Benefits Guide

2015
Benefits Guide
Benefits to Fit Your Style
WELCOME TO STEVE MADDEN’S 2015 BENEFITS PROGRAM
Page
Eligibility....................................................................................1
Enrollment...............................................................................2
Wellness
Steve Madden Wellness Tools & Resources .......3
Health Care
Medical......................................................................................4
Dental.........................................................................................6
Vision..........................................................................................7
Financial Protection
Life & Accident Insurance...............................................8
Benefits are an important part of your total compensation at Steve
Madden. As a Steve Madden employee, you receive a competitive
package of benefits offering flexibility, financial protection and
a foundation for future security. Your benefits work together
to provide you and your family the coverages that best fit your
personal situation.
This Benefits Guide describes the details of our benefits as well
as the information you need to make your elections. Please be
sure to carefully review your Benefits Guide so you have a better
understanding of the plans offered and elect the coverages that
are right for you and your family.
Disability....................................................................................9
Work/Life
Commuter Benefits.........................................................10
Steve Madden Benefit Service Center
Flexible Spending Accounts (FSAs).......................11
Call Toll-Free l 877.459.9696
Other Benefits.................................................................13
2015 Employee Contributions............................14
Benefit Specialists are available Monday to Friday,
9:00 a.m. – 5:00 p.m., EST
Important Contact Information.........................15
Email l stevemaddenbenefits@yourbenefitsmanager.com
Legal Notifications.......................................................16
S end email inquiries anytime; emails received after 5:00 p.m. Monday
to Friday will be answered the following business day
Domestic Partnership ..............................................28
Affidavit of Marriage...................................................31
This Benefits Guide provides only a brief summary of the benefits available under
the Steve Madden Benefits Program. In the event of a discrepancy between this
Guide and the Plan Document, the Plan Document will prevail. Steve Madden
retains the right to modify or eliminate these or any other benefits at any time and
for any reason.
2
ELIGIBILITY
Eligibility
l
For You. All regular full-time employees are eligible to
participate in the Steve Madden medical, dental, vision, life
and accidental death/dismemberment and disability plans,
commuter, flexible spending, and health savings accounts.
C
hild(ren): Birth certificate or copy of the first page of the
previous year’s tax return or proof of legal guardianship
Making Changes During the Year
The IRS requires that elections for benefits paid for on a
before-tax basis remain in effect for the full calendar year.
However, the IRS permits mid-year changes within 31 days of
a qualifying life event. Examples of qualifying life events are:
Benefits become effective:
Corporate: 1 st of the month following 30 days
Retail (Stores):1st of the month following 60 days
l
If you are a Variable Hour Employee who averages at least 30
hours worked per week over a 12 month period (and are still
employed by Steve Madden at the end of the period), you will
be offered health insurance for you and your dependents. If
you accept the offer of coverage and pay for the coverage, you
may maintain the coverage through a 12-month period, also
known as “stability period”.
l
l
Eligible Dependents:
l
Your legal spouse or domestic partner
l
l Your unmarried children who depend on you for support,
including stepchildren, adopted children, and children of
your domestic partner
l
Dependent Eligibility Through:
l Medical: to the end of the month of their 26th birthday
l Dental:
to age 20 or 26th birthday if full-time student
l Vision:
to age 20 or 26th birthday if full-time student
status
status
l
l
l Y
our disabled child of any age who is dependent on you
for support due to a mental or physical handicap that
occurs while your child is covered under the plan(s).
l
Dependent Verification
Steve Madden has a responsibility to ensure that only eligible
expenses are paid from the benefit plans. This requirement is
consistent with IRS regulations that govern the operation of a
qualified plan.
Y
our dependent’s/dependent of domestic partner’s
eligibility or ineligibility for coverage (for example, he or
she reaches the plan’s eligibility age limit, becomes or
ceases to be a student or becomes married),
A
change in work location or home address for you,
your spouse/domestic partner or your dependents/
dependent’s of domestic partner,
A
change in coverage of your spouse or your dependent
under another employer’s plan. This would include
election changes resulting from election cycles that
differ from Steve Madden’s,
Your
qualification for a special enrollment under the
Health Insurance Portability and Accountability Act of
1996 (HIPAA),
A
court order received by the plan, such as a Qualified
Medical Child Support Order (QMCSO), or
Y
ou, your spouse/domestic partner’s or your dependent/
dependent of domestic partner’s qualification for
Medicare or Medicaid.
Any change in coverage must be consistent with your life
status change. If you need to make an election change
during the year or have questions about what constitutes a
life status change, contact the Steve Madden Benefit Service
Center at 877.459.9696.
The following are acceptable forms of Dependent Verification:
l Spouse: Marriage certificate or affidavit
l
T he birth of your baby, or adoption or placement of a
child with you for adoption, or another change in the
number of your dependents,
It is your responsibility to notify the Steve Madden Benefit
Service Center within 31 days of any qualifying event and
provide any required documentation as proof of your life
status change.
Therefore, in order to complete your dependent enrollment,
you will be required to submit verification. If you do not
submit the required documentation within 31 days from your
benefits effective date, your dependents will not have benefits
coverage.
Y
our marriage, divorce, legal separation or annulment,
D
omestic Partner: Domestic partner affidavit and joint
lease/bank account or proof of same residence
1
ENROLLMENT
This is your opportunity to choose health and other insurance
coverage for you and your family for the year. Before you make
any decisions about your benefits, it’s important that you
understand all of your options. Be sure to review the remainder
of this Guide to learn more about your benefits as well as the
information available on the Steve Madden Benefit Portal.
Your Contributions
You and Steve Madden share the cost of your benefits.
Costs for your 2015 benefit options are shown online
when you enroll. Steve Madden helps you save on
taxes by deducting your contributions for medical,
dental, and vision plans, and flexible spending and
health savings accounts from your paycheck on a
pre-tax basis.
To enroll, you will need to access the Steve Madden Benefit
Portal to view the benefits available to you and make your
elections. See below for instructions on how to enroll for
benefits.
Contributions for other benefits such as voluntary life
and disability are deducted from your paycheck on an
after-tax basis.
After You Enroll
Once you have completed your online enrollment, you can print
or request a confirmation statement. If you need to correct a
discrepancy, contact the Steve Madden Benefit Service Center
at 877.459.9696 as soon as possible. Generally, you cannot
make any changes after your enrollment deadline unless you
experience a qualifying life event as described on page 1.
Coverage Levels
Medical
l Employee only
l Employee + Spouse
l Employee + Child
l Family
You will receive ID cards in the mail at home.
Dental & Vision
l Employee only
l Employee + spouse/
domestic partner
l Employee + child(ren)
l Family
How to Enroll
l
Visit: www.crystalconnect.com/stevemadden
l
Username: stevemadden
l
Password: benefits
Select “Click Here”, you will then be brought to the Steve Madden Benefit Portal login screen
l
Create an account
l
Make a note of your Username and Password for future use
l
Review the benefits information available online and then click “Enroll Now” to make your elections.
Remember! If you are a new hire, you must enroll within 30 days of your benefit effective date. Otherwise, you may
not have all of the coverages you need.
2
STEVE MADDEN WELLNESS TOOLS & RESOURCES
At Steve Madden, we encourage everyone to take an active
role in managing his or her health. Getting an annual physical
and health screening as well as eating healthy and staying
active help to maintain a healthier lifestyle.
reductions, please call the Steve Madden Benefit Service
Center at 877.459.9696.
How to complete your Well Being Assessment
1.Log in to Empire’s secure member website at www.
empireblue.com and select “Register” to complete the
registration screens. Once you’ve registered, log in to get
started.
Reduce your Medical Premiums
You can receive a total reduction of $20 bi-weekly on your
2015 medical premiums by completing the steps below.
Non-Tobacco Status. If you are a non-tobacco user, or if
you are a tobacco user and will enroll in a tobacco cessation
program, you will receive a $10 bi-weekly reduction to your
2015 medical premiums. Complete your attestation at www.
stevemadden.hrintouch.com upon benefit enrollment.
2. Click on “Health & Wellness” tab
Well Being Assessment. Receive a $10 bi-weekly reduction
on your 2015 medical premiums by completing a confidential
online well being assessment at www.empireblue.com.
5.Select “Well Being Assessment”, and then select “Start”.
Answer all of the questions then click “Finish”.
3. Select “Get Started” under the Healthy Lifestyles section
4. Accept the Healthy Lifestyles terms and conditions and click
“Submit”.
6. Once you have clicked “Finish”, wait for the system to process
your answers, then you can view your results. You may also
call 877.252.8410 to confirm completion of the assessment.
To qualify for the Well Being Assessment (WBA)
reduction, you must complete the steps under “How
to complete your Well Being Assessment”. Your payroll
reduction will become effective 1st of the month
following 30 days from the date you complete the WBA.
