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2017-2018
BENEFIT GUIDE
2017-2018 Open Enrollment Guide 1
ENROLL ONLINE WITH Scan this code with
WELCOME TO YOUR BENEFITS
SMARTBEN
your smart phone
or tablet to go to WHAT TO EXPECT FOR THIS PLAN YEAR
JULY 10 - 28
SmartBen! OPEN ENROLLMENT!
OPEN ENROLLMENT: JULY 10 - 28, 2017 HIGHLIGHTS SPOUSAL SURCHARGE
Do I Need to Enroll? Kaiser Medical Plan Changes Employees are subject to a surcharge when covering
a spouse or registered same-sex domestic partner
Your benefits will rollover to the new plan year, with the Plan Feature Last Year This Year under their Forever 21 health plan who has the option to
exception of the Flexible Spending Account (FSA). For those Office visit $25 copay $30 copay elect health care coverage through their employer. The
who participate in the Health and Dependent Care FSA’s, additional cost is $70 dollars per pay period if the below
Outpatient hospital $150 copay $250 copay
you will have to make a new election amount for 2018. Those situation applies to you.
Urgent care $25 copay $30 copay
Step 1 who participate in the commuter parking and transit may
make changes monthly as always. Emergency Room $100 copay $150 copay You will be subject to a surcharge if:
Visit https://enroll.smartben.com from your Ambulance $50 copay $150 copay
If you would like to make changes or enroll in benefits, you • Your spouse or registered same-sex domestic partner
computer or smart device’s web browser and can do so by visiting https://enroll.smartben.com from July Non-Preferred Brand Rx Retail: $30, Mail: $60 Retail: $35, Mail: $70 is working at an employer who offers group health
enter your username and password: 10 through July 28, 2017. Use the instructions to the left to Specialty Medications $30 copay You pay 20%, max. $100 insurance, but has declined that coverage and wants
• Username: Enter “F21” plus your log on and complete your enrollment before the deadline. to remain on the Forever 21 health plan.
employee ID number. For example, for Additionally, if you need technical assistance, more
Medical Plan Premiums • Your spouse or registered same-sex domestic partner
an employee ID 54321 you would enter information about the new voluntary benefit plans or would Kaiser and UHC plan premiums will increase by $1.00 per is eligible and/or enrolled in Medicare, still actively
F2154321. like to enroll in the Voya Financial Whole Life Insurance plan, pay period (see page 4 for updated rates). working at their own employer that offers group health
please contact the Benefits Enrollment Support Center insurance and covered under your Forever 21 health
• Password: Enter your date of birth as during the Open Enrollment period at (855) 210-1940. In Dental plan.
MMDDYYYY (no dashes or slashes). If your order to avoid potential wait times to speak with a benefit Aetna DMO
• Your spouse or registered same-sex domestic partner
birthday was May 9, 1989, you would enter counselor, make an appointment online in advance by • Exam copay increasing from $5 to $10 is offered coverage for any time period throughout the
05091989. (You will be prompted to change visiting http://forever21.myannualenrollment.com. year with their employer, and you choose to continue
• Orthodontia copay increasing from $2,300 to $2,400
your password at this time.) their coverage under the Forever 21 health plan.
All changes made during Open Enrollment Vision
Step 2 are effective as of October 1, 2017. There are no changes to the vision plan offered through VSP. You will NOT be subject to a surcharge if:
From the home page, click the “Begin • You and your spouse or registered same-sex domestic
Enrollment” icon and then the “Annual Smoker/Tobacco Surcharge partner are BOTH employed at Forever 21 and are
Important Notes About Enrollment
Enrollment” button. Smokers and all types of tobacco users, including pipes, covered under the company’s health plan.
Employees Hired On/After August 2 e-cigarettes, cigars, cigarettes and chewing tobacco are • Your spouse or registered same-sex domestic partner
Step 3 All benefits eligible employees hired on or after August 2, subject to a $20 per pay period surcharge. Please contact is eligible and/or enrolled in Medicare, and is covered
2017, are not required to participate in Open Enrollment and HR Benefits for solutions to help you quit using tobacco. under your Forever 21 health plan.
Click on each benefit to enroll or make will be provided with enrollment instructions before their
changes to a selection. enrollment period. Voluntary Benefits • Your spouse or registered same-sex domestic partner
If you wish to enroll in a voluntary plan for the first time is a retiree from another employer, is not actively
Step 4 during Open Enrollment, some plans may require EOI working and is covered under your Forever 21 health
Once your elections are complete, each (Evidence of Insurability). Learn more on page 9. plan.
benefit will have a green light next to it. To • Your spouse or registered same-sex domestic partner
DEPENDENT AUDIT
CONTENTS
proceed to the next step, click the button is self-employed, regardless of whether or not they
labeled ”Elect & Continue.” offer insurance to their employees and is covered
A dependent audit will be conducted at the end of 2017.
under your Forever 21 health plan.
What To Expect For This Year ..............................................2 It’s important for you to review members on your plan to
Step 5 Medical Plan Overview..........................................................3 make sure they’re qualifying dependents. • Your spouse or registered same-sex domestic partner
Be sure to review everything for accuracy. Click is a part-time employee, doesn’t have access to health
Medical Plan Comparisons...................................................4 As a reminder only the following dependents are eligible
coverage and is covered under your Forever 21 health
“Continue” when prompted. You will then Virtual and Telephonic Medical Care...................................5 to be on your plan:
plan.
need to enter your initials to agree to your Dental Coverage...................................................................7 • Legal spouse
enrollment selections. • Your spouse or registered same-sex domestic partner
Vision Coverage ....................................................................8 • Same-sex registered domestic partner has insurance available through their own employer,
Voya Voluntary Benefits.........................................................9
Step 6 Flexible Spending Accounts ..............................................11
• Your child (ren), the child (ren) of your legal spouse or the employer does not make contributions toward the
registered same-sex domestic partner, until age 26. cost of the health insurance and is covered under your
Success! You have enrolled. Print your EAP and Travel Assistance..................................................12 Forever 21 health plan.
confirmation statement for your records. Take the opportunity during Open Enrollment to remove
Legal Notices.......................................................................13 non-qualifying dependents from your plans to remain
Contacts.......................................................................... Back in compliance. Remember, you are responsible for all
medical claim cost for ineligible dependents.
