BENEFIT GUIDE

Transcription

1 BENEFIT GUIDE

2 MAKE AN APPOINTMENT WITH A BENEFIT COUNSELOR Scan this code with your smart phone or tablet to go to the scheduling site WELCOME TO YOUR NEW HIRE BENEFITS ENROLLMENT! FOLLOW THESE EASY STEPS TO ENROLL IN YOUR NEW BENEFITS PROGRAM: Step 1 Review your Benefit Guide. Step 2 Prepare for your enrollment. Discuss the benefit plan options with your family and gather your dependent and/or beneficiary information, such as Social Security numbers, birth dates, etc. Step 3 Schedule your appointment online or through the Employee Benefit Resource Center. It s quick and easy. Visit If you DO NOT have access to the Internet, you can call (855) , Monday through Friday, to schedule an appointment. We understand the important role that our benefit programs play in the lives of our employees and their families. That s why we re committed to offering excellent benefits that not only protect your physical and financial health, but provide peace of mind when it comes to protecting your lifestyle and planning for the future. Again, welcome to Forever 21! All benefit elections are in effect throughout the remainder of the plan year that ends on September 30, If you would like more detailed information on the benefit plans available to you, log on to User ID: f21 + your 9-digit SSN Password: Your birthdate as MMDDYYYY Step 4 At your scheduled time, the Benefit Counselor will call the phone number you provided. From there, they will take your elections and answer any questions you may have about your benefit choices. Shortly after your enrollment, you will receive a confirmation statement detailing your elections, any covered dependents, and paycheck deduction amounts. Enrolling is easy! Please note that your benefits are effective the 1st of the month following 60 days of continuous employment. You must enroll BEFORE YOUR EFFECTIVE DATE. If you do not enroll in a timely manner, you must wait for the next Open Enrollment period and may be subject to insurance company approval for some plans. Do not wait! CONTENTS Benefit Basics...2 Medical Plan Overview...3 Medical Plan Comparisons...4 Dental Coverage...5 Vision Coverage...6 Voya Voluntary Benefits...7 Commuter Parking & Transit...9 EAP and Travel Assistance...9 Contacts Forever 21 Your Style, Your Benefits!

3 BENEFIT BASICS DEPENDENT AUDIT A dependent audit will be conducted at the end of It s important for you to review members on your plan to make sure they re qualifying dependents. As a reminder only the following dependents are eligible to be on your plan: Legal spouse Your child (ren), the child (ren) of your legal spouse or registered same-sex domestic partner, until age 26. You can only make changes to your benefits during the plan year if you have a qualified life event. You can process these events in SmartBen within 30 days of the event. Qualified life event examples include: You and/or your dependents become covered by another group health plan End of COBRA Continuation Coverage through another employer Marriage Birth or Adoption of a Child Court order requiring you to add coverage for a dependent child SPOUSAL SURCHARGE Employees are subject to a surcharge when covering a spouse under their Forever 21 health plan that has the option to elect health care coverage through their employer. The additional cost is $70 dollars per pay period if the below situation applies to you. You will be subject to a surcharge if: Your spouse is working at an employer who offers group health insurance, but has declined that coverage and wants to remain on the Forever 21 health plan. Your spouse is eligible and/or enrolled in Medicare, still actively working at their own employer that offers group health insurance and covered under your Forever 21 health plan. Your spouse is offered coverage for any time period throughout the year with their employer, and you choose to continue their coverage under the Forever 21 health plan. You will NOT be subject to a surcharge if: You and your spouse are BOTH employed at Forever 21 and are covered under the company s health plan. Your spouse is eligible and/or enrolled in Medicare, and is covered under your Forever 21 health plan. Your spouse is a retiree from another employer, is not actively working and is covered under your Forever 21 health plan. Your spouse is self-employed, regardless of whether or not they offer insurance to their employees and is covered under your Forever 21 health plan. Your spouse is a part-time employee, doesn t have access to health coverage and is covered under your Forever 21 health plan. Your spouse has insurance available through their own employer, the employer does not make contributions toward the cost of the health insurance and is covered under your Forever 21 health plan New Hire Enrollment Guide 2