For example; If you complete the WBA on 3/15/15, your
reduction will be reflected in your paycheck effective
5/1/15.
What You Can Expect
During the well being assessment, you will be asked about
your health history — conditions you have and your current
weight.
You’ll also see questions about your modifiable health risks.
These are the health habits you can change, like eating more
fruits and vegetables or wearing SPF when you’re in the sun.
Important Note: You must wait 15 days after your medical
effective date to complete your WBA. If you make your
medical election after your medical effective date, you
must wait an additional 15 days to complete your WBA. If
you attempt to complete the WBA earlier, your record will
not be in the Empire system.
Your answers can help you:
l Understand your health needs and goals
l Pick an online wellness program that fits your needs
l Better manage your health risks
Completing an online well being assessment can help you
take positive steps to get and stay healthy.
l Identify health concerns to share with your doctor
If you have any questions regarding the status of your
www.empireblue.com
As an Empire member, you can log on to Empire’s secure website (www.empireblue.com) and take advantage of:
l H
ealth information. To learn about various diseases and conditions and the ways to prevent them
l I nsurance information. To become an informed consumer
l P
ersonalized tools. To help you better manage your health
l Financial tools. To help you spend your health care dollars more wisely
3
MEDICAL BENEFITS
Empire Prism EPO Plan
Steve Madden offers you a choice of three medical plans. All
Steve Madden medical plans give you access to the same
Empire network in your area. Regardless of the plan you elect,
you will have access to a wide range of doctors, hospitals
and other health care providers who have agreed to provide
services at a discounted rate—a significant savings for you
and Steve Madden.
The Empire EPO Plan is an open access exclusive provider
organization, which gives you the flexibility to go to any
doctor or hospital you wish. It does not require you to select a
primary care physician (PCP), obtain referrals to see a specialist
or go to the hospital.
The EPO plan provides for in-network coverage; no out-ofnetwork benefits are covered except in an emergency.
If you do not want to enroll you can choose to waive medical
coverage.
Empire Prism PPO Plan and Empire HSA Plan
The Empire PPO Plan and Empire HSA Plan are open access,
which gives you the flexibility to go to any doctor or hospital
you wish. They do not require you to select a primary care
physician (PCP), obtain referrals to see a specialist or go to the
hospital. These plans also give you the freedom to go outside
the network for care whenever you like. However, you’ll pay
more for your care if you use an out-of-network provider.
Filing Claims for Out-of-Network Benefits
With the Empire medical plans, you may be required to
submit claim forms if you use out-of-network providers.
Claim forms are available from Empire Member Services.
If you have questions about submitting claims, call
Empire Member Services at 855.880.0575. Claim forms
are also available online at www.empireblue.com.
Please note: Empire HSA Plan members are eligible to enroll
in the Health Savings Account.
The following information further explains the differences
between in-network and out-of-network coverage in a PPO plan.
Empire PPO Plans: In-Network vs. Out-of-Network
In-Network:
Out-of-Network:
l You can see any network provider without a referral l Y
ou pay a higher percentage of the cost of services.
from a PCP.
l The
cost of out-of-network services may exceed the
l Y
ou pay lower out-of-pocket costs.
usual, customary and reasonable (UCR) limits. The
plan pays 70% of the UCR after you meet the annual
l There
are no claim forms and no surprises with usual,
deductible. You pay the full cost for charges not covered
customary and reasonable (UCR) limits.
by the plan.
l T
he plan pays 100% of most office visits after you pay a
l Y
ou must pay the full cost at the time of service and
modest copay for services; no deductible applies.
you may be required to submit claim forms to Empire
l Preventive
care services are covered at 100%.
for reimbursement.
l
There
is no in-network lifetime maximum.
l
l
Preventive
care services are covered 70% after
deductible for adults.
There
is no out-of-network lifetime maximum.
Find a Network Provider
2015 Medical Contributions
To find a network provider in your area,
please call Empire at 855.880.0575 or log
on to www.empireblue.com.
For monthly and per pay period pre-tax
medical contributions, see page 14.
4
MEDICAL BENEFITS (cont.)
The chart below provides a brief comparison of the coverage levels under each medical plan option available to you.
Empire PPO Plan
Annual
Deductible
l Individual
l Family
Plan
Coinsurance
Annual Outof-Pocket
Maximum2
l Individual
l Family
Empire EPO Plan
Empire HSA Plan
In-Network
Out-of-Network
In-Network Only
In-Network
Out-of-Network1
N/A
N/A
$750
$1,875
N/A
N/A
$1,500
$3,000
$3,000
$6,000
100%
70%
100%
80%
50%
(includes Rx cost shares)
(includes Rx cost shares)
1
(includes Rx cost shares)
$5,250
$10,500
$5,250
$13,125
$6,350
$12,700
$4,000
$8,000
$25,000
$50,000
$30 copay
$30 copay
Covered 70% after ded.
Covered 70% after ded.
$30 copay
$30 copay
Covered 80% after ded.
Covered 80% after ded.
Covered 50% after ded.
Covered 50% after ded.
Covered 100%
Covered 100%
Covered 100%
Covered 70% after ded.
Covered 100%
Covered 100%
Covered 100%
Covered 100%
Covered 50% after ded.
Covered 50% after ded.
Diagnostic
Lab & X-Ray
(Outpatient)
Covered 100%
Covered 70% after ded.
Covered 100%
Covered 80% after ded.
Covered 50% after ded.
Inpatient
Hospital
Covered 100%
Covered 70% after ded.
Covered 100%
Covered 80% after ded.
Covered 50% after ded.
Outpatient
Surgery
Covered 100%
Covered 70% after ded.
Covered 100%
Covered 80% after ded.
Covered 50% after ded.
Emergency
Room3
$75 copay
$75 copay
$75 copay
Covered 80% after ded.
Covered 50% after ded.
Urgent Care
$35 copay
Covered 70% after ded.
$35 copay
Covered 80% after ded.
Covered 50% after ded.
Durable
Medical
Equipment
Covered 100%
Covered 70% after ded.
Covered 100%
Covered 80% after ded.
Covered 50% after ded.
Covered 100%
$30 copay
Covered 70% after ded.
Covered 70% after ded.
Covered 100%
$30 copay
Covered 80% after ded.
Covered 80% after ded.
Covered 50% after ded.
Covered 50% after ded.
Office Visits
l Primary Care
l Specialist
Preventive Care
l Child(ren)
l Adult
Mental Health
& Substance
Abuse
l Inpatient
l Outpatient
Prescription Drug Coverage
Retail
(30-day supply)
l Generic
l Formulary
Brand Name
l Non-Formulary
Brand Name
Mail Order
(90-day supply)
l Generic
l Formulary
Brand Name
l Non-Formulary
Brand Name
(Ded. waived for selective preventative
drugs)
$10 copay
$25 copay
N/A
N/A
$10 copay
$25 copay
$50 copay
N/A
$50 copay
Deductible then;
$10 copay
$25 copay
$50 copay
N/A
N/A
N/A
(Ded. waived for preventative drugs)
$20 copay
$50 copay
N/A
N/A
$20 copay
$50 copay
Deductible then;
$20 copay
$50 copay
N/A
N/A
$100 copay
N/A
$100 copay
$100 copay
N/A
1
Out-of-network services are subject to usual, customary and reasonable (UCR) limits for similar services in your geographic area. There are no UCR limits for in-network care.
Annual out-of-pocket maximum includes prescription drug cost-share.
3
No coverage if not a true emergency; copay/deductible waived if admitted to hospital for the PPO and EPO plans only..
2
5
DENTAL BENEFITS
The Guardian network dentists charge you only the patient’s
share at the time of treatment. You have the freedom to choose
a dental provider outside the Guardian network and receive
out-of-network benefits.
Steve Madden offers a dental plan administered by Guardian.
You may enroll in dental coverage even if you do not enroll
in any other benefits offered through Steve Madden.
If you do not want to enroll in the dental plan, you have the
option to waive coverage.
Note: Non-participating providers may require you to pay
the entire amount of the bill in advance. You will then have to
submit a claim form for reimbursement. You will receive an ID
card
Guardian PPO Plan: In-Network & Out-of-Network
The PPO Plan gives you the freedom to choose any dentist
you like, however, you pay less out-of-pocket when you see
a participating provider. Dentists participating in the provider
network, have agreed to negotiated fees and there is no
balance billing.
Maximum Rollover Provision
If you utilize dental benefits at least once during the
calendar year, this plan has a provision to rollover a
portion of your unused calendar-year maximum to the
following year into a Maximum Rollover Account (MRA)
to be used in future years when you reach the plan’s
calendar-year maximum.
When using out-of-network providers, claims will be
reimbursed at the 90th percentile of Reasonable & Customary,
which means you may be balance billed for any amounts
over what is considered reasonable and customary for your
geographic region.