1 Forever 21 – Your Style, Your Benefits! 2017-2018 Open Enrollment Guide 2
MEDICAL PLAN OVERVIEW MEDICAL PLAN COMPARISONS
Forever 21 offers five comprehensive medical plans through Kaiser Permanente and KAISER PERMANENTE HMO / UHC EPO (AVAILABLE IN CALIFORNIA ONLY)
UnitedHealthcare (UHC). Premium Contributions (per paycheck) Kaiser Permanente HMO Plan UnitedHealthcare Choice EPO Plan
Employee Only $42.54 $49.53
Employee + Spouse* $84.08 $97.83
MEDICAL PLAN OPTIONS MEDICAL PLAN HIGHLIGHTS Employee + Child(ren) $79.46 $93.85
• Kaiser Permanente HMO – California Only Employee + Family $125.62 $144.70
Kaiser Permanente HMO (California Only) Benefits and Covered Services In Network Only In Network Only
• UHC Choice EPO – California Only
• There is no deductible for the HMO plan. Annual Deductible None $500 individual / $1,000 family
• UHC Choice Plus PPO HDHP – All States
• You are required to use doctors and facilities that are Coinsurance (plan / member) 100% / 0% 90% / 10%
• UHC Choice Plus PPO Low – All States Maximum Out of Pocket $1,500 individual / $3,000 family $2,000 individual / $4,000 family
in the Kaiser Permanente HMO network. If you go
• UHC Choice Plus PPO High – All States outside of the network, benefits will not be covered Lifetime Maximum Benefit None None
(except in certain emergency situations). Physician Office Visit $30 copay per visit $30 copay per visit
About the Plans Urgent Care $30 copay per visit $30 copay per visit
• Preventive care services are covered at 100% when
All of our plans provide coverage for medical care and Inpatient Hospital $500 copay per admission You pay 10% after deductible plus $500 copay per admission
performed by a Kaiser Permanente network provider.
prescription drugs. The company pays a portion of the Emergency Room $150 copay per visit You pay 10% after $200 copay per visit
plan’s premium for you and your enrolled dependents. UHC EPO (California Only) Prescription Drug Benefits Kaiser Permanente HMO Plan UnitedHealthcare Choice EPO Plan
Please review the details on page 4 to compare the plans Generic $15 copay, up to 30-day supply $15 copay
• Under the UHC EPO plan, you must first meet a
that are available to you. Brand Name $35 copay, up to 30-day supply $35 copay
deductible before the insurance will start covering
Non Preferred Brand $35 copay, up to 30-day supply** $50 copay
health care expenses, with the exclusion of copays.
Specialty You pay 20% coinsurance, up to $100 max. You pay 20% up to $100 copay
• You are required to use doctors and facilities that *Forever 21 supports registered same-sex domestic partner coverage in all states. Please contact the HR Benefits Department at (213) 741-8897 or
are in the UHC EPO network. If you go outside of the HR.benefits@forever21.com for more information. Domestic partnership is processed on a post-tax basis. Imputed income will apply. See page 2 for
network, benefits will not be covered (except in certain spousal surcharge information.
emergency situations). ** Medications in this category require the provider to submit an exception request for it to be covered.
• Preventive care services are covered at 100% when UHC PPO OPTIONS (AVAILABLE IN ALL STATES)
performed by a UHC network provider. Premium Contributions (per paycheck) UHC Choice Plus PPO HDHP UHC Choice Plus PPO Low UHC Choice Plus PPO High
Employee Only $31.35 $43.35 $66.00
UHC Choice Plus PPO Plans (All States) Employee + Spouse* $61.77 $85.50 $130.69
There are three PPO plan options to choose from: Employee + Child(ren) $58.73 $82.03 $125.36
Employee + Family $91.00 $126.40 $193.47
PPO HDHP, PPO Low and PPO High.
Benefits and Covered Services In Network Out of Network In Network Out of Network In Network Out of Network
• All the PPO plans cover in network preventive care at $2,000 individual $4,000 individual $1,000 individual $2,000 individual
100%. $3,000 individual $6,000 individual
Annual Deductible $4,000 2 persons $8,000 2 persons $2,000 2 persons $4,000 2 persons
$6,000 family $12,000 family
$6,000 family $12,000 family $3,000 family $6,000 family
• You will have set copays for doctor visits and
Coinsurance (plan / member) 70% / 30% 50% / 50% 70% / 30% 50% / 50% 80% / 20% 60% / 40%
prescription drug expenses in-network and
$5,000 individual $8,000 individual $4,000 individual $8,000 individual
coinsurance for all other health care expenses. $6,000 individual $12,000 individual
Maximum Out of Pocket $10,000 2 persons $16,000 2 persons $8,000 2 persons $16,000 2 persons
$12,000 family $24,000 family
• You must first meet a deductible before the insurance $15,000 family $24,000 family $12,000 family $24,000 family
will start covering health care expenses, with the Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited
exclusion of copays. $20 copay per
Physician Office Visit $25 copay per visit You pay 50% $25 copay per visit You pay 50% You pay 40%
visit
• The PPO Plans provide coverage for both in-network $20 copay per
and out-of-network service providers, but you can Urgent Care $125 copay per visit You pay 50% $25 copay per visit You pay 50% You pay 40%
visit
save money and spend less out of your own pocket by You pay 30% after
using in-network providers. Inpatient Hospital You pay 30% You pay 50% $250 copay per You pay 50% You pay 20% You pay 40%
day, up to 3 days
• You can review the differences between the three PPO
Emergency Room $250 copay per visit You pay 30% after $100 copay per visit You pay 20%
plans on page 4.