4 MEDICAL PLAN OVERVIEW Forever 21 offers five comprehensive medical plans through Kaiser Permanente and UnitedHealthcare (UHC). MEDICAL PLAN OPTIONS Kaiser Permanente HMO California Only UHC Choice EPO California Only UHC Choice Plus PPO HDHP All States UHC Choice Plus PPO Low All States UHC Choice Plus PPO High All States About the Plans All of our plans provide coverage for medical care and prescription drugs. The company pays a portion of the plan s premium for you and your enrolled dependents. Please review the details on page 4 to compare the plans that are available to you. MEDICAL PLAN HIGHLIGHTS Kaiser Permanente HMO (California Only) There is no deductible for the HMO plan. You are required to use doctors and facilities that are in the Kaiser Permanente HMO network. If you go outside of the network, benefits will not be covered (except in certain emergency situations). Preventive care services are covered at 100% when performed by a Kaiser Permanente network provider. UHC EPO (California Only) Under the UHC EPO plan, you must first meet a deductible before the insurance will start covering health care expenses, with the exclusion of copays. You are required to use doctors and facilities that are in the UHC EPO network. If you go outside of the network, benefits will not be covered (except in certain emergency situations). Preventive care services are covered at 100% when performed by a UHC network provider. UHC Choice Plus PPO Plans (All States) There are three PPO plan options to choose from: PPO HDHP, PPO Low and PPO High. All the PPO plans cover in network preventive care at 100%. You will have set copays for doctor visits and prescription drug expenses in-network and coinsurance for all other health care expenses. You must first meet a deductible before the insurance will start covering health care expenses, with the exclusion of copays. The PPO Plans provide coverage for both in-network and out-of-network service providers, but you can save money and spend less out of your own pocket by using in-network providers. You can review the differences between the three PPO plans on page 4. 3 Forever 21 Your Style, Your Benefits!

5 MEDICAL PLAN COMPARISONS KAISER PERMANENTE HMO / UHC EPO (AVAILABLE IN CALIFORNIA ONLY) Premium Contributions (per paycheck) Kaiser Permanente HMO Plan UnitedHealthcare Choice EPO Plan Employee Only Employee + Spouse* Employee + Child(ren) Employee + Family $41.54 $83.08 $78.46 $ $48.53 $96.83 $92.85 $ Benefits and Covered Services In Network Only In Network Only Annual Deductible None $500 individual / $1,000 family Coinsurance (plan / member) 100% / 0% 90% / 10% Maximum Out of Pocket $1,500 individual / $3,000 family $2,000 individual / $4,000 family Lifetime Maximum Benefit None None Physician Office Visit $25 copay per visit $30 copay per visit Urgent Care $25 copay per visit $30 copay per visit Inpatient Hospital $500 copay per admission You pay 10% after deductible plus $500 copay per admission Emergency Room $100 copay per visit You pay 10% after $200 copay per visit Prescription Drug Benefits Kaiser Permanente HMO Plan UnitedHealthcare Choice EPO Plan Generic $15 copay, up to 30-day supply $15 copay Brand Name $30 copay, up to 30-day supply $35 copay Non Preferred Brand $30 copay, up to 30-day supply $50 copay Specialty $30 copay, up to 30-day supply You pay 20% up to $100 copay *See page 2 for spousal surcharge information. UHC PPO OPTIONS (AVAILABLE IN ALL STATES) Premium Contributions (per paycheck) UHC Choice Plus PPO HDHP UHC Choice Plus PPO Low UHC Choice Plus PPO High Employee Only Employee + Spouse* Employee + Child(ren) Employee + Family $30.35 $60.77 $57.73 $90.00 $42.35 $84.50 $81.03 $ $65.00 $ $ $ Benefits and Covered Services In Network Out of Network In Network Out of Network In Network Out of Network Annual Deductible $3,000 individual $6,000 family $6,000 individual $12,000 family $2,000 individual $4,000 2 persons $6,000 family $4,000 individual $8,000 2 persons $12,000 family $1,000 individual $2,000 2 persons $3,000 family $2,000 individual $4,000 2 persons $6,000 family Coinsurance (plan / member) 70% / 30% 50% / 50% 70% / 30% 50% / 50% 80% / 20% 60% / 40% Maximum Out of Pocket $6,000 individual $12,000 family $12,000 individual $24,000 family $5,000 individual $10,000 2 persons $15,000 family $8,000 individual $16,000 2 persons $24,000 family $4,000 individual $8,000 2 persons $12,000 family $8,000 individual $16,000 2 persons $24,000 family Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited Physician Office Visit $25 copay per visit You pay 50% $25 copay per visit You pay 50% $20 copay per visit You pay 40% Urgent Care $125 copay per visit You pay 50% $25 copay per visit You pay 50% $20 copay per visit You pay 40% Inpatient Hospital You pay 30% You pay 50% You pay 30% after $250 copay per day, up to 3 days You pay 50% You pay 20% You pay 40% Emergency Room $250 copay per visit You pay 30% after $100 copay per visit You pay 20% Prescription Drug Benefits UHC Choice Plus PPO HDHP UHC Choice Plus PPO Low UHC Choice Plus PPO High Generic $15 copay $15 copay $10 copay Brand Name $35 copay $35 copay $35 copay Non-Preferred Brand $60 copay $60 copay $60 copay Specialty You pay 30% up to a $150 copay You pay 30% up to a $150 copay You pay 30% up to a $150 copay *See page 2 for spousal surcharge information New Hire Enrollment Guide 4