You can learn more about the maximum rollover
provision and view your MRA account when you log
on to www.guardiananytime.com.
Guardian Plan Features
In-Network
Out-of-Network
$50
$150
$50
$150
Calendar-Year Maximum (Basic & Major)
$1,500
$1,500
Diagnostic & Preventive Services
(e.g., teeth cleanings, fluoride treatments, x-rays)
100%
80%
Basic Restorative Services
(e.g., anesthesia, fillings, simple extractions)
80%
80%
Major Restorative Services
(e.g., crowns, bridges and dentures, inlays/onlays)
50%
50%
Not covered
Not covered
Calendar-Year Deductible
l Individual
l Family
Orthodontia Services
2015 Dental Contributions
Find a Network Provider
For monthly and per pay period pre-tax
dental contributions, see page 14.
To find a network provider in your area, please
call Guardian at 800.541.7846 or log on to
www.guardiananytime.com.
6
VISION BENEFITS
Steve Madden offers a vision plan administered by Guardian.
You may enroll in vision coverage even if you do not enroll in
any other benefits offered through Steve Madden.
If you do not want to enroll in the vision plan, you have the
option to waive coverage.
Guardian VSP Plan: In-Network and Out-of-Network
The Steve Madden Vision Service plan (VSP) gives you the
freedom to use VSP network providers or to go outside of the
VSP network.
l
l
If you enroll in the vision plan, you’ll also be eligible
for discounts and savings on laser vision correction,
antireflective coatings and progressive lenses,
prescription glasses and sunglasses, and exclusive
pricing on annual supplies of popular brand-name
contacts.
Note: You will receive a special ID card for vision
coverage.
If you use a VSP provider, the vision plan will pay most of
your vision expenses and you will not have to submit a
claim form.
If you do not use a VSP provider, you’ll pay your provider
in full at the time of service and will submit a claim form
to VSP for partial reimbursement.
Guardian Vision Plan Features
In-Network
Out-of-Network
Exams
(once every 12 months)
100% after $10 copay
Plan pays up to $46
Eyeglass Lenses
(once every 12 months)
Single vision, lined bifocal and lined trifocal
lenses; includes scratch-resistant coating
100% after $20 copay
Single: Plan pays up to $47
Bifocal: Plan pays up to $66
Trifocal: Plan pays up to $85
Lenticular: Plan pays up to $125
Frames
(once every 24 months)
Contact Lenses
(onceevery12monthsinsteadoflenses/frames)
l E
lective
l M
edically Necessary
l E
valuation & Fitting
$115 allowance and a 20% discount
above the allowance
Up to $47
Plan pays up to $105
100% after $20 copay
15% off UCR
Plan pays up to $105
Plan pays up to $210
No discounts
Find a Network Provider
2015 Vision Contributions
To find a VSP vision care provider in your area,
please call VSP directly at 800.877.7195 or
search through Guardian by visiting
www.guardiananytime.com.
For monthly and per pay period pre-tax
vision contributions, see page 14.
7
LIFE INSURANCE BENEFITS
Life & Accident Insurance
Evidence of Insurability
The Company offers you valuable financial protection for you
and your family in the event of death or a serious accident.
Steve Madden pays the full cost for your basic life and
accidental death and dismemberment insurance coverage;
you pay nothing. Life insurance coverage is offered through
Guardian.
If you elect voluntary life insurance coverage over the
guaranteed issue amount or elect for it the first time at the next
open enrollment period, you will need to provide Evidence
of Insurability. For any voluntary coverage that is subject to
Evidence of Insurability, your contributions will take effect
once your application is received and approved by Guardian.
Basic Life Insurance
As a Steve Madden employee, you receive $50,000 of basic life
insurance coverage automatically at no cost to you.
Benefit Reduction at Age 70
If you have reached age 70, your amount of life insurance
will be reduced by 35%. Then, reduced by an additional
20% at age 75 and further reduced by 15% at age 80.
Basic Accidental Death and Dismemberment (AD&D)
Insurance
In addition to basic life insurance, you also receive basic
accidental death and dismemberment (AD&D) insurance
automatically at no cost to you. Your coverage is equal to
your basic life insurance amount ($50,000). The amount of the
benefit you or your beneficiary receive is based on the severity
of your loss.
Beneficiary Designation
You must designate a beneficiary for company paid
life insurance coverage. If you name more than one
beneficiary, be sure to indicate the percentage you
wish each beneficiary to receive. The percentages
must total 100%.
Voluntary Life Insurance & AD&D
For Yourself. You may elect voluntary life insurance & AD&D
coverage for yourself in $10,000 increments up to a maximum
of 5x your annual salary or $500,000, whichever is less. If you
do not want voluntary life insurance coverage, you may waive
it. You may elect up to $250,000 at guaranteed issue. That is,
you do not have to provide Evidence of Insurability.
You can update your beneficiary designations anytime
during the year.
Note: It is important to keep your beneficiary
designations up-to-date. Be sure to review your
beneficiary designation elections and make any
updates as necessary.
For Your Dependents. In addition to your own life insurance
coverage, you may also want protection from the financial
burdens that could accompany the death of a spouse/
registered domestic partner or a dependent child. You are
automatically the beneficiary for this coverage.
l
l
l
Voluntary Life/AD&D Insurance Monthly Rates for
Employee/Spouse
S
pouse/registered domestic partner: Benefit in $5,000
increments up to a maximum of 2.5x your annual salary
or $250,000, whichever is less, not to exceed 50% of your
elected voluntary life amount. Any amount elected over
$50,000 is subject to Evidence of Insurability.
C
hild(ren) (14 days to age six months): $250
C
hild(ren) (age six months to age 19 or age 25 if fulltime student): $10,000
Note: In order to elect coverage for your dependents, you
must elect voluntary coverage for yourself.
8
Age of
Employee
Under 29
Rates per
$1,000
$0.067
Age of
Employee
55-59
Rates per
$1,000
$0.677
30-34
35-39
40-44
45-49
50-54
$0.077
$0.107
$0.157
$0.237
$0.437
60-64
65-69
70-74
75-79
80+
$0.737
$1.337
$2.717
$7.747
$17.097
DISABILITY BENEFITS
Disability Benefits
You have the Option to choose “Tax Free” or “Taxable”
Steve Madden provides you with disability benefits in the
event you are out of work for a period of time due to a nonwork related injury or illness. Disability coverage is offered
through Guardian.
lIf
Short-Term Disability (STD)
lIf
you choose the “Tax-Free” option, the cost of the LTD
premium will be included in your W-2 as taxable income.
By doing so, the monthly benefit – should you file an
LTD claim – will convert to a tax-free benefit.
you choose “taxable” – should you file an LTD claim
– you will be required to pay taxes on benefit monies
received. Should you file an LTD claim, the monthly
benefit would be taxed.
Should you be absent from work due to an extended illness or
injury, you may be eligible for Short Term Disability. You must be
disabled and out of work for eight days (14 days for manager)
before benefits may begin. Steve Madden pays the full cost of
your basic short-term disability insurance coverage; you pay
nothing. The plan pays:
How the LTD Plan Works
After 180 days of disability, you become eligible for LTD benefits
if the claims administrator certifies that you cannot perform
the duties of your regular job because of illness or injury.
After 24 months of disability payments, you are eligible for
continued LTD benefits if the claims administrator determines
that you are unable to work at any job for which you are
reasonably qualified, based on training, education and
experience.
50% of your weekly earnings up to $500 per week while
you are disabled for up to 26 weeks.
Voluntary Short-Term Disability (STD)
You can elect to increase, or “buy-up”, your weekly STD benefit
if your current annual salary is higher than $52,001. If Eligible
and you enroll, the plan pays:
Your LTD benefit is reduced by any disability income payable
from the following sources:
50 % of your weekly earnings up to $1,000 per week while
you are disabled for up to 26 weeks.
Voluntary Short Term Disability Contributions
$0.16 per $10 of weekly benefit
Social Security (that you or your family receives),
l
Workers’ Compensation or a similar law,
l
New! Effective 01/01/2015
l
ny Steve Madden-sponsored pension plan or group
A
insurance plan providing benefits for loss of work because
of disability, and
State-mandated disability programs.
However, LTD benefits are not reduced by federal, state, local
income taxes or FICA. In addition, LTD benefits are not reduced
by any private disability coverage that you have purchased.
There is a 24-month limit on mental health and self-reported
claims (such as a sore back that cannot be substantiated by a
doctor).
Steve Madden added a paid leave policy! If you have an
FMLA qualified reason, you may be eligible for paid leave.
Benefits are based on seniority and supporting medical
documentation will be required. For more information contact
HumanResources@stevemadden.com.