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
*Forever 21 supports registered same-sex domestic partner coverage in all states. Please contact the HR Benefits Department at (213) 741-8897 or
HR.benefits@forever21.com for more information. Domestic partnership is processed on a post-tax basis. Imputed income will apply. See page 2 for
spousal surcharge information.
3 Forever 21 – Your Style, Your Benefits! 2017-2018 Open Enrollment Guide 4
UHC VIRTUAL VISITS KAISER TELEPHONE APPOINTMENTS
NOW, YOU CAN GET CARE FROM A DOCTOR— CALL FOR CARE AT A LOCATION NEAR YOU
WHEREVER YOU ARE Baldwin Park, Downey, and Panorama City Medical
Center
Do you have a minor health condition? If it doesn’t require South Bay
an in-person medical exam, you may be able to address it Mon–Fri, 7 a.m. to 7 p.m.
with a doctor by phone. Baldwin Park Medical 1-888-778-5000
Center
You’ll get great care, and you’ll save time. Woodland Hills Medical
Mon–Fri, 7 a.m. to 7 p.m. Center
Some examples of conditions:*
Virtual Visits
1-800-780-1277
Mon–Fri, 7 a.m. to 7 p.m.
• Allergies Downey Medical Center 1-888-515-3500
• Colds and coughs Mon–Fri, 7 a.m. to 7 p.m.
Sat–Sun, 7 a.m. to 1 p.m. Los Angeles
• Some follow-up visits 1-800-823-4040
Get access to care online. • Upper respiratory infections South Bay Medical
Los Angeles Medical
Center
Any where. Any time. When you call us, we will: Center Mon–Fri, 7 a.m. to 7 p.m.
7 days, 24 hours 1-800-954-8000
• Make sure you’re 18 and over
1-800-780-1230 West Los Angeles
• Confirm you’ve had at least 1 face-to-face visit with us
Medical Center
When you don’t feel well, or your child is sick, the last thing you want to do is leave • Schedule a 1-hour window for the doctor to call you Inland Empire and Mon–Fri, 7 a.m. to 7 p.m.
the comfort of home to sit in a waiting room. Now, you don’t have to. Use virtual visits when: *Telephone appointments are not appropriate for emergency Coachella Valley 1-800-954-8000
A virtual visit lets you see and talk to a doctor from your mobile device or computer • Your doctor is not available conditions, such as severe shortness of breath, severe abdominal pain,
Fontana Medical Center
without an appointment. Most visits take about 10-15 minutes and doctors can write severe bleeding, or urgent conditions— like sprains, falls, or cuts needing
Mon–Fri, 7 a.m. to 7 p.m.
Orange County
• You become ill while traveling stitches.
a prescription*, if needed, that you can pick up at your local pharmacy. And, it’s part Sat, 7 a.m. to 3:30 p.m Orange County–Anaheim
of your health benefits. • You are considering visiting a hospital If you reasonably believe you have an emergency medical condition, call Medical Center
1-888-750-0036
emergency room for a non-emergency 911 or go to the nearest emergency department. An emergency medical
health condition condition is a medical or psychiatric condition that requires immediate Moreno Valley Medical Mon–Fri, 7 a.m. to 7 p.m.
Conditions commonly treated through a virtual visit medical attention to prevent serious jeopardy to your health. For the Center 1-888-988-2800
Doctors can diagnose and treat a wide range of non-emergency medical complete definition of an emergency medical condition, please refer to
conditions, including: Not good for: your Evidence of Coverage. Mon–Fri, 7 a.m. to 7 p.m. Orange County–Irvine
Sat, 7 a.m. to 3 p.m. Medical Center
• Anything requiring an exam or test
• Bladder infection/ • Diarrhea • Rash 1-866-984-7483 Mon–Fri, 7 a.m. to 7 p.m.
Urinary tract infection • Complex or chronic conditions
• Fever • Sinus problems Ontario Medical Center 1-888-988-2800
• Bronchitis • Injuries requiring bandaging or Mon–Fri, 7 a.m. to 7 p.m.
• Migraine/headaches • Sore throat
• Cold/flu
sprains/ broken bones Sat, 7 a.m. to 3:30 p.m. San Diego
• Pink eye • Stomach ache
1-888-750-0036 San Diego Medical
Access virtual visits Center
* Prescription services may not be available in all states. Riverside Medical Center
Mon–Fri, 7 a.m. to 7 p.m. 7 days a week, 7 a.m. to 7
Log in to myuhc.com® and choose from provider sites where you can register for Access to virtual visits and prescription services may not
be available in all states or for all groups. Go to myuhc.com
Sat, 7 a.m. to 3:30 p.m. p.m.
a virtual visit. After registering and requesting a visit you will pay your portion of the for more information about availability of virtual visits and
1-800-290-5000
service costs according to your medical plan, and then you will enter a virtual waiting prescription services. Always refer to your plan documents
1-866-984-7483
for your specific coverage. Virtual visits are not an insurance
room. During your visit you will be able to talk to a doctor about your health concerns, product, health care provider or a health plan. Virtual visits
symptoms and treatment options. are an internet based service provided by contracted Kern County, Valleys,
UnitedHealthcare providers that allow members to select
and interact with independent physicians and other health Western Ventura
care providers. It is the member’s responsibility to select
health care professionals. Care decisions are between the Antelope Valley Service
To learn more, login to myuhc.com consumer and physician. Virtual visits are not intended to
Area
address emergency or life-threatening medical conditions
and should not be used in those circumstances. Services Mon–Fri, 7 a.m. to 7 p.m.
may not be available at all times or in all locations.
