WELCOME TO OPEN ENROLLMENT Plan Year: 10/01/2020 – 9/30/2021 ** North Carolina Employees Only **
WELCOME TO OPEN ENROLLMENT
PICK THE BEST BENEFITS FOR YOU AND YOUR FAMILY. On behalf of Hauser, we would like to welcome you to the 2020 – 2021 annual benefits summary package for Polytex Environmental Inks, Inc., Daybreak Technologies, Inc., and DBT Coatings LLC (known as PEI/NC from here on). This packet contains detailed summaries of the benefits offered to you by PEI/NC. We encourage you to take the time to educate yourself about your options and choose the best coverage for you and your family. Whether you are a newly hired employee or a current employee enrolling during open enrollment, elections you make at this time will remain in effect until PEI/NC’s next open enrollment period, unless you have a qualifying event that allows a mid-year plan change.
Table of Contents Health Insurance ..................................................................................... Pages 4-8 Health Savings Account .......................................................................... Page 9 UHC Virtual Visits .................................................................................... Page 10 Dental Insurance ..................................................................................... Page 11 Vision Insurance ...................................................................................... Page 12 Life & AD&D Insurance ........................................................................... Page 13 Disability Income Benefits ...................................................................... Page 14 Group Contacts ....................................................................................... Page 15
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Who is Eligible? If you are a full-time employee who has satisfied the new hire waiting period, you are eligible to enroll in the benefits outlined in this guide. Full-time employees are those who work 30 or more hours per week.
How to enroll Are you ready to enroll? The first step is to review your current benefits. Did you move recently or get married? Verify all your personal information and make any necessary changes. Once all your information is up to date, it’s time to make your benefit elections. The decisions you make during open enrollment can have a significant impact on your life and finances, so it is important to weigh your options carefully. Once all necessary forms have been completed, please return them to Deborah Jenkins.
When to enroll Open enrollment begins on 9/21/2020 and runs through 9/25/2020. The benefits you choose during open enrollment will become effective on 10/01/2020.
Qualifying Life Events Unless you experience a life-changing qualifying event, you cannot make changes to your benefits until the next open enrollment period. Qualifying events include things like: •
Marriage, divorce, or legal separation
•
Birth or adoption of a child
•
Change in child’s dependent status
•
Death of a spouse, child, or other qualified dependent
•
Change in residence
•
Change in employment status or a change in coverage under another employer-sponsored plan
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Medical and Prescription Drug Plans Plan Year – October 1st through September 30th United Health Care
PEI/NC offers a comprehensive benefits program to help you and your family protect your health and financial security. Your benefits are a valuable part of your compensation; we encourage you to learn how your plans work so you can get the most from them. PEI/NC offers you a choice between medical plans. All eligible employees can choose from three different medical plans offered through United HealthCare. All medical plans include pharmacy benefits. Employees who elect the Silver Navigate HMO plan will not have access to Out-of-Network benefits and they will need to obtain a referral from their Primary Care Physician in order to visit a Specialist. The following provides a summary of the main features of the medical benefit options. Please refer to your Summary of Benefits and Coverage which explains the full range of covered services.