Long-Term Disability (LTD)
Voluntary Long Term Disability Contributions
$0.19 per $100 of monthly covered payroll
The LTD Plan provides a source of income if you are totally
disabled for more than 180 days and you are unable to return to
work. The LTD plan pays a continuing monthly income as follows:
Class 1:
Manager
Class 2:
Non-Manager
l
Steve Madden contributes 75% of the cost for LTD coverage; you
pay the remaining 25%.
60% of your average monthly earnings
up to $10,000 per month
60% of your average monthly earnings
up to $5,000 per month
9
COMMUTER BENEFITS
Commuter benefits, available through Benefit Resource Inc.,
allow you to pay for eligible transportation expenses incurred
when commuting to and from work with tax-free money. This
means you can receive an eTrac card to purchase passes and
tickets for all major public transportation (e.g., subway, train,
bus, ferry), nationwide. You can even pay for parking expenses.
Register for your commuter benefits
through The Steve Madden Benefit Portal
Contribution Amount
You may contribute up to the following monthly maximums
determined by the IRS:
Transportation
Transit expenses
Parking expenses
Amount Per Month
$130*
$250*
* Monthly amounts subject to change by the IRS
*
The full elected contibution will be taken on the second
paycheck of the month.
Like premiums for your health care benefits and contributions
to an FSA, all commuter benefit contributions are deducted
from your paycheck on a pre-tax basis up to the monthly IRS
limits. This means your contributions are deducted from your
paycheck before Social Security, Federal and State income
taxes are withheld, further lowering your income for tax
purposes. You can also elect to contribute above the pretax monthly amounts above. Any election above the pre-tax
amounts will be deducted post-tax. You should only elect PostTax Transit and Post-Tax Parking plans if you’ve elected the pretax maximum in the Pre-Tax Transit and Pre-Tax Parking plans.
Any available balances you have for transit and parking are
rolled over from month to month automatically. There is no
restriction on the amount you can carry over.
Keep in mind that if you leave the company, your account
will be transferred to an individual plan and you will receive
a new Beniversal Card. The new card will be loaded with the
remaining funds directly from Benefit Resource Inc.
Enrolling or Changing Your Election
If you need to enroll in or change your Commuter
Benefit election, you may do so throughout the year.
You may enroll or change your transit or parking plan
elections during the first seven days of each month. All
enrollments or election changes are effective the 1st
of a calendar month subsequent to the close of the
monthly election period. For example, if you enroll on
January 3rd, you will receive your eTrac card at the end
of February and available to use for March expenses.
You can make your Commuter Benefit elections and
changes by visiting the Steve Madden Benefit Portal
at www.stevemadden.hrintouch.com and click on
“Employee Login.”
10
FLEXIBLE SPENDING ACCOUNTS
With the Dependent Care FSA, you can pay for nursery
schools, summer day camps, daycare and other similar
expenses.
There are two separate Flexible Spending Account choices:
Health Care and Dependent Care. Both are offered through
Benefit Resource Inc. By participating in a Flexible Spending
Account, you can experience valuable tax savings while
guaranteeing money is available for important expenditures.
For the FSAs, pre-tax dollars are deducted from your pay before
federal income taxes and Social Security taxes are calculated.
That means you pay for eligible expenses with dollars that
have not already been subject to these taxes.
The Health Care FSA enables you to set aside money for
covered health-related, out-of-pocket medical expenses, such
as physician or prescription copays, insulin, first aid supplies,
prescription eyeglasses, contact lens solutions and supplies
and out-of-pocket dental expenses.
The chart below highlights the features of each account —
how much you can contribute, who’s eligible and how you’re
reimbursed.
If you are enrolled in the Empire HSA plan, you can set money
aside tax-free under a Limited Purpose FSA which allows
you to reimburse dental and vision expenses only.
FSA Feature
Health Care FSA/Limited Purpose Health Care FSA Dependent Care FSA
How much you
can contribute
each plan year
Up to $2,550.
Up to $5,000.
(Up to $2,500 if you file taxes as “married, filing separately.” Your contribution cannot be greater than
your spouse’s annual salary.)
Eligible
dependents
Eligible dependents include:
l Y
our children for whom you are a legal guardian and
who depend on you for financial support and you
claim as dependents on your income tax return; and
l Your legal spouse.
Eligible dependents include:
l Your children under age 13;
l Your spouse, if physically or mentally incapable of self-care; and
l A
ny other person residing in your household
and considered a dependent for tax purposes
who is physically or mentally incapable of selfcare, regardless of age.
How much you’re
reimbursed
Up to the total amount you elected for the calendar year. Up to the amount of the current contributions in
your account; if your expense is greater than your
account balance, you’ll be reimbursed once you’ve
contributed enough to pay for the expense.
Effect on future
benefits
The amount of your future Social Security benefits may be slightly reduced because neither you nor the
Company will pay Social Security taxes on your FSA contributions. Your Social Security benefit will not be reduced at all if your earnings after your FSA deductions are more than the Social Security Wage Base ($115,500
for 2014).
11
Do the Math: Example of How a Health Care and Dependent Care FSA Can Save You Money
Cindy is married and filing jointly with a household income of $60,000. Cindy anticipates that her family will have $5,000 in
eligible health care and dependent care expenses:
Without FSA
With FSA
Combined Annual Income
$60,000
$60,000
Pre-Tax Health Care & Dependent Care Contributions
$0
$5,000
Taxable Income
$60,000
$55,000
Federal Income Tax and Social Security Taxes
$21,390
$19,608
After-Tax Health Care & Dependent Care Contributions
$5,000
$0
Take Home Pay
$33,610
$35,392
Cindy saves $1,782 annually in taxes by participating
in a Health Care and Dependent Care FSA.
Note: Above example assumes 28% federal tax rate and 7.65% for Social Security; example has not
taken into account any state or local taxes.
Plan Carefully: Use It or Lose It for Balances Over $500
Although there’s no way to completely predict what the future will bring, it’s a good idea to take a few minutes to review your
current health care and dependent care expenses and estimate what your expenses will be for 2015.
Monies must be used within the plan year. You can carry forward up to $500 of unused funds which can be used after April
of the following year. Any balances above $500 will be forfeited.
For a complete listing of reimbursable health care and dependent care expenses, you may call the IRS at
800.829.3676 and request Publications #502 (health care) or #503 (dependent care). You may also access
these publications through the Internet at: www.irs.gov or the Steve Madden Benefit Portal.
12
OTHER BENEFITS
Employee Assistance Program (EAP)
Gym Reimbursement
Steve Madden has teamed up with Guardian to provide
assistance to you when you need it most. EAP offers you
guidance with personal issues and concerns from balancing a
career and life to obtaining legal guidance. The WorkLifeMatters
program, through a dedicated team of counselors and service
professionals, is able to help provide help and support with
issues such as:
If you participate in the Empire Medical Plans, you have the
oppurtinuty to be reimbursed up to $600 per benefit plan year
for your fitness center’s membership dues.
• Emotional Well‐being
• Health and Wellness
• Relationship Issues
• Community Resources
• Workplace Challenges
• Manager Resources
• Legal and Financial
• Assist with resolving
Concerns
claims and billing issues
If you would like to contact the EAP Support Center, please call
800.386.7055 or log on www.ibhworklife.com.
TravelAid Services
This benefit provides you and your dependents with a safety
net for both personal and business travel. No matter if you
are 100 miles or over 5,000 miles away from home, TravelAid
is available around the clock and around the world to ensure
assistance when you need help the most - whether it’s a
medical emergency or simply replacing travel documents. For
more information, visit www.guardiananytime.com.
College Tuition Reimbursement
Earn free Tuition Rewards for participation in the Guardian
Dental Plan. Your participation in the Guardian Dental Plan will
earn you Tuition Rewards that can be used to pay for up to one
year’s tuition at a SAGE Scholar college.
Following your dental plan enrollment, you will receive a
Welcome email. Check your spam folder. If you do not receive
a welcome email contact Admin@CollegeTuitionBenefit.com.
The welcome email is notification that an online account is
established. You can log in to see the points posted to your
account, and add additional students as you wish. One Tuition
Reward point = $1. If you do not log in to your account in the
first 6 months, your Tuition Reward may be reduced.
For more information, visit www.collegetuitionbenefit.com.
This benefit is being provided to you by Steve Madden at no
cost to you.
1. W
ork out 50 times at a qualifying fitness center for each
6-month period within your beenfit plan year.
2. Track your workout sessions. You can use your fitness
center’s computer printout or the fitness log sheet on the
back of the Gym Reimbursment form.
3. Once you have met the visit requirements, send in a Gym
Reimbursement form with a copy of the Fitness Facility
Member Verification (FFMV) Form, proof of your fitness
center membership payment and record of you workout
sessions.
For each 6-month period, you will get up to one-half the yearly
max reimbursement amount, or your membership dues for
the 6-month period, whichever is less.