Members have cost share responsibility and all claims are 1-877-554-4404
adjudicated according to the terms of the member’s benefit
* Prescription services may not be available in all states.
Access to virtual visits and prescription services may not be available in all states or for all groups. Go to myuhc.
plan. Payment for virtual visit services does not cover Kern County Service
pharmacy charges; members must pay for prescriptions (if
com for more information about availability of virtual visits and prescription services. Always refer to your plan
documents for your specific coverage. Virtual visits are not an insurance product, health care provider or a health any) separately. Insurance coverage provided by or through Area Mon–Fri, 7 a.m. to 7
plan. Virtual visits are an internet based service provided by contracted UnitedHealthcare providers that allow UnitedHealthcare Insurance Company or its affiliates. p.m. 1-877-524-7373
members to select and interact with independent physicians and other health care providers. It is the member’s Administrative services provided by United HealthCare
responsibility to select health care professionals. Care decisions are between the consumer and physician. Virtual Services, Inc. or their affiliates.
visits are not intended to address emergency or life-threatening medical conditions and should not be used in
5 thoseForever 21 Services
circumstances. – Yourmay Style,
not be Your
availableBenefits!
at all times or in all locations. Members have cost share 2017-2018 Open Enrollment Guide 6
responsibility and all claims are adjudicated according to the terms of the member’s benefit plan. Payment for
DENTAL COVERAGE VISION COVERAGE
Forever 21’s Freedom of Choice dental coverage includes a choice Forever 21’s vision benefits are administered through VSP. With two options to choose from,
of two dental options, DMO and PPO, that cover preventive and YOU HAVE THE FREEDOM TO you and your family can get quality care and materials at an affordable cost.
diagnostic, basic and major services, as well as orthodontia.
SWITCH DENTAL PLANS MONTHLY
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 You have the flexibility to choose between the VSP Core and the VSP Premium plans. Please review the side-by-side
change. If you wish to change plans, you’ll need to call Aetna at (855) 850-9664 comparison below to determine which option is right for you.
by the 15th of the month for the change to be effective the first of the following CHECK OUT THE MOBILE APP!
month. VSP VISION PLAN OPTIONS
1. Go to https://www.aetna.
com/individuals-families/ Premium Contributions
Core Coverage Premium Coverage
AETNA DMO AETNA PPO using-your-aetna-benefits/
(per paycheck)
The Aetna DMO plan provides The Aetna PPO plan provides the aetna-mobile.html or scane Employee Only $0.23 $1.98
coverage inside of the Aetna DMO freedom to visit any licensed dentist Employee + Spouse* $0.35 $3.96
the code below. Employee + Child(ren) $0.35 $4.25
network. If you use a dentist outside without a referral. If you pick a dentist
Employee + Family $0.46 $6.78
of the network, benefits will not be from Aetna’s PPO network of over 2. Download the Aetna mobile
covered. Under the DMO, you choose 130,000 providers, your benefit app to your smartphone. Covered Services Description Copay Description Copay
a primary care dentist from Aetna’s dollars will go farther when you use 3. Use the app to find a Well Vision Exam • Focuses on your eyes and • Focuses on your eyes and
network of over 10,000 providers. network dentists. overall wellness $10 overall wellness $10
provider, view claims, see • Every plan year** • Every plan year**
Your primary care dentist will help you Like the DMO plan, most preventive your ID card, and contact
manage your care. Prescription Glasses $25 $25
care services are covered at no Aetna customer service.
cost. The difference is that you will Frames • $130 allowance for a wide • $175 allowance for a wide
*DMO is not offered in the following states/
selection of frames selection of frames
territories: AL, AK, ME, MS, ND, NH, PR, SC, need to meet the PPO plan’s annual Scan this code with your • $150 allowance for • $195 allowance for
SD, VT, WY, Virgin Islands, and Guam. deductible before non-preventive smart phone or tablet to Included in $25 Included in $25
featured frame brands featured frame brands
download the app prescription prescription
services are covered, and there is a • $70 allowance at Costco • $95 allowance at Costco
glasses copay glasses copay
limit to how much the plan will pay • 20% off amount over your • 20% off amount over your
for services each year. allowance allowance
• Every other plan year** • Every plan year**
Lenses • Single vision, lined bifocal, • Single vision, lined bifocal,
and lined trifocal lenses Included in $25 and lined trifocal lenses Included in $25
• Polycarbonate lenses for prescription • Polycarbonate lenses for prescription
dependent children glasses copay dependent children glasses copay
AETNA DENTAL® FREEDOM OF CHOICE (CHOOSE BETWEEN TWO PLAN OPTIONS MONTHLY) • Every other plan year** • Every plan year**
Premium Contributions (per paycheck) Aetna DMO Aetna PPO Lens Enhancements • Scratch-resistant coating $0 • UV protection $0
• Standard progressive $0 • Scratch-resistant coating $0
Employee Only $6.15 $6.15 lenses $55 • Standard progressive $55
Employee + 1 Dependent $11.06 $11.06 • Premium progressive lenses
Employee + 2 or More Dependents $18.40 $18.40 lenses $95-105 • Premium progressive $95-105
Benefits and Covered Services In Network Only In Network Out of Network • Custom progressive lenses lenses
(Plus, get an average of 20- $150-$175 • Custom progressive $150-$175
Calendar Year Deductible None $50 individual / $150 family $100 individual / $300 family
25% off other lens options) lenses
Calendar Year Benefit Maximum (Plus, get an average of 20-
None $1,500 per person $1,500 per person
The most the plan will pay 25% off other lens options)
Preventive and Diagnostic Serivces Contact Lenses (instead • $130 allowance for • $175 allowance for
Covered 100% with $10 copay for exam Covered 100% You pay 50%, no deductible
Exams, cleanings, x-rays, sealants of glasses) contacts and contact contacts and contact
Basic Services lens exam (fitting and lens exam (fitting and
Covered 100% You pay 30% after deductible You pay 50% after deductible evaluation) $0 evaluation) $0
Fillings, simple tooth extractions, root canals, gum treatment, oral surgery
• 15% off contact lens exam • 15% off contact lens exam
Major Services (fitting and evaluation) (fitting and evaluation)
You pay 40% You pay 50% after deductible You pay 50% after deductible
Crowns, inlays, onlays, cast restorations, bridges, dentures, implants
• Every other plan year** • Every plan year**
Orthodontia for Adults and Children Covered 100% after $2,400 copay You pay 50%, no deductible You pay 50%, no deductible
* Forever 21 supports registered same-sex domestic partner coverage in all states. Please contact the HR Benefits Department at (213) 741-8897 or
Orthodontia Lifetime Benefit Maximum 24 months $1,500 per person $1,500 per person
HR.benefits@forever21.com for more information. Domestic partnership is processed on a post-tax basis. Imputed income will apply.
