rights, a description of how you may exercise those review rights and a description of how you may complain to HHS. Right to Amend You have the right to request the Plan to amend your PHI or a record about you in a designated record set for as long as the PHI is maintained in the designated record set. If the request is denied in whole or part, the Plan must provide you with a written denial that explains the basis for the denial. You or your personal representative may then submit a written statement disagreeing with the denial and have that statement included with any future disclosures of your PHI. You or your personal representative will be required to complete a form to request amendment of the PHI in your designated record set. You must make requests for amendments in writing and provide a reason to support your requested amendment. Right to Receive an Accounting of PHI Disclosures At your request, the Plan will also provide you with an accounting of disclosures by the Plan of your PHI during the six years prior to the date of your request. However, such accounting need not include PHI disclosures made: (1) to carry out treatment, payment or health care operations; (2) to individuals about their own PHI; (3) pursuant to a valid authorization; (4) incident to a use or disclosure otherwise permitted or required under the Privacy Regulations; (5) as part of a limited data set; or (6) prior to the date the Privacy Regulations were effective for the Plan on April 14, 2004. If you request more than one accounting within a 12-month period, the Plan will charge a reasonable, cost-based fee for each subsequent accounting. Right to Receive Confidential Communications You have the right to request to receive confidential communications of your PHI. This may be provided to you by alternative means or at alternative locations if you clearly state that the disclosure of all or part of the information could endanger you. Right to Receive a Paper Copy of This Notice Upon Request To obtain a paper copy of this Notice, contact the Privacy Official at the address and telephone number set forth in the Contact Information section below. A Note About Personal Representatives You may exercise your rights through a personal representative. Your personal representative will be required to produce evidence of his or her authority to act on your behalf before that person will be given access to your PHI or allowed to take any action for you. Proof of such authority may take one of the following forms: a power of attorney for health care purposes, notarized by a notary public a court order of appointment of the person as the conservator or guardian of the individual an individual who is the parent of a minor child The Plan retains discretion to deny access to your PHI to a personal representative to provide protection to those vulnerable people who depend on others to exercise their rights under these rules and who may be subject to abuse or neglect. This also applies to personal representatives of minors. Page 37
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Information contained in this Benefits Enrollment Guide is a summarization and not intended to replace the full details regarding eligibility, covered expenses, exclusions, limitations, definitions and other provisions of each plan contained in legal documents, handbooks and group contracts. Legal documents shall govern any differences.