6 DENTAL COVERAGE YOU HAVE THE FREEDOM TO SWITCH DENTAL PLANS MONTHLY! Forever 21 s Freedom of Choice dental coverage includes a choice of two dental options, DMO and PPO, that cover preventive and diagnostic, basic and major services, as well as orthodontia. The chart below shows a side-by-side comparison of the two plan options. You can begin by choosing one plan then switch to the other plan if your needs change. If you wish to change plans, you ll need to call Aetna at (855) by the 15th of the month for the change to be effective the first of the following month. AETNA DMO The Aetna DMO plan provides coverage inside of the Aetna DMO network. If you use a dentist outside of the network, benefits will not be covered. Under the DMO, you choose a primary care dentist from Aetna s network of over 10,000 providers. Your primary care dentist will help you manage your care. *DMO is not offered in the following states: AL, AK, AR, LA, ME, MS, ND, NH, PR, SC AETNA PPO The Aetna PPO plan provides the freedom to visit any licensed dentist without a referral. If you pick a dentist from Aetna s PPO network of over 130,000 providers, your benefit dollars will go farther when you use network dentists. Like the DMO plan, most preventive care services are covered at no cost. The difference is that you will need to meet the PPO plan s annual deductible before non-preventive services are covered, and there is a limit to how much the plan will pay for services each year. There are three ways to find a participating dentist: 1. Online at 2. By phone call Member Services at (855) Download the Aetna mobile app to your smartphone Learn more about the Aetna Freedom of Choice Plan at AETNA DENTAL FREEDOM OF CHOICE (CHOOSE BETWEEN TWO PLAN OPTIONS MONTHLY) Premium Contributions (per paycheck) Aetna DMO Aetna PPO Employee Only Employee + 1 Dependent Employee + 2 or More Dependents $6.15 $11.06 $18.40 Benefits and Covered Services In Network Only In Network Out of Network Calendar Year Deductible None $50 individual / $150 family $100 individual / $300 family Calendar Year Benefit Maximum The most the plan will pay None $1,500 per person $1,500 per person Preventive and Diagnostic Services Exams, cleanings, x-rays, sealants Covered 100% with $5 copay for exam Covered 100% You pay 50%, no deductible Basic Services Fillings, simple tooth extractions, root canals, gum treatment, oral surgery Covered 100% You pay 30% after deductible You pay 50% after deductible Major Services Crowns, inlays, onlays, cast restorations, bridges, dentures, implants You pay 40% You pay 50% after deductible You pay 50% after deductible Orthodontia for Adults and Children Covered 100% after $2,300 copay You pay 50%, no deductible You pay 50%, no deductible Orthodontia Lifetime Benefit Maximum 24 months $1,500 per person $1,500 per person *Forever 21 supports registered same-sex domestic partner coverage in California only. Please contact the HR Benefits Department at (213) or HR.benefits@forever21.com for more information. Domestic partnership is processed on a post-tax basis. Imputed income will apply. $6.15 $11.06 $ Forever 21 Your Style, Your Benefits!