*Forever 21 supports registered same-sex domestic partner coverage in all states. Please contact the HR Benefits Department at (213) 741-8897 or
HR.benefits@forever21.com for more information. Domestic partnership is processed on a post-tax basis. Imputed income will apply. ** Plan year begins October 1
7 Forever 21 – Your Style, Your Benefits! 2017-2018 Open Enrollment Guide 8
VOYA VOLUNTARY BENEFITS VOYA VOLUNTARY BENEFITS
SHORT TERM DISABILITY INSURANCE CRITICAL ILLNESS INSURANCE ACCIDENT INSURANCE TERM LIFE INSURANCE WHOLE LIFE INSURANCE
A short-term, non-occupational injury or illness can prevent If serious illness strikes, the last thing you need to worry about is The Compass Accident Insurance plan Group term life insurance is available Premier Whole Life insurance policies
you from working for a period of time. Should this happen, how to pay the bills: medical copayments and deductibles, car pays you a direct benefit for specific to you, your spouse and your can provide protection for both
the Short Term Disability plan will replace a portion of payments, rent or mortgage, and utilities. With Compass Critical injuries and events resulting from a dependent children. Rates are based working years and post-retirement,
your lost income. The amount of coverage available varies Illness Insurance, if you are diagnosed with a covered illness, you covered on or off the job accident. The on age and salary. while building cash value. Your
based on your location. Some states provide a state receive a lump sum cash benefit – even if you receive benefits plan also includes a hospital confinement monthly premiums are based on your
disability benefit. This voluntary benefit is available to from other insurance. Use the cash benefit however it is needed benefit for illness. The amount paid Coverage Options: age at time of enrollment and will not
retail and distribution center employees only. – whether for treatments not covered by insurance or a dream depends on the type of injury and care Employee must be covered to elect increase as you get older.
vacation to celebrate your recovery – you decide. Employees received. You can use your payment to spouse or child coverage. If you are
Benefit Amount: must have access to comprehensive medical coverage with help pay for unexpected expenses, such enrolling for the first time or if Coverage Options:
• Employees residing in CA, HI, NJ, NY, RI – 70% of your Forever 21 or another source in order to enroll in this plan. as deductibles and copays, home health you are increasing your coverage, Employee does not need to be
weekly earnings, to a maximum of $1,250 per week care costs, lost time from work, everyday you will be asked to complete an covered to elect spouse or child
(benefit amount is offset by the state disability benefit) Coverage Options: expenses, utilities, and groceries. Evidence of Insurability (EOI) form. coverage. If you are enrolling for the
Employee must be covered to elect spouse or child Employees must have access to first time or if you are increasing
• All other employees – 60% of your weekly earnings, to
a maximum of $1,250 per week
coverage, no minimum benefit comprehensive medical coverage with TERM LIFE your coverage, you will be asked to
Forever 21 or another source in order to • You can increase by up to 1x your complete an Evidence of Insurability
• Employee: $5,000 - $30,000, in increments of $5,000
Benefits become payable after the 7th day of injury or enroll in this plan. salary to a maximum of $500,000; (EOI) form.