For more information, visit www.empireblue.com.
Health Advocate
Steve Madden has teamed up with Health Advocate
to assist employees with questions during enrollment,
as well as provide Clinical Services, Administrative
Services, Health Coaching, and Information & Service
Support. Health Advocate can also research provider
quality information to assist employees in making
informed decisions about where to have elective tests
and surgeries performed.
T he first time you call, you will be assigned a Personal Health Advocate who will help you:
• Find the best doctors
• Assist with eldercare
• Save money on
healthcare
• Help Members better
understand their
condition
• Assist with resolving
• Untangle insurance
claims
• Save money on
healthcare
• Locate and research
treatments for medical
condition
• Secure second opinions
claims and billing issues
If you have any questions, please contact Health
Advocate at 866.695.8622.
13
2015 EMPLOYEE CONTRIBUTIONS
Below are the monthly and per pay period employee pre-tax contributions for medical, dental and vision coverage.
Medical Plan Pre-Tax Contributions
Employee only
Employee + Spouse
Employee + Child
Family
Empire PPO
Empire EPO
Per Pay
Period
$74.58
$167.37
$167.37
$251.34
Per Pay
Period
$58.64
$143.01
$143.01
$208.66
Empire EPO
Base Salary Less than
$50,000
Empire HSA
Empire HSA
Base Salary Less
than $50,000
Per Pay Period
Per Pay Period
Per Pay Period
$50.91
$89.19
$89.19
$128.63
$41.04
$102.05
$102.05
$148.13
$34.73
$56.92
$56.92
$81.01
Reduce your medical premiums by $10 or $20 bi-weekly!
See page 3 for details on how to obtain your medical
premium reductions.
Dental Plan Pre-Tax Contributions
Guardian Dental PPO
Per Pay Period
Employee only
Employee + spouse
Employee + children
Family
$3.16
$6.14
$5.67
$8.65
Vision Plan Pre-Tax Contributions
Employee only
Employee + spouse
Employee + children
Family
VSP Plan
Per Pay Period
$0.67
$1.13
$1.15
$1.83
Contributions for any Voluntary coverages (Short Term Disability, Long Term
Disability, Life, Health Savings Account, Flexible Spending Accounts and
Commuter Benefit) will depend on specific election amounts and/or annual
salary. Please refer to each benefit page to see rates for your voluntary benefits.
14
IMPORTANT CONTACT INFORMATION
If you have questions regarding your eligibility or have general benefit questions, please call the Steve Madden Benefit
Service Center by phone at 877.459.9696 or send an email to stevemaddenbenefits@yourbenefitsmanager.com.
You may also contact the carrier directly. See below for carrier contact information.
Benefit
Medical & Prescription
Drug Plans
Dental Plan
Vision Plan
Flexible Spending
Accounts (FSAs)
Commuter Benefits
Life & AD&D Insurance
Short Term Disability
Long Term Disability
Health Advocate
Employee Assistance
Plan (EAP)
Provider
Empire
Telephone
855.880.0575
Website
www.empireblue.com
Guardian
Guardian
(Vision Service Plan (VSP)
Signature network)
Benefit Resource Inc.
800.541.7846
800.877.7195
www.guardiananytime.com
www.vsp.com
800.473.9595
www.benefitresource.com
Benefit Resource Inc.
Guardian
Guardian
Guardian
Health Advocate
800.473.9595
800.538.4583
888.262.5670
800.538.4583
866.695.8622
Guardian
800.386.7055
www.benefitresource.com
www.guardiananytime.com
www.guardiananytime.com
www.guardiananytime.com
www.healthadvocate.com/
stevemadden
www.ibhworklife.com
Username: Matters
Password: Wlm70101
15
LEGAL DISCLOSURES
Coordination of Benefits
Mental Health Parity
Your medical and dental options contain a coordination of
benefits provision that is designed to prevent the duplication
of coverage and overpayment of benefits when you or your
eligible dependents are covered by more than one plan. Here
is how coordination of benefits works:
The Mental Health Parity and Addiction Equity Act of 2008
requires plans to provide mental health and substance abuse
benefits at the same level that benefits for medical and surgical
related benefits are offered. Key changes that will affect most
group health plans include:
If you are the patient, the Steve Madden plan will pay benefits
first. The other plan will pay benefits according to its own
coordination of benefits rule after you submit a claim.
l
l
l
If your spouse is the patient and has coverage through
another plan, his or her plan will pay benefits first. The
Steve Madden plan will pay its normal benefits minus
any benefits paid by the first plan. This means that
your spouse will not receive any benefit from the Steve
Madden plan if your spouse’s plan pays benefits that
are equal to or greater than the benefits Steve Madden
would pay.
I f your child is the patient and he or she is covered by the
Steve Madden plan and your spouse’s plan, the decision
about which plan pays first is covered by the “birthday
rule.” This means that the Steve Madden plan pays first if
your birthday (month/day) comes before your spouse’s in
the calendar year. For example, if your birthday is March
1 and your spouse’s is April 1, Steve Madden benefits
pay first. Otherwise, your spouse’s plan pays first. If the
Steve Madden plan pays second, it will reduce its normal
benefit by the amount paid by the other plan.
l
l
Group health plans are prohibited from having annual or
lifetime maximum dollar limits for mental health benefits
that are lower than medical or surgical benefits.
T he new law expands mental health benefits to include
substance use disorder benefits.
ost-sharing provisions, such as deductibles and copays,
C
or a plan’s terms regarding the amount, duration and
scope of mental health benefits are no longer restricted
from the plan.
Privacy Rights Under HIPAA
A federal law, the Health Insurance Portability and
Accountability Act of 1996 (HIPAA), requires that health plans
protect the confidentiality of your private health information.
Continuing Coverage Through COBRA
The Consolidated Omnibus Budget Reconciliation Act (COBRA)
allows you to temporarily extend you and your dependents’
medical, dental and vision benefits and Health Care FSA in
certain situations where coverage would otherwise end (like
at your termination of employment). If you elect COBRA
coverage, your medical, dental and vision benefits will continue
for a defined period of time. Your spouse and dependent
children can also continue coverage under COBRA. You will
be required to pay the premiums for this continued coverage,
which will be the full cost of the plan plus a 2% administrative
fee. For more information about continuing coverage through
COBRA, please call the Steve Madden Benefit Service Center at
877.459.9696.
16
This Plan, the Plan Administrator and the Plan Sponsor will
not use or disclose information that is protected by HIPAA
(protected health information) except as necessary for
treatment, payment, and other health care operations of the
Plan, or as permitted or required by law. In particular, the Plan
will not, without authorization, use or disclose protected health
information for employment-related actions and decisions, or
in connection with any other benefit or employee benefit plan
of your Employer.
The Plan also requires all of its business associates (as that term
is defined by HIPAA) to observe HIPAA’s privacy requirements.
Protected health information may be used by and disclosed
to Human Resources, and Benefits and Finance/Accounting
employees of your Employer who are responsible for carrying
out administrative functions for the Plan (such as enrollment/
disenrollment, determinations of eligibility and benefits due,
provider payments, participant reimbursements and audits).
However, these employees will only have access to the
information on a “need to know” basis and will use only
the minimum necessary protected health information to
accomplish the intended Plan administration purpose.
Women’s Health and Cancer Rights Act
Newborns’ and Mothers’ Health Protection Act
The Women’s Health and Cancer Rights Act of 1998 requires
that all health insurance plans that cover mastectomy also
cover the following medical care:
Federal law (Newborns’ and Mothers’ Health Protection
Act of 1996) prohibits the plan from limiting a mother’s
or newborn’s length of hospital stay to less than 48 hours
for a normal delivery or 96 hours for a Cesarean delivery or
from requiring the provider to obtain preauthorization for
a stay of 48 or 96 hours, as appropriate. However, federal
law generally does not prohibit the attending provider,
after consultation with the mother, from discharging the
mother or her newborn earlier than 48 hours for normal
delivery or 96 hours for Cesarean delivery.
l
l
l
l
Reconstruction of the breast on which the mastectomy
was performed;
Surgery and reconstruction of the other breast to produce
symmetrical appearance;
Treatment of physical complications in all stages of
mastectomy, including lymphedema; and
astectomy bras and external prostheses limited to the
M
lowest cost alternative available that meets the patient’s
physical needs.
If you have questions about your benefits under the Empire
medical plans, please call the member services number on
your medical ID card or contact the Steve Madden Benefit
Service Center.
Summary of Benefits and Coverage (SBC)
As required by law, across the US, insurance companies and group health plans like ours are providing plan participants
with a consumer-friendly SBC as a way to help understand and compare medical benefits. Each SBC contains concise
medical plan information, in plain language, about benefits and coverage, including, what is covered, what you need to
pay for various benefits, what is not covered and where to go for more information or to get answers to questions. SBC
documents are updated when there is a change to the benefits information displayed on an SBC.