7 VISION COVERAGE Forever 21 s vision benefits are administered through VSP. With two options to choose from, you and your family can get quality care and materials at an affordable cost. New for 2016 Vision and Medical Are Unbundled This year, we are offering vision as a separate option from the medical plan, so you can get just the coverage you need! Whether or not you enroll in a medical plan with Forever 21, you now have the flexibility to choose between the VSP Core and the VSP Premium plans. Please review the side-by-side comparison below to determine which option is right for you. Premium Contributions (per paycheck) Employee Only Employee + Spouse Employee + Child(ren) Employee + Family VSP VISION PLAN OPTIONS Core Coverage $0.23 $0.35 $0.35 $0.46 Premium Coverage $1.98 $3.96 $4.25 $6.78 Covered Services Description Copay Description Copay Well Vision Exam Focuses on your eyes and overall wellness $10 Focuses on your eyes and overall wellness $10 Every 12 months Every 12 months Prescription Glasses $25 $25 Frames Lenses Lens Options Contact Lenses (instead of glasses) $130 allowance for a wide selection of frames $70 allowance at Costco 20% off amount over your allowance Every 24 months Single vision, lined bifocal, and lined trifocal lenses Polycarbonate lenses for dependent children Every 24 months UV protection Scratch-resistant coating Standard progressive lenses Premium progressive lenses Custom progressive lenses (Plus, get an average of 20-25% off other lens options) $130 allowance for contacts and contact lens exam (fitting and evaluation) 15% off contact lens exam (fitting and evaluation) Every 24 months Included in $25 prescription glasses copay Included in $25 prescription glasses copay $0 $0 $55 $ $150-$175 $0 $175 allowance for a wide selection of frames $95 allowance at Costco 20% off amount over your allowance Every 12 months Single vision, lined bifocal, and lined trifocal lenses Polycarbonate lenses for dependent children Every 12 months UV protection Scratch-resistant coating Standard progressive lenses Premium progressive lenses Custom progressive lenses (Plus, get an average of 20-25% off other lens options) $175 allowance for contacts and contact lens exam (fitting and evaluation) 15% off contact lens exam (fitting and evaluation) Every 12 months Included in $25 prescription glasses copay Included in $25 prescription glasses copay $0 $0 $55 $ $150-$175 $ New Hire Enrollment Guide 6

8 VOYA VOLUNTARY BENEFITS SHORT TERM DISABILITY INSURANCE A short-term, non-occupational injury or illness can prevent you from working for a period of time. Should this happen, the Short Term Disability plan will replace a portion of your lost income. The amount of coverage available varies based on your location. Some states provide a state disability benefit. This voluntary benefit is available to retail and distribution center employees only. Benefit Amount: Employees residing in CA, HI, NJ, NY, RI 70% of your weekly earnings, to a maximum of $1,250 per week (benefit amount is offset by the state disability benefit) All other employees 60% of your weekly earnings, to a maximum of $1,250 per week Benefits become payable after the 7th day of injury or illness and will pay for up to 12 weeks. HOSPITAL CONFINEMENT INDEMNITY INSURANCE The Compass Hospital Confinement Indemnity insurance pays daily and initial confinement benefits if you have a covered stay in a hospital, critical care unit or rehabilitation facility. The benefit amount is determined based on the type of facility and the number of days you stay. Employees must have access to comprehensive medical coverage with Forever 21 or another source in order to enroll in this plan. Plan Features: HOSPITAL CONFINEMENT INDEMNITY Who is eligible? Coverage is available for the employee, spouse, and children Initial confinement benefit $1,000 Daily hospital confinement $100 per day, up to 30 days Critical care unit benefit $200 per day, up to 15 days Rehabilitation facility benefit $50 per day, up to 30 days 7 Forever 21 Your Style, Your Benefits! CRITICAL ILLNESS INSURANCE If serious illness strikes, the last thing you need to worry about is how to pay the bills: medical copayments and deductibles, car payments, rent or mortgage, and utilities. With Compass Critical Illness Insurance, if you are diagnosed with a covered illness, you receive a lump sum cash benefit even if you receive benefits from other insurance. Use the cash benefit however it is needed whether for treatments not covered by insurance or a dream vacation to celebrate your recovery you decide. Employees must have access to comprehensive medical coverage with Forever 21 or another source in order to enroll in this plan. Coverage Options: Employee must be covered to elect spouse or child coverage, no minimum benefit Employee: $5,000 - $30,000, in increments of $5,000 Spouse: $5,000 - $15,000, in increments of $5,000 Child: $1,000, $2,500, $5,000 or $10,000 Examples of Covered Illnesses Include: Heart attack Stroke End stage renal (kidney) failure Coronary artery bypass Coma Major organ failure Permanent paralysis Cancer, carcinoma in situ, skin cancer Also includes deafness, blindness, benign brain tumor and occupational HIV Plan Features Include: $75 wellness benefit when a covered person has a health screening test $200 mammogram benefit Restoration of benefits* pays an additional benefit if a covered person experiences a second covered illness for a different condition (must occur after a defined period of consecutive months) Recurrence benefit* receive a benefit for the same critical illness or condition a second time (must occur after a defined period of consecutive months) *Restoration and recurrence do not apply to cancer.