2020-2021
UHC HSA Plan Base Plan
UHC PPO Plan Buy-Up
UHC HMO Plan Premium Buy-Up
Services
In-Network
In-Network
In-Network
Network Name
Choice Plus
Choice Plus
Choice Plus
Plan Code
BQMP/ B17
BQM7/ B15V
BQMA/ B19
$5,000 $10,000 You pay 30% / Plan pays 70%
$2,500 $5,000 You pay 20% / Plan pays 80%
$2,000 $4,000 You pay 20% / Plan pays 80%
$6,000 $12,000
$8,150 $16,300
$6,500 $13,000
Deductible then Coinsurance
$50/$150 Copay
$30/$60 Copay
Covered at 100%
Covered at 100%
Covered at 100%
Emergency Room
Deductible then Coinsurance
Deductible then Coinsurance
Deductible then Coinsurance
Urgent Care
Deductible then Coinsurance
$50 Copay
$50 Copay
Inpatient Service
Deductible then Coinsurance
Deductible then Coinsurance
Deductible then Coinsurance
Outpatient Services
Deductible then Coinsurance
Deductible then Coinsurance
Deductible then Coinsurance
YES
YES
NO
$10/$35/$75/$150
$20/$65/$100/$200
$10/$50/$125/$250
Deductible - Individual - Family - Coinsurance Out-of-Pocket Max - Individual - Family (includes deductible, coinsurance & copays) Physician Office Visit (primary/specialist) Preventive Care (Adult/Well-Child)
Out-of-Network Benefits Available Prescription Drugs Retail (30-day supply)
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Prescription Drug Coverage When you elect medical coverage, you are automatically covered under the prescription drug plan. You may fill your prescriptions at participating retail pharmacies. There are several categories of drugs under the plan. Formulary tiers and which drugs are covered in each tier vary by carrier. Find individualized information on your benefit coverage, determine tier status, check the status of claims and search for network pharmacies by logging on to www.myuhc.com or by calling United HealthCare member services.
Employee Cost In compliance with the Affordable Care Act premiums are based upon the age of the employee and their dependents. PEI/NC pays a significant portion of your medical premium; however, we do require employees contribute toward their health care costs as well. Premiums are calculated by adding the sum of the rates for each of the member categories (Employee, Spouse, up to 3 Dependents) set forth in the tables below. Please use the tables on the following pages for calculating the cost of your medical benefits. The employee cost shown below, and throughout the rest of this guide, is shown as MONTHLY. To calculate your “per pay period” deductions please use the following formulas. Monthly (12 pays per year) No Calculations Needed. Semi-Monthly (24 pays per year) Multiply Monthly Rate by twelve then divide by 24. Bi-Weekly (26 pays per year) Multiple Monthly Rate by twelve then divide by 26.
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Employee Cost UHC HSA Plan Base Plan Age Ranges 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64+
Monthly Rates $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $112.85 $117.84 $123.34 $128.90 $134.90 $140.91 $147.41 $153.99 $161.00 $164.47 $171.49 $177.55 $181.54 $186.53 $189.56
*** Same Rates as 2019-2020 *** UHC PPO Plan Buy Up Age Ranges 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64+
Monthly Rates $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.93 $111.12 $114.86 $119.31 $124.32 $130.05 $135.70 $142.06 $148.33 $155.25 $162.26 $169.82 $177.37 $185.56 $193.83 $202.66 $207.03 $215.86 $223.50 $228.52 $234.79 $238.61
UHC HMO Plan Premium Buy-Up Age Ranges 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64+
Monthly Rates $177.05 $182.48 $188.09 $193.91 $193.91 $193.91 $193.91 $194.69 $198.57 $203.22 $210.78 $216.98 $220.09 $224.75 $229.39 $232.31 $235.41 $236.96 $238.51 $240.06 $241.62 $244.71 $247.82 $252.48 $256.93 $263.14 $270.89 $280.00 $290.87 $303.08 $317.05 $330.82 $346.33 $361.65 $378.51 $395.58 $414.00 $432.42 $452.40 $472.56 $494.08 $504.75 $526.27 $544.89 $557.11 $572.42 $581.73
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Spouse Cost
*** Same Rates as 2019-2020 ***
UHC HSA Plan Base Plan Age Ranges 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64+