illness and will pay for up to 12 weeks. • Spouse: $5,000 - $15,000, in increments of $5,000 Employee guarantee issue $200,000
If you are enrolling for the first time or if you are • Child: $1,000, $2,500, $5,000 or $10,000 Examples of Covered Injuries Include: • Benefits reduce to 65% at age 70 WHOLE LIFE
and to 50% at age 75
increasing your coverage, you will be asked to • Broken bones •
Non-tobacco user: $5,000 - $500,000
Examples of Covered Illnesses Include: • $10,000, $25,000, $50,000 or •
Tobacco user: $5,000 - $250,000
complete an Evidence of Insurability (EOI) form. • Joint dislocations / torn ligaments $100,000, not to exceed 100% of
• Heart attack •
$1,000 increments
• Ruptured discs the employee amount; guarantee •
Ages 15-65 coverage is guaranteed
Spouse
HOSPITAL CONFINEMENT INDEMNITY INSURANCE • Stroke
• Burns
issue $50,000
• Benefits reduce to 65% at age 70
Employee up to $20 per week, not to exceed
The Compass Hospital Confinement Indemnity insurance • End stage renal (kidney) failure $100,000
• Concussions and to 50% at age 75 • Ages 66-70 coverage is contingent
pays daily and initial confinement benefits if you have a • Coronary artery bypass • Eye injuries on medical questions for $25,000 of
• Live birth to 6 months - $1,000
covered stay in a hospital, critical care unit or rehabilitation • Coma Child • 6 months to age 26 - $5,000 or guarantee issue
facility. The benefit amount is determined based on the • Major organ failure Plan Features Include: $10,000 • Non-tobacco user: $5,000 - $500,000
type of facility and the number of days you stay. Employees • Tobacco user: $5,000 - $250,000
• Permanent paralysis • Coverage available for the
must have access to comprehensive medical coverage with
employee, spouse and child(ren) Plan Features Include: • $1,000 increments
Forever 21 or another source in order to enroll in this plan. • Cancer, carcinoma in situ, skin cancer • Ages 15-65 coverage is contingent on
• Waiver of premium Spouse
• Hospital care – admission, medical questions for the greater of
• Also includes deafness, blindness, benign brain tumor and
Plan Features: occupational HIV
confinement to a hospital, critical • Accelerated death benefit
$5 per week or $5,000
care unit or rehabilitation facility, • Ages 66-77 requires medical
• Accidental death & questions
HOSPITAL CONFINEMENT INDEMNITY Plan Features Include: surgery
dismemberment benefit • $12,500, $15,000, $20,000 or
Coverage is available for the employee, • $75 wellness benefit when a covered person has a • Follow up care – medical Children
Who is eligible? $25,000
spouse, and children equipment, physical therapy, • Employee Assistance Program 15 days to
• Coverage is contingent on medical
health screening test 24 years
Initial confinement benefit $1,000 prosthetic devices (EAP) questions
• $200 mammogram benefit
Daily hospital confinement $100 per day, up to 30 days • Emergency care – • Travel Assistance
• Restoration of benefits* – pays an additional
Critical care unit benefit $200 per day, up to 15 days
benefit if a covered person experiences
ground/air ambulance, • Funeral planning and concierge Plan Features Include:
emergency room services
Rehabilitation facility
$50 per day, up to 30 days a second covered illness for a different • Waiver of premium
benefit treatment, initial doctor
condition (must occur after a defined treatment, follow-up • Long term care benefit
period of consecutive months) doctor treatment • Accidental death benefit
• Recurrence benefit* – receive a
benefit for the same critical • Accelerated death benefit
illness or condition a second
time (must occur after
a defined period of Voya Financial voluntary plan provisions
consecutive months)
and availability may vary by state; some
*Restoration and recurrence do not apply
to cancer. exclusions and limitations may apply.
9 Forever 21 – Your Style, Your Benefits! 2017-2018 Open Enrollment Guide 10
FLEXIBLE SPENDING ACCOUNTS ADDITIONAL BENEFITS
COMMUTER PARKING, TRANSIT, DEPENDENT CARE, AND HEALTH CARE
Forever 21 offers flexible spending accounts (FSAs) that allow you to use tax-free dollars to pay for qualifying expenses depending EMPLOYEE ASSISTANCE PROGRAM FOR UNITEDHEALTHCARE (UHC) MEMBERS
on which account you choose.
Through Voya, you have access to ComPsych Rally Wellness: Better Health Starts Online!
COMMUTER PARKING & TRANSIT DEPENDENT CARE AND HEALTH CARE FSAs GuidanceResources®, which provides support, resources
and information for personal and work-life issues. This plan
Forever 21 offers two additional types of flexible spending
Paying for Covered Expenses: Use Your P&A Benefits Card accounts (FSAs): the health care FSA and dependent care
includes three telephone counseling sessions per issue.
Employee Assistance Program (EAP) services are provided by
If you enroll in the parking and/or transit plan, you will FSA. These plans enable you to set aside money on a pre-tax ComPsych® Corporation, Chicago, IL. For help, call (877) 533-2363.
receive a debit card that can be used to pay for your basis to pay for your out-of-pocket health and daycare costs.
parking and/or transportation expenses to and from work.
Employees who enroll in both the health care FSA and
You must re-enroll annually in these plans in order to TRAVEL ASSISTANCE
participate for the next calendar year. The plans run on a
parking and/or transit FSA will receive one debit card When traveling more than 100 miles from home, Voya
calendar-year basis (January 1-December 31). You may make
for all accounts. If you are currently enrolled in the health Travel Assistance offers enhanced security for your leisure
your election for 2018 during Open Enrollment in July.
care FSA and enroll in the parking and/or transit account, and business trips. You and your dependents can take
your election amount will be automatically added to your If you are currently enrolled in one of the flexible spending advantage of four types of services: pre-trip information,
current debit card. accounts, you can find detailed information on qualifying emergency personal services, medical assistance services
expenses at www.padmin.com. and emergency transportation services.
No Out-of-Pocket Claim Submissions Allowed Voya Travel Assistance services are provided by Europ Assistance USA,
P&A does not allow reimbursement of out-of-pocket Bethesda, MD. For help, call (800) 859-2821.
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. The Rally Wellness portal and app are FREE for
Contribution Amounts Forever 21 employees enrolled in UHC Visit myuhc.
com or http://Forever21.werally.com to get started!
There are limits to how much you can set aside into your
parking and/or transit account. Below are the IRS pre-set Rally Mobile Registration Code: FORE01
maximum pre-tax contribution for the year 2017.
Tobacco Cessation Program
• PARKING: $255 per month
UnitedHealthcare’s tobacco cessation program is tailored
• TRANSIT: $255 per month to your individual smoking habits and needs. You’ll set a
“Quit Date” and begin a staged approach to stop smoking.
Making Changes To access this program, log on to www.myuhc.com, click
Your commuting expenses may change over time; the ‘Health&Wellness,’ then ‘Your Personal Health Center’ on
parking and transit plans are designed to be flexible and the right side of the screen. Enrolling in a tobacco cessation
allow you to change your election amount each month. program may qualify you for the non-tobacco user discount on
the medical plan premium. Proof of enrollment/ or completion
When Changes are Effective will be requested by HR Benefits.