9 VOYA VOLUNTARY BENEFITS ACCIDENT INSURANCE The Compass Accident Insurance plan pays you a direct benefit for specific injuries and events resulting from a covered on or off the job accident. The plan also includes a hospital confinement benefit for illness. The amount paid depends on the type of injury and care received. You can use your payment to help pay for unexpected expenses, such as deductibles and copays, home health care costs, lost time from work, everyday expenses, utilities, and groceries. Employees must have access to comprehensive medical coverage with Forever 21 or another source in order to enroll in this plan. Examples of Covered Injuries Include: Broken bones Joint dislocations / torn ligaments Ruptured discs Burns Concussions Eye injuries Plan Features Include: Coverage available for the employee, spouse and child(ren) Hospital care admission, confinement to a hospital, critical care unit or rehabilitation facility, surgery Follow up care medical equipment, physical therapy, prosthetic devices Emergency care ground/ air ambulance, emergency room treatment, initial doctor treatment, followup doctor treatment TERM LIFE INSURANCE Group term life insurance is available to you, your spouse and your dependent children. Rates are based on age and salary. Coverage Options: Employee must be covered to elect spouse or child coverage. Employee Spouse Child TERM LIFE 1x, 2x, or 3x annual salary, to a maximum of $500,000; guarantee issue $200,000 Benefits reduce to 65% at age 70 and to 50% at age 75 $10,000, $25,000, $50,000 or $100,000, not to exceed 100% of the employee amount; guarantee issue $50,000 Benefits reduce to 65% at age 70 and to 50% at age 75 Live birth to 6 months - $1,000 6 months to age 26 - $5,000 or $10,000 Plan Features Include: Waiver of premium Accelerated death benefit Accidental death & dismemberment benefit Employee Assistance Program (EAP) Travel Assistance Funeral planning and concierge services WHOLE LIFE INSURANCE Premier Whole Life insurance policies can provide protection for both working years and post-retirement, while building cash value. Your monthly premiums are based on your age at time of enrollment and will not increase as you get older. Coverage Options: Employee does not need to be covered to elect spouse or child coverage Employee Spouse Children 15 days to 24 years WHOLE LIFE Non-tobacco user: $5,000 - $500,000 Tobacco user: $5,000 - $250,000 $1,000 increments Ages coverage is guaranteed up to $20 per week, not to exceed $100,000 Ages coverage is contingent on medical questions for $25,000 of guarantee issue Non-tobacco user: $5,000 - $500,000 Tobacco user: $5,000 - $250,000 $1,000 increments Ages coverage is contingent on medical questions for the greater of $5 per week or $5,000 Ages requires medical questions $12,500, $15,000, $20,000 or $25,000 Coverage is contingent on medical questions Plan Features Include: Waiver of premium Long term care benefit Accidental death benefit Accelerated death benefit Voya Financial voluntary plan provisions and availability may vary by state; some exclusions and limitations may apply New Hire Enrollment Guide 8