Monthly Rates $115.38 $118.92 $122.58 $126.37 $126.37 $126.37 $126.37 $126.88 $129.40 $132.44 $137.37 $141.41 $143.44 $146.47 $149.50 $151.39 $153.42 $154.43 $155.44 $156.45 $157.46 $159.48 $161.51 $164.54 $167.44 $171.49 $176.55 $182.48 $189.56 $197.52 $206.62 $215.59 $225.70 $235.68 $246.68 $257.80 $269.81 $281.81 $294.83 $307.97 $322.00 $328.95 $342.98 $355.11 $363.07 $373.05 $379.12
UHC PPO Plan Buy Up Age Ranges 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64+
Monthly Rates $130.30 $134.31 $138.45 $142.72 $142.72 $142.72 $142.72 $143.29 $146.15 $149.58 $155.14 $159.70 $162.00 $165.43 $168.84 $170.98 $173.26 $174.40 $175.55 $176.69 $177.83 $180.11 $182.41 $185.84 $189.11 $193.67 $199.39 $206.10 $214.09 $223.08 $233.36 $243.49 $254.91 $266.17 $278.59 $291.16 $304.72 $318.28 $332.98 $347.81 $363.66 $371.51 $387.35 $401.05 $410.05 $421.32 $428.17
UHC HMO Plan Premium Buy-Up Age Ranges 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64+
Monthly $234.74 $241.94 $249.38 $257.10 $257.10 $257.10 $257.10 $258.13 $263.27 $269.44 $279.46 $287.69 $291.80 $297.98 $304.14 $308.00 $312.12 $314.18 $316.23 $318.28 $320.35 $324.45 $328.58 $334.74 $340.65 $348.88 $359.17 $371.24 $385.66 $401.84 $420.36 $438.62 $459.18 $479.49 $501.85 $524.48 $548.90 $573.33 $599.82 $626.55 $655.08 $669.23 $697.76 $722.44 $738.65 $758.95 $771.29
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Child Cost
*** Same Rates as 2019-2020 ***
UHC HSA Plan Base Plan Age Ranges 0 -14 15 16 17 18 19 20 21 22 23 24 25 26
Monthly Rate $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85 $107.85
UHC PPO Plan Buy Up Age Ranges 0 -14 15 16 17 18 19 20 21 22 23 24 25 26
Monthly Rate $107.85 $107.85 $107.85 $107.85 $107.85 $110.52 $113.93 $117.45 $117.45 $117.45 $117.45 $117.92 $120.27
UHC HMO Plan Premium Buy-Up Age Ranges 0-14 15 16 17 18 19 20 21 22 23 24 25 26
Monthly Rate $177.34 $193.11 $199.13 $205.16 $211.66 $218.16 $224.87 $231.82 $231.82 $231.82 $231.82 $232.76 $237.39
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Health Savings Accounts (HSAs) Navia Benefit Solutions
When you participate in a high-deductible health plan, you can set aside money in a Health Savings Account (HSA) before taxes are deducted to pay for eligible medical, dental and vision expenses. An HSA is similar to a flexible spending account in that you are able to pay for health care expenses with pre-tax dollars. There are, however, several advantages to an HSA. For instance, upon reaching a minimum balance threshold money in an HSA can be invested much like 401(k) funds are invested. Unused money in an HSA account is not forfeited at the end of the year and is carried forward. Also, your HSA account is yours to keep which means that you can take it with you if you change jobs or retire. If you have any money remaining in your HSA after your retirement, you may withdraw the money as cash. The maximum amount that you can contribute to an HSA in 2020 is $3,550 for individual coverage and $7,100 for family coverage. If you are age 55 or older, you may make an additional “catch-up” contribution of $1,000. These maximums include employer and employee contributions. Note: If you contribute to an HSA and a Health Care FSA, there are restrictions on the types of expenses you can claim via your FSA. Please see the FSA section of this guide.
HSA Contributions PEI/NC will make contributions towards the Health Savings Accounts of those members who elect the HSA Qualified High Deductible Health Plan.
MONTHLY EMPLOYER HSA CONTRIBUTIONS
UHC HSA Plan Base Plan
Employee O l $75.00
Employee & Spouse
Employee & Child(ren)
Employee & Family
$150.00
$150.00
$150.00
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Tools myuhc.com
All your health plan information in one place. How convenient is that? myuhc.com® is your personalized member website to help you access and manage your medical, dental and vision plan details 24/7.*
Find and price care. Find a provider and get personalized estimates for the services in your network, including doctors, dentists, hospitals, labs and convenience and urgent care clinics. For minor health concerns, register for a Virtual Visit** and pay $50† or less to see a doctor on your smartphone,†† tablet or computer.