Government regulations are very specific about the information that can and cannot be included in each SBC. Plans are
not allowed to customize very much of the SBC documents. There are detailed instructions the Plan had to follow about
how the SBCs look, how many pages the SBC should be (maximum 4-pages), the font size, the colors used when printing
the SBC and even which words were to be bold.
The SBC for our Empire medical plans are available from Steve Madden Benefit Service Center. To get a copy of the most
current Summary of Benefits and Coverage (SBC) documents for our medical plans, contact the Benefit Service Center
at 877.459.9696.
17
Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state
may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If
you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you
may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.
healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid
or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be
eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDSNOW or www.insurekidsnow.
gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an
employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan,
your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment”
opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have
questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444EBSA(3272).
If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The
following list of states is current as of July 31, 2014. Contact your State for more information on eligibility–
ALABAMA – Medicaid
Website: http://www.medicaid.alabama.gov
Phone: 1-855-692-5447
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
ARIZONA – CHIP
Website: http://www.azahcccs.gov/applicants
Phone (Outside of Maricopa County): 1-877-764-5437
Phone (Maricopa County): 602-417-5437
COLORADO – Medicaid
Medicaid Website: http://www.colorado.gov/
Medicaid Phone (Instate): 1-800-866-3513
Medicaid Phone (Out of state): 1-800-221-3943
FLORIDA – Medicaid
Website: https://www.flmedicaidtplrecovery.com/
Phone: 1-877-357-3268
GEORGIA – Medicaid
Website: http://dch.georgia.gov/
-Click on Programs, then Medicaid, then Health Insurance
Premium Payment (HIPP)P
Phone: 1-800-869-1150
MONTANA – Medicaid
Website: http://medicaidprovider.hhs.mt.gov/clientpages/clientindex.shtml
Phone: 1-800-694-3084
IDAHO – Medicaid
Medicaid Website: http://healthandwelfare.idaho.gov/
Medical/Medicaid/PremiumAssistance/tabid/1510/Default.aspx
MedicaidPhone:1-800-926-2588
18
INDIANA – Medicaid
Website: http://www.in.gov/fssa
Phone: 1-800-889-9949
IOWA – Medicaid
Website: www.dhs.state.ia.us/hipp/
Phone: 1-888-346-9562
KANSAS – Medicaid
Website: http://www.kdheks.gov/hcf/
Phone: 1-800-792-4884
KENTUCKY – Medicaid
Website: http://chfs.ky.gov/dms/default.htm
Phone: 1-800-635-2570
NEBRASKA– Medicaid
Website: www.ACCESSNebraska.ne.gov
Phone: 1-855-632-7633
PENNSYLVANIA – Medicaid
Website: http://www.dpw.state.pa.us/hip
Phone: 1-800-692-7462
NEVADA – Medicaid
Medicaid Website: http://dwss.nv.gov/Medicaid
Phone: 1-800-992-0900
NEW HAMPSHIRE – Medicaid
Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf
Phone: 603-271-5218
LOUISIANA – Medicaid
Website: http://www.lahipp.dhh.louisiana.gov
Phone: 1-888-695-2447
NEW JERSEY – Medicaid and CHIP
Medicaid Website: http://www.state.nj.us/humanservices/
dmahs/clients/medicaid/
Medicaid Phone: 609-631-2392
CHIP Website: http://www.njfamilycare.org/index.htmlCHIPPhone: 1-800-701-0710
MAINE – Medicaid
NEW YORK – Medicaid
Website: http://www.maine.gov/dhhs/ofi/public-assistance/index. Website: http://www.nyhealth.gov/health_care/medicaid/
html
Phone: 1-800-541-2831
Phone:1-800-977-6740
TTY1-800-977-6741
MASSACHUSETTS – Medicaid and CHIP
NORTH CAROLINA – Medicaid
Website: http://www.mass.gov/MassHealth
Website: http://www.ncdhhs.gov/dma
Phone: 1-800-462-1120
Phone: 919-855-4100
MINNESOTA – Medicaid
NORTH DAKOTA – Medicaid
Website: http://www.dhs.state.mn.us/
Website: http://www.nd.gov/dhs/services/medicalserv/med-Click on Health Care, then Medical Assistance
icaid/
Phone: 1-800-657-3629
Phone: 1-800-755-2604
MISSOURI – Medicaid
UTAH – Medicaid and CHIP
Website: http://www.dss.mo.gov/mhd/participants/pages/
Website: http://health.utah.gov/upp
hipp.htm
Phone: 1-866-435-7414
Phone: 573-751-2005
OKLAHOMA – Medicaid and CHIP
VERMONT – Medicaid
Website: http://www.insureoklahoma.org
Website: http://www.greenmountaincare.org/
Phone: 1-888-365-3742
Phone: 1-800-250-8427
19
OREGON – Medicaid
Website: http://www.oregonhealthykids.go
http://www.hijossaludablesoregon.gov
Phone: 1-800-699-9075
VIRGINIA – Medicaid and CHIP
Medicaid Website: http://www.coverva.org/programs_premium_assistance.cfm
Medicaid Phone: 1-800-432-5924
CHIP Website: http://www.coverva.org/programs_premium_
assistance.cfm
CHIP Phone: 1-855-242-8282
To see if any other states have added a premium assistance program since July 31, 2014, or for more information on special
enrollment rights, contact either:
U.S. Department of Labor
Security Administration
U.S. Department of Health and Human Services Employee Benefits
Centers for Medicare & Medicaid Services
www.dol.gov/ebsa
1-866-444-EBSA(3272)
www.cms.hhs.gov
1-877-267-2323, Menu Option 4, Ext. 61565
OMB Control Number1210-0137 (expires10/31/2016)
20
Medicare Part D Notice of Creditable Coverage
Important Notice from the Company About Your
Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find
it. This notice has information about your current prescription
drug coverage with the Company and about your options
under Medicare’s prescription drug coverage. This information
can help you decide whether or not you want to join a Medicare
drug plan. If you are considering joining, you should compare
your current coverage, including which drugs are covered at
what cost, with the coverage and costs of the plans offering
Medicare prescription drug coverage in your area. Information
about where you can get help to make decisions about your
prescription drug coverage is at the end of this notice.
1. Medicare prescription drug coverage became available in
2006 to everyone with Medicare. You can get this coverage
if you join a Medicare Prescription Drug Plan or join a
Medicare Advantage Plan (like an HMO or PPO) that offers
prescription drug coverage. All Medicare drug plans provide
at least a standard level of coverage set by Medicare. Some
plans may also offer more coverage for a higher monthly
premium.
2. The Company has determined that the prescription drug
coverage offered by the Company’s Benefit Program is, on
average for all plan participants, expected to pay out as
much as standard Medicare prescription drug coverage
pays and is considered Creditable Coverage.
Because your existing coverage is, on average, at least as good
as standard Medicare prescription drug coverage (creditable
coverage), you can keep this coverage and not pay a higher
premium (a penalty) if you later decide to join a Medicare drug
plan.
You can join a Medicare drug plan when you first become
eligible for Medicare and each year from October 15th through
December 7th. However, if you lose creditable prescription drug
coverage, through no fault of your own, you will also be eligible
for a 60-day Special Enrollment Period (SEP) to join a Medicare
drug plan.
21
If you decide to join a Medicare drug plan, your current
coverage with the Company will not be affected. See
the Company’s Benefit Summaries for more information
about what happens to your current coverage if you join a
Medicare drug plan.
If you do decide to join a Medicare drug plan and drop your
current prescription drug coverage with the Company, be
aware that you and your dependents may not be able to
get this coverage back.
You should also know that if you drop or lose your
coverage with the Company and do not join a Medicare
drug plan within 63 continuous days after your current
coverage ends, you may pay a higher premium (a penalty)
to join a Medicare drug plan later.
If you go 63 continuous days or longer without prescription
drug coverage that is at least as good as Medicare’s
prescription drug coverage, your monthly premium may
go up by at least 1% of the base beneficiary premium
per month for every month that you did not have that
coverage. For example, if you go 19 months without
coverage, your premium may consistently be at least 19%
higher than the base beneficiary premium. You may have
to pay this higher premium (a penalty) as long as you have
Medicare prescription drug coverage. In addition, you may
have to wait until the following October to join.
For more information about this notice or your
current prescription drug coverage:
Contact the Benefit Service Center for further information
at 877.459.9696. Note: You will get this notice each year.
You will also get it before the next period you can join
a Medicare drug plan, and if this coverage through the
Company changes. You also may request a copy of this
notice at any time.