Please note that any change you make will become effective
with the first pay period beginning on or after the following Baby on the way?
month. For example, if you are going on a vacation and will If so, UnitedHealthcare has a program just for you. A healthy
not be commuting to work, you can change your election pregnancy helps ensure a healthy mom and baby. The
amount for that month in SmartBen through a life event. Maternity Support Program offers you and your dependents
health and educational support from the time you consider
starting or expanding your family, through the first few months
of your new baby’s life. This free, confidential program is
offered to you as part of your regular benefit package. To get
the most from the program, it’s
best to enroll during the first
trimester of your pregnancy. To GIF T CARD
enroll call 877-201-5328.
$150
11 Forever 21 – Your Style, Your Benefits! 2017-2018 Open Enrollment Guide 12
LEGAL NOTICES CAN I SAVE MONEY ON MY HEALTH INSURANCE **Even if your employer intends your coverage to be affordable, you
may still be eligible for a premium discount through the Marketplace.
PREMIUMS IN THE MARKETPLACE?
As part of Forever 21’s compliance obligations Forever 21 must If you go 63 continuous days or longer without creditable prescription The Marketplace will use your household income, along with other
provide certain legal notices to its U.S. benefit eligible employees. The drug coverage, your monthly premium may go up by at least 1% of You may qualify to save money and lower your monthly premium, but factors, to determine whether you may be eligible for a premium
required disclosure notices included within this packet are: the Medicare base beneficiary premium per month for every month only if your employer does not offer coverage, or offers coverage that discount. If, for example, your wages vary from week to week (perhaps
that you did not have that coverage. For example, if you go nineteen doesn’t meet certain standards. The savings on your premium that you are an hourly employee or you work on a commission basis), if you
• Medicare Part D Notice you’re eligible for depends on your household income.
months without creditable coverage, your premium may consistently are newly employed mid-year, or if you have other income losses, you
• New Health Insurance Marketplace Coverage Options and Your
Health Coverage
be at least 19% higher than the Medicare base beneficiary premium. DOES EMPLOYER HEALTH COVERAGE AFFECT may still qualify for a premium discount.
You may have to pay this higher premium (a penalty) as long as you ELIGIBILITY FOR PREMIUM SAVINGS THROUGH THE If you decide to shop for coverage in the Marketplace, HealthCare.gov
• Continuation of Benefits under COBRA have Medicare prescription drug coverage. In addition, you may have
MARKETPLACE? will guide you through the process. Here’s the employer information
• Notice of Privacy Practices to wait until the following October to join. you’ll enter when you visit HealthCare.gov to find out if you can get a
Yes. If you have an offer of health coverage from your employer that
• HIPAA Special Enrollment Rights For More Information About This Notice Or Your Current tax credit to lower your monthly premiums.
meets certain standards, you will not be eligible for a tax credit through
• Employer-Sponsored Wellness Programs Prescription Drug Coverage… the Marketplace and may wish to enroll in your employer’s health plan. CONTINUATION COVERAGE RIGHTS UNDER COBRA
• Newborns and Mothers Health Protection Act Contact the person listed below for further information. NOTE: You’ll However, you may be eligible for a tax credit that lowers your monthly
get this notice each year. You will also get it before the next period you premium, or a reduction in certain cost-sharing if your employer does Introduction
• Women’s Health and Cancer Rights Act (WHCRA) can join a Medicare drug plan, and if this coverage through Forever 21 You’re getting this notice because you recently gained coverage under
not offer coverage to you at all or does not offer coverage that meets
changes. You also may request a copy of this notice at any time. certain standards. If the cost of a plan from your employer that would a group health plan (the Plan). This notice has important information
IMPORTANT NOTICE FROM FOREVER 21 ABOUT YOUR about your right to COBRA continuation coverage, which is a
cover you (and not any other members of your family) is more than 9.5%
PRESCRIPTION DRUG COVERAGE AND MEDICARE For More Information About Your Options Under temporary extension of coverage under the Plan. This notice explains
of your household income for the year, or if the coverage your employer
Please read this notice carefully and keep it where you can find it. This Medicare Prescription Drug Coverage… COBRA continuation coverage, when it may become available
provides does not meet the “minimum value” standard set by the
notice has information about your current prescription drug coverage More detailed information about Medicare plans that offer prescription Affordable Care Act, you may be eligible for a tax credit. to you and your family, and what you need to do to protect your
with Forever 21 and about your options under Medicare’s prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy right to get it. When you become eligible for COBRA, you may also
drug coverage. This information can help you decide whether or not of the handbook in the mail every year from Medicare. You may also be NOTE: If you purchase a health plan through the Marketplace instead become eligible for other coverage options that may cost less than
you want to join a Medicare drug plan. If you are considering joining, contacted directly by Medicare drug plans. of accepting health coverage offered by your employer, then you COBRA continuation coverage.
you should compare your current coverage, including which drugs are may lose the employer contribution (if any) to the employer-offered
For more information about Medicare prescription drug The right to COBRA continuation coverage was created by a federal
covered at what cost, with the coverage and costs of the plans offering coverage. Also, this employer contribution -as well as your employee
coverage: law, the Consolidated Omnibus Budget Reconciliation Act of 1985
Medicare prescription drug coverage in your area. Information about contribution to employer-offered coverage- is often excluded from
• Visit www.medicare.gov (COBRA). COBRA continuation coverage can become available to you
where you can get help to make decisions about your prescription drug income for Federal and State income tax purposes. Your payments for
and other members of your family when group health coverage would
coverage is at the end of this notice. • Call your State Health Insurance Assistance Program (see the coverage through the Marketplace are made on an after-tax basis.
otherwise end. For more information about your rights and obligations
inside back cover of your copy of the “Medicare & You” handbook HOW CAN I GET MORE INFORMATION? under the Plan and under federal law, you should review the Plan’s
There are two important things you need to know about your current
for their telephone number) for personalized help Summary Plan Description or contact the Plan Administrator.
coverage and Medicare’s prescription drug coverage: For more information about your coverage offered by your employer,
• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call please check your summary plan description or contact: You may have other options available to you when you lose
1. Medicare prescription drug coverage became available in 2006
1-877-486-2048. group health coverage. For example, you may be eligible to buy
to everyone with Medicare. You can get this coverage if you join Human Resources – 3880 N. Mission Road, Los Angeles, CA 90031
a Medicare Prescription Drug Plan or join a Medicare Advantage If you have limited income and resources, extra help paying for an individual plan through the Health Insurance Marketplace. By
Medicare prescription drug coverage is available. For information (213) 741-5100 enrolling in coverage through the Marketplace, you may qualify for
Plan (like an HMO or PPO) that offers prescription drug coverage.
All Medicare drug plans provide at least a standard level of about this extra help, visit Social Security on the web at www. The Marketplace can help you evaluate your coverage options, lower costs on your monthly premiums and lower out-of-pocket costs.
coverage set by Medicare. Some plans may also offer more socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778). including your eligibility for coverage through the Marketplace and Additionally, you may qualify for a 30-day special enrollment period for
coverage for a higher monthly premium. its cost. Please visit HealthCare.gov for more information, including another group health plan for which you are eligible (such as a spouse’s
an online application for health insurance coverage and contact plan), even if that plan generally doesn’t accept late enrollees.
2. Forever 21 has determined that the prescription drug coverage Remember: Keep this Creditable Coverage notice. If you decide to information for a Health Insurance Marketplace in your area.
offered by Kaiser and UnitedHealthcare is, on average for all plan join one of the Medicare drug plans, you may be required to provide What is COBRA continuation coverage?
participants, expected to pay out as much as standard Medicare a copy of this notice when you join to show whether or not you have PART B: INFORMATION ABOUT HEALTH COVERAGE COBRA continuation coverage is a continuation of Plan coverage
prescription drug coverage pays and is therefore considered maintained creditable coverage and, therefore, whether or not you are OFFERED BY YOUR EMPLOYER when it would otherwise end because of a life event. This is also
Creditable Coverage. Because your existing coverage is required to pay a higher premium (a penalty). called a “qualifying event.” Specific qualifying events are listed later
This section contains information about any health coverage offered by
Creditable Coverage, you can keep this coverage and not pay a in this notice. After a qualifying event, COBRA continuation coverage
your employer. If you decide to complete an application for coverage
higher premium (a penalty) if you later decide to join a Medicare must be offered to each person who is a “qualified beneficiary.” You,
Date: October, 2016 in the Marketplace, you will be asked to provide this information. This
drug plan. your spouse, and your dependent children could become qualified
information is numbered to correspond to the Marketplace application.
Name of Entity/Sender: Forever 21 beneficiaries if coverage under the Plan is lost because of the
When Can You Join A Medicare Drug Plan?
Contact--Position/Office: HR Benefits Department 3. Employer Name 4. Employer Identification qualifying event. Under the Plan, qualified beneficiaries who elect
You can join a Medicare drug plan when you first become eligible for Forever 21 Number (EIN): 33-0994795
Medicare and each year from October 15th to December 7th. Address: 3880 N. Mission Road COBRA continuation coverage must pay for COBRA continuation
Los Angeles, CA 90031 5,7-9. Employer Address
6. Employer phone number
coverage.
However, if you lose your current creditable prescription drug 3880 N. Mission Road,
coverage, through no fault of your own, you will also be eligible for a Phone Number: 213-741-5100 Los Angeles CA 90031
(213) 741-5100 If you’re an employee, you’ll become a qualified beneficiary if you
two (2) month Special Enrollment Period (SEP) to join a Medicare drug lose your coverage under the Plan because of the following qualifying
10. Who can we contact about employee
plan. NEW HEALTH INSURANCE MARKETPLACE COVERAGE health coverage at this job?
12. Email address events:
OPTIONS AND YOUR HEALTH COVERAGE Forever 21 Human Resource Department • Your hours of employment are reduced, or
What Happens To Your Current Coverage If You Decide
to Join A Medicare Drug Plan? As your employer, we offer a health plan to some employees. Eligible • Your employment ends for any reason other than your gross
PART A: GENERAL INFORMATION misconduct.
employees are regular, full-time employees, unless otherwise covered
If you decide to join a Medicare drug plan, your current Forever 21 When key parts of the health care law take effect in 2014, there will be under a collective bargaining agreement. Variable hour employees If you’re the spouse of an employee, you’ll become a qualified
coverage will not be affected. If you do decide to join a Medicare drug a new way to buy health insurance: the Health Insurance Marketplace. who meet the ACA requirements of 130 hours per month after an 11 beneficiary if you lose your coverage under the Plan because of the
plan and drop your current Forever 21 coverage, be aware that you and To assist you as you evaluate options for you and your family, this notice month measurement period following their date of hire are also eligible following qualifying events:
your dependents will be able to get this coverage back. provides some basic information about the new Marketplace and for coverage.
employment-based health coverage offered by your employer. • Your spouse dies;
When Will You Pay A Higher Premium (Penalty) To Join A With respect to dependents, we do offer coverage. Eligible
Medicare Drug Plan? • Your spouse’s hours of employment are reduced;
WHAT IS THE HEALTH INSURANCE MARKETPLACE? dependents are Natural, step, adopted, and foster children