See what’s covered. Easily see what your plan covers and how much it costs for common services, including preventive care visits, urgent care visits, flu vaccines, chiropractic services and more. You also have access to your plan documents, member handbook, required notices and welcome materials.
Check your plan balances. Get quick access to review the status of your deductible, coinsurance and out-of-pocket limit. If included in your plan, you also have access to your health savings account (HSA), flexible spending account (FSA) or health reimbursement account (HRA). CONTINUED
Sign up in minutes at myuhc.com today. • Easily access and manage your health plan details. • Dependents 18 and over can also create their own accounts. • Have your health plan ID card handy.
WELCOME TO OPEN ENROLLMENT
Dental Plan Year – October 1st through September 30th MetLife PEI/NC offers one dental plan. This dental plan encourages you to go to an In-Network provider. If you choose to seek coverage from an Out-of-Network provider, the benefit will reduce and costs for services could increase. The Out-ofNetwork provider can bill you the difference between the amount charged and the amount paid by MetLife. This “balance billing” will not occur if you seek care from a MetLife In-Network provider. The following chart shows the main features of the Dental benefit options. A complete benefit summary is available from Human Resources.
MetLife PPO Plan
Services
In-Network
Applies to basic and major services only: $50 Individual $150 Family
Deductible Preventive Services
Exams, Cleanings, Bitewing X-rays - 100%
Basic Services
Fillings, Periodontal Maintenance, Prefabricated Crowns - 80%
Major Services
Dentures, Implant Services, Bridges - 50%
Orthodontia
Not Covered
Annual Maximum
$1,000
Out-of-Network Reimbursement
90th% UCR
The following monthly DENTAL Employee Payroll Deductions will be effective for this plan year and will be reflected on your first paycheck after your effective date. DENTAL: EMPLOYEE MONTHLY DEDUCTIONS
Plan
Employee
Employee & Spouse
Employee & Child(ren)
Family
Dental
$18.81
$38.11
$41.64
$65.16
*** Same Rates as 2019-2020 *** Monthly (12 pays per year) No Calculations Needed. Semi-Monthly (24 pays per year) Multiply Monthly Rate by twelve then divide by 24. Bi-Weekly (26 pays per year) Multiple Monthly Rate by twelve then divide by 26.
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Voluntary Vision Plan Year – October 1st through September 30th MetLife Your vision health is an important part of complete wellness. MetLife is pleased to present your vision benefits which are designed to give you and your covered family members the care, value, and service to help maintain good vision and overall health. The following chart shows the main features of this Vision benefit option. A complete benefit summary is available from Human Resources. Vision Benefits
In-Network Member Cost
Out-of-Network Reimbursement
Annual Comprehensive Eye Exam (every 12 months)
$10 copay
Up to $45
Materials
$25 copay
See below
Standard Plastic Lenses (every 12 months) Single Vision Bifocal Trifocal
$10 copay $10 copay $10 copay
Up to $30 after copay Up to $50 after copay Up to $65 after copay
Frames (Every 24 months)
$130 Allowance, 20% discount on remaining balance
Up to $70
Contact Lenses (every 12 months in lieu of frames/ lenses) Elective
$130 Allowance
Up to $105
Medically Necessary
$0 copay, Paid in Full
Up to $210
The following monthly VISION Employee Payroll Deductions will be effective for this plan year and will be reflected on your first paycheck after your effective date. VISION: EMPLOYEE MONTHLY DEDUCTIONS
Plan
Employee
Employee & Spouse
Family
Vision
$3.32
$6.23
$8.87
*** Same Rates as 2019-2020 *** Monthly (12 pays per year) No Calculations Needed. Semi-Monthly (24 pays per year) Multiply Monthly Rate by twelve then divide by 24. Bi-Weekly (26 pays per year) Multiple Monthly Rate by twelve then divide by 26.