For more information about your options under Medicare
prescription drug coverage:
More detailed information about Medicare plans that
offer prescription drug coverage is in the “Medicare & You”
handbook. You will get a copy of the handbook in the mail
every year from Medicare. You may also be contacted directly
by Medicare drug plans.
For more information about Medicare prescription drug
coverage:
l
l
l
Visit www.medicare.gov
all your State Health Insurance Assistance Program for
C
personalized help,
all 800.MEDICARE (800.633.4227). TTY users should call
C
877.486.2048.
If you have limited income and resources, extra help paying
for Medicare prescription drug coverage is available. For
information about this extra help, visit Social Security on
the web at www.socialsecurity.gov, or call them at
800.772.1213 (TTY 800.325.0778).
22
Remember: Keep this Creditable Coverage notice. If you decide
to join one of the Medicare drug plans, you may be required to
provide a copy of this notice when you join to show whether
or not you have maintained creditable coverage and whether
or not you are required to pay a higher premium (a penalty).
Date:January 1, 2015
Name of Entity/Sender:
Steve Madden
Contact - Position/Office: Human Resources
Address: 52-16 Barnett Avenue
Long Island City, NY 11104
Phone Number:
8 7 7 . 4 5 9 . 9 6 9 6
(Steve Madden Benefit
Service Center)
NOTICE OF PRIVACY PRACTICES
This Notice Describes How Medical Information About
You May Be Used and Disclosed and How You Can Get
Access To This Information. Please Review It Carefully.
Our Company’s Pledge to You
This notice is intended to inform you of the privacy practices
followed by Steve Madden (the Plan) and the Plan’s legal
obligations regarding your protected health information
under the Health Insurance Portability and Accountability Act
of 1996 (HIPAA). The notice also explains the privacy rights you
and your family members have as participants of the Plan. It is
effective on September 18, 2012.
The Plan often needs access to your protected health
information in order to provide payment for health services
and perform plan administrative functions. We want to assure
the plan participants covered under the Plan that we comply
with federal privacy laws and respect your right to privacy.
Steve Madden requires all members of our workforce and
third parties that are provided access to protected health
information to comply with the privacy practices outlined
below.
Protected Health Information
Your protected health information is protected by the HIPAA
Privacy Rule. Generally, protected health information is
information that identifies an individual created or received by
a health care provider, health plan or an employer on behalf of
a group health plan that relates to physical or mental health
conditions, provision of health care, or payment for health
care, whether past, present or future.
How We May Use Your Protected Health Information
Under the HIPAA Privacy Rule, we may use or disclose your
protected health information for certain purposes without
your permission. This section describes the ways we can use
and disclose your protected health information.
23
• Payment.
We use or disclose your protected health
information without your written authorization in order to
determine eligibility for benefits, seek reimbursement from
a third party, or coordinate benefits with another health
plan under which you are covered. For example, a health
care provider that provided treatment to you will provide
us with your health information. We use that information in
order to determine whether those services are eligible for
payment under our group health plan.
• Health Care Operations. We use and disclose your protected
health information in order to perform plan administration
functions such as quality assurance activities, resolution
of internal grievances, and evaluating plan performance.
For example, we review claims experience in order to
understand participant utilization and to make plan design
changes that are intended to control health care costs.
• Treatment. Although the law allows use and disclosure
of your protected health information for purposes of
treatment, as a health plan we generally do not need to
disclose your information for treatment purposes. Your
physician or health care provider is required to provide you
with an explanation of how they use and share your health
information for purposes of treatment, payment, and health
care operations.
• As permitted or required by law. We may also use or disclose
your protected health information without your written
authorization for other reasons as permitted by law. We are
permitted by law to share information, subject to certain
requirements, in order to communicate information on
health-related benefits or services that may be of interest
to you, respond to a court order, or provide information
to further public health activities (e.g., preventing the
spread of disease) without your written authorization. We
are also permitted to share protected health information
during a corporate restructuring such as a merger, sale, or
acquisition. We will also disclose health information about
you when required by law, for example, in order to prevent
serious harm to you or others.
• Pursuant to your Authorization. When required by law, • Right to Amend. If you believe that information within
we will ask for your written authorization before using or
disclosing your protected health information. If you choose
to sign an authorization to disclose information, you can
later revoke that authorization to prevent any future uses
or disclosures.
your records is incorrect or if important information is
missing, you have the right to request that we correct
the existing information or add the missing information.
Your request to amend your health information must be
submitted in writing to the person listed below. In some
circumstances, we may deny your request to amend your
health information. If we deny your request, you may file
a statement of disagreement with us for inclusion in any
future disclosures of the disputed information.
• To
Business Associates. We may enter into contracts
with entities known as Business Associates that provide
services to or perform functions on behalf of the Plan. We
may disclose protected health information to Business
Associates once they have agreed in writing to safeguard
the protected health information. For example, we may
disclose your protected health information to a Business
Associate to administer claims. Business Associates are also
required by law to protect protected health information.
• Right to an Accounting of Disclosures. You have the right
to receive an accounting of certain disclosures of your
protected health information. The accounting will not
include disclosures that were made (1) for purposes of
treatment, payment or health care operations; (2) to you;
(3) pursuant to your authorization; (4) to your friends or
family in your presence or because of an emergency; (5) for
national security purposes; or (6) incidental to otherwise
permissible disclosures.
• To the Plan Sponsor. We may disclose protected health
information to certain employees of Steve Madden for the
purpose of administering the Plan. These employees will
use or disclose the protected health information only as
necessary to perform plan administration functions or as
otherwise required by HIPAA, unless you have authorized
additional disclosures. Your protected health information
cannot be used for employment purposes without your
specific authorization.
Your request to an accounting must be submitted in writing
to the person listed below. You may request an accounting
of disclosures made within the last six years. You may request
one accounting free of charge within a 12-month period.
• Right to Request Restrictions. You have the right to request
Your Rights
that we not use or disclose information for treatment,
payment, or other administrative purposes except when
specifically authorized by you, when required by law, or
in emergency circumstances. You also have the right to
request that we limit the protected health information
that we disclose to someone involved in your care or the
payment for your care, such as a family member or friend.
• Right to Inspect and Copy. In most cases, you have the
right to inspect and copy the protected health information
we maintain about you. If you request copies, we will
charge you a reasonable fee to cover the costs of copying,
mailing, or other expenses associated with your request.
Your request to inspect or review your health information
must be submitted in writing to the person listed below. In
some circumstances, we may deny your request to inspect
and copy your health information. To the extent your
information is held in an electronic health record, you may
be able to receive the information in an electronic format.
24
• Your request for restrictions must be submitted in writing
Our Legal Responsibilities
to the person listed below. We will consider your request,
but in most cases are not legally obligated to agree to those
restrictions. However, we will comply with any restriction
request if the disclosure is to a health plan for purposes of
payment or health care operations (not for treatment) and
the protected health information pertains solely to a health
care item or service that has been paid for out-of-pocket
and in full.
We are required by law to protect the privacy of your protected
health information, provide you with certain rights with
respect to your protected health information, provide you
with this notice about our privacy practices, and follow the
information practices that are described in this notice.
We may change our policies at any time. In the event that we
make a significant change in our policies, we will provide you
with a revised copy of this notice. You can also request a copy
of our notice at any time. For more information about our
privacy practices, contact the person listed below.
• Right to Request Confidential Communications. You have
the right to receive confidential communications containing
your health information. Your request for restrictions must
be submitted in writing to the person listed below. We
are required to accommodate reasonable requests. For
example, you may ask that we contact you at your place of
employment or send communications regarding treatment
to an alternate address.
If you have any questions or complaints, please contact:
Date:January 1, 2015
• Right to be Notified of a Breach. You have the right to
be notified in the event that we (or one of our Business
Associates) discover a breach of your unsecured protected
health information. Notice of any such breach will be made
in accordance with federal requirements.
Name of Entity/Sender:
Steve Madden
Contact - Position/Office: Human Resources
Address: 52-16 Barnett Ave
Long Island City, NY 11104
Phone Number: 718.446.1800
Complaints
If you are concerned that we have violated your privacy rights,
or you disagree with a decision we made about access to
your records, you may contact the person listed above. You
also may send a written complaint to the U.S. Department
of Health and Human Services — Office of Civil Rights. The
person listed above can provide you with the appropriate
address upon request or you may visit www.hhs.gov/ocr for
further information. You will not be penalized or retaliated
against for filing a complaint with the Office of Civil Rights or
with us.
• Right to Receive a Paper Copy of this Notice. If you have
agreed to accept this notice electronically, you also have a
right to obtain a paper copy of this notice from us upon
request. To obtain a paper copy of this notice, please
contact the person listed to the right.
25
EVALUATING YOUR HEALTH INSURANCE OPTIONS
What You Need to Know
This letter has been created to help you understand your health insurance options. The recently passed health care reform law (called
the Patient Protection & Affordable Care Act) requires most Americans to carry health insurance coverage or pay a penalty.