10 COMMUTER PARKING AND TRANSIT Forever 21 offers parking and transit flexible spending accounts (FSAs) that allow you to use tax-free dollars to pay for your commute to and from work. You can change the amount you set aside into your parking and/or transit account each month. PAYING FOR COVERED EXPENSES Use Your P&A Benefits Card If you enroll in the parking and/or transit plan, you will receive a debit card that can be used to pay for your parking and/or transportation expenses to and from work. Employees who enroll in both the health care FSA and parking and/or transit FSA will receive one debit card for all accounts. No Out-of-Pocket Claim Submissions Allowed P&A does not allow reimbursement of out-of-pocket parking and/or transit expenses. You must pay with your P&A benefits card in order to use your parking and/or transit plan funds. CONTRIBUTION AMOUNTS There are limits to how much you can set aside into your parking and/or transit account. Below are the IRS pre-set maximum pre-tax contribution for the year PARKING: $255 per month TRANSIT: $255 per month MAKING CHANGES Your commuting expenses may change over time; the parking and transit plans are designed to be flexible and allow you to change your election amount each month. When Changes are Effective Please note that any change you make will become effective with the first pay period beginning on or after the following month. For example, if you are going on a vacation and will not be commuting to work, you can change your election amount for that month in SmartBen through a life event. MORE WAYS TO SAVE WITH TWO ADDITIONAL FSAs Forever 21 offers two additional types of flexible spending accounts (FSAs): the health care FSA and dependent care FSA. These plans enable you to set aside money on a pre-tax basis to pay for your out-of-pocket health and daycare costs. You must re-enroll annually in these plans in order to participate for the next calendar year. Healthcare FSA Contribute up to $2,550 annually; includes a $500 rollover feature per plan year Dependent Care FSA Contribute up to $5,000 annually ADDITIONAL BENEFITS Employee Assistance Program Through Voya, you have access to ComPsych GuidanceResources, which provides support, resources and information for personal and work-life issues. This plan includes three telephone counseling sessions per issue. Employee Assistance Program (EAP) services are provided by ComPsych Corporation, Chicago, IL. For help, call (877) Forever 21 Your Style, Your Benefits! Travel Assistance When traveling more than 100 miles from home, Voya Travel Assistance offers enhanced security for your leisure and business trips. You and your dependents can take advantage of four types of services: pre-trip information, emergency personal services, medical assistance services and emergency transportation services. Voya Travel Assistance services are provided by Europ Assistance USA, Bethesda, MD. For help, call (800) AVAILABLE TO ALL EMPLOYEES!

11 BENEFIT CONTACTS BENEFIT CONTACTS Core Benefit Plans Carrier Phone Number / Website Medical California Medical All States Dental Vision Kaiser Permanente Southern California Group # Northern California Group # UnitedHealthcare Policy # Aetna Policy # VSP Policy # (800) (888) (855) (800) Life Insurance Voya (800) Short and Long Term Disability Voya (888) Group Accident, Group Critical Illness, and Group Hospital Voya (877) Indemnity Whole Life Insurance Voya (800) Employee Assistance Program Voya (877) Company Web ID: MY5848i Travel Assistance Voya (800) Group ID: N1VOY Activation Code: Flexible Spending Accounts P&A (800) Information and Enrollment Forever 21 HR Benefits Phone: (213) Fax: (213) HR.benefits@forever21.com Enrollment for Whole Life Insurance Hodges-Mace (855) Make an appointment at Voya Claims Voya Claim forms can be accessed in SmartBen. You can start a claim and upload a claim form online at by hovering over Contacts & Services and selecting the Start a Claim or the Upload a Claim option. Life Claims (888) LifeClaims@voya.com Short and Long Term Disability (888) Claims@disabilityrms.com Critical Illness/Wellness Claims (888) VoyaClaims@voya.com Accident & Hospital Confinement (855) VoyaClaims@PAISC.com New Hire Enrollment Guide 10

12 General Disclaimer: The material provided in this guide is for general information purposes only. The details of the plans and policies are contained in the official plan and policy documents including some insurance contracts. The plan (and underlying coverage of benefits) can be amended at any time for any reason without prior notice, at Forever 21 s sole and absolute discretion. In the event of any conflict between this guide and the plan document, the actual plan document will govern.