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Basic Life and AD&D Insurance Plan Year – October 1st through September 30th MetLife
Life and Accidental Death & Dismemberment (AD&D) Coverage is made available through MetLife. Life and AD&D insurance is an important benefit as it provides your beneficiaries financial protection in the event of a tragic loss. Life Insurance PEI/NC provides full-time employees with group life and accidental death and dismemberment (AD&D) insurance in the amount of 1X Annual Salary up to $50,000 and pays for 100% of the coverage. This benefit will reduce: Age 65 Age 70
65% remaining 50% remaining
Voluntary Life and AD&D Insurance Plan Year – October 1st through September 30th MetLife
Employees who would like to supplement their group life insurance may purchase additional coverage. When you enroll yourself and/or your dependents in this benefit, you pay the full cost through payroll deductions. Employee: Increments of $10,000 Maximum Coverage up to 5X Annual Salary to a Maximum of $500,000 Guarantee Issue for members age 70 and under: $50,000 Spouse: Increments of $5,000 Maximum Coverage 50% of employee coverage election with a maximum of $100,000 Guarantee Issue for dependents age 70 and under: $ $25,000 Child(ren): Increments of $1,000 Maximum Coverage 100% of employee coverage elections with a maximum of $10,000
MONTHLY Cost Per $1,000 for Employee and Spouse Life Insurance Coverage Age
<30
Life and AD&D $0.076
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70+
$0.096
$0.106
$0.136
$0.203
$0.318
$0.478
$0.726
$1.286
$2.279
Cost for Child Life Insurance Coverage Dependent Children
$0.29
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Long Term Disability Income Benefits Plan Year – October 1st through September 30th MetLife
PEI/NC provides full-time employees with Long Term Disability and pays 100% of the cost. In the event you become disabled due to injury or sickness, disability income benefits are provided as a supplemental source of income. A complete benefit summary is available from Human Resources.
Long-Term Disability Elimination Period
90 days
Income Replacement
60% of covered pre-disability earnings
Maximum Benefit
$6,000/month
Maximum Benefit Period
SSNRA
Pre-Existing Condition Waiting Period
Look-back: 3 month / Limitation Period: 12 months
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Contacts – Carriers Contact Name
Contact Information
Medical United Health Care
Phone: (866) 414-1959 www.myuhc.com
Dental MetLife
Phone: (800) 638-5433 www.MetLife.com
Vision MetLife
Phone: (800) 638-5433 www.MetLife.com
Life and AD&D, Voluntary Life and AD&D, LTD MetLife
Phone: (800) 638-5433 www.MetLife.com
Contacts – Your Human Resource Team Contact Name
Title
Phone
Deborah Jenkins
US Controller
(336) 515-1412
djenkins@polytexink.com
Contacts – Hauser Insurance Group Team Contact Name
Contact Information
Description
Talia Townes, Client Relationship Manager
Phone: (513) 936-7368 Fax: (513) 984-7068 Email: ttownes@thehausergroup.com
Talia is the day to day point of contact for plan questions, eligibility, and assistance in resolving a claim.
Annelle Schaeper, Benefits Analyst
Phone: (513) 984-7022 Fax: (513) 984-7023 Email: aschaeper@thehausergroup.com
Annelle assists with the marketing of your health plan, while also providing assistance with ID card requests.
The information in this Enrollment Guide is presented for illustrative purposes and the text contained herein was taken from various summary plan descriptions and benefit information. While every effort was taken to accurately report your benefits, discrepancies or errors are always possible. In case of discrepancy between the Guide and the actual plan documents the actual plan documents will prevail. All information is confidential, pursuant to the Health Insurance Portability and Accountability Act of 1996. If you have any questions about your Guide, contact Human Resources
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The benefit plan information shown in this guide is illustrative only. To the extent the benefit plans contained herein differ from those in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide, the benefit plans in the underlying insurance documents will govern in all cases.
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