You can:
•
Elect employer-provided health insurance (if offered).
•
Purchase health insurance through the Marketplace.
You have likely heard about the Marketplace (formerly known as the health insurance exchange) in the news and around the water
cooler. The Marketplace, which started on October 1, 2013, is designed to help you find health insurance plans that fit minimum
standards for coverage and family budget.
•
ou may be able to save money on premiums if your employer does not offer coverage, or offers coverage that does not
Y
meet government standards. Your potential savings on health insurance premiums would be dependent on household
size and income. If you are offered employer-provided health insurance that meets those government standards, you may
not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. If the cost
of your employer’s plan to cover yourself only (and not other members of your family) is more than 9.5% of your annual
household income, you may be eligible for a tax credit.
Open enrollment for health insurance coverage through the Marketplace began on October 1, 2014, and coverage takes effect as
early as January 1, 2014. Visit www.healthcare.gov to learn more about your options, or to request assistance.
Want to Buy on the Marketplace? Start with This Information
STEP 1. Visit www.healthcare.gov and begin the application process
STEP 2. You will need the information below to apply. (Numbers correspond directly to numbers on actual application.)
3.  Employer Name:
Steven Madden Ltd
4.  Employer Identification Number (EIN)
Whl-133588231/Rtl-133850272
5.  Employer Address:
52-16 Barnett Avenue
6.  Employer Phone Number:
718.446.1800
7.  Employer City:
Long Island City
8.  Employer State
NY
9.  Who can we contact about employee health coverage at
this job?
Benefit Service Center
10. Employer Contact Phone Number (If different from above)
877.459.9696
11. Email Address
stevemaddenbenefits@yourbenefitsmanager.com
26
Basic Information About Steve Madden’s Health Coverage
As your employer, we offer medical plans to full-time employees scheduled to work 30 or more hours per week. We also extend coverage to eligible dependents as follows:
•
Your spouse
•
our domestic partner (Person with whom the employee lives together and share a common domestic life but are neither
Y
joined by marriage nor a civil union; same sex as the employee)
•
Your married or unmarried child(ren) up to age 20 or 26 including:
•
A newborn, biological child or a child placed with you for adoption
•
A stepchild who receives more than one-half of his or her support from you; or
•
ny other child for whom you have legal guardianship or court-ordered custody, provided that the child receives more
A
than one-half of his or her support from you
•
our unmarried child who is beyond the age limit at the initial enrollment if you provide proof of handicap and deY
pendence at the time of enrollment
Child(ren) of a domestic partner who meet the age requirements above
•
Our health coverage meets the minimum value standard, and the cost of our coverage to you is intended to be affordable (based on
wages).
Note: Although our coverage is intended to be affordable, you may still be eligible for a premium discount through the Marketplace.
The Marketplace will use your household income, along with other factors, to determine whether you may be eligible for a premium
discount. If, for example, your wages vary from week to week (perhaps you are an hourly employee or you work on a commission
basis), if you are newly employed mid-year, or if you have other income losses, you may still qualify for a premium discount.
If you decide to shop for coverage in the Marketplace, healthcare.gov will guide you through the process.
The Impact of Purchasing Coverage Through the Marketplace
If you choose to purchase health insurance through the Marketplace instead of electing the health insurance provided by your employer:
•
You may lose your employer’s contribution to your health insurance.
•
ou may also lose any tax deductions from your employer contribution — in addition to your employee contributions to
Y
employer-sponsored coverage — on your Federal and State income taxes.
•
Payments to the Marketplace are made on an after-tax basis.
27
DOMESTIC PARTNERSHIP
TAX ISSUES:
Medical, dental, and vision coverage is available for domestic
partners meeting the definitions and criteria as described
below assuming adequate documentation is presented.
Carefully review the information and consider each section as
it relates to you, especially the tax ramifications.
In a private letter ruling (PLR 9603011), the IRS ruled that
benefits paid under a group health plan for a domestic
partner who would not qualify as a spouse under state law or
as a dependent under the IRC caused the employee to receive
additional compensation taxable as wages. In other words, the
employee is required to declare as taxable income the value of
the domestic partner’s health coverage.
Along with your online enrollment, you and your partner will
be asked to complete a Declaration of Domestic Partnership
and provide several items documenting your relationship and
cohabitation. All information submitted to Benefit Service
Center will be held in the strictest of confidence.
The above is predicated on applicable state law where the
taxpayer resides and determines whether or not domestic
partners are “spouses.” Since very few states recognize
domestic partnerships, it is extremely difficult for a domestic
partner to qualify as a spouse and receive benefits tax-free.
Therefore, in this case, employers extending coverage to an
employee’s domestic partner must include the value of the
coverage provided to the domestic partner in the employee’s
wages. The amount to be included is the “fair market value”
of the coverage minus any after tax employee’s contributions
toward coverage.
Domestic Partners as defined as:
• Who are both at least (18) years of age and mentally
competent to sign the required affidavit;
• Who share a common residence for at least twelve (12)
consecutive months, be jointly responsible for each
other’s common welfare as evidenced by either joint
financial arrangements or joint ownership of real estate or
personal property for at least twelve (12) consecutive
months;
OTHER ISSUES TO NOTE:
• Who have had an emotional and financial commitment • Termination of the partnership and thus benefits for the
partner will need to be communicated in writing. The
completed Declaration of Termination of Domestic
Partnership needs to be submitted to the Benefits
Coordinator within 31 days of the status change.
to one another for a minimum of twelve (12) consecutive
months; and
Documentation Required:
• Completion, by both partners, of the enclosed Declaration • An employee will be eligible to seek benefits for another
of Domestic Partnership The Declaration of Domestic
domestic partner one (1) year from the date indicated on
the Declaration of Termination.
Partnership must be notarized.
• Termination of coverage for domestic partners DOES NOT
And Either:
• Joint-tenancy lease and jointly-held mortgage with both
qualify that person for continuation of coverage under
Consolidated Omnibus Budget Reconciliation Act of 1985
(COBRA).
partner’s signature or,
• Two (2) additional forms of documentation as evidence • At present, the Family and Medial Leave Act (FMLA) of 1993
that the partners are committed to one another.
does not include unmarried domestic partners within its
definition of “spouse.”
Examples:
• Joint checking account, bills or driver’s licenses showing the • The domestic partner will NOT be recognized as an eligible
dependent under Flexible Spending Program.
same address, an insurance policy or will indicating partner
as beneficiary or a copy of a registration certificate filed with
those cities or states recognizing domestic partnerships.
• If the partnership is, at any time, found to be invalid,
coverage for the partner will be terminated retroactively.
Steve Madden is entitled to seek reimbursement for any
claims and/or premium paid on the partner’s behalf.
28
Declaration of Domesic Partnership
We declare, under penalty or perjury, under the laws of the State of _____________________that the assertions in this Declaration
are true to the best of our knowledge. We understand that this form is not an application for dental and or health insurance
coverage and that the purpose for this form is to establish the eligibility of persons named herein for the coverage provided
under Steve Madden’s dental and or health insurance program.
Employee’s Name
Employee’s Signature
Date of Birth
Date
Date of Birth
Date
Social Security Number
Domestic Partner’s Name
Domestic Partner’s Signature
Social Security Number
Employee & Domestic Partner Home Address:
Street Address
City ST
Zip
Date
Notary Public
My Commission expires: _______________
29
Domestic Partner Statement
Please check each statement that applies to you. If both statements are checked, you will not have any imputed income.
____ My domestic partner is a member of my household and lives with me the entire year.
____ I provide more than 50% of my domestic partner’s and partner’s child(ren) (if applicable)
support for the year.
By signing below, I certify that my domestic partner and my partner’s child(ren) (if applicable) qualify as eligible tax dependents
for employer sponsored benefit purposes under Section 152 of the Internal Revenue Code for the entire current tax year. I agree
to notify Human Resources at Steve Madden if there is a change in my situation that disqualifies my domestic partner or my
partner’s child(ren) as an eligible IRS dependent for employer sponsored benefits.
_________________________________ __________________
Signature
Date
__________________________________
Print Name
30
AFFIDAVIT OF MARRIAGE
Affidavit of Marriage
This is to confirm that I, ________________________________________, am currently
(print employee name)
legally married to ________________________________________, who is listed as a dependent on my employer
(print employee name)
sponsored health insurance plan(s).
________________________________________
____________________
Signature of Employee Date
STATE OF ___________________ )
) ss.:
COUNTY OF _________________)
On this _____ day of _______________ 20__, before me personally came _______________________________________
_ to be known and known to me to be the person described and who executed the foregoing Agreement, and (s)he duly
acknowledged to me that (s)he executed the same.
________________________________________
Notary Public
My Commission expires: _______________
31
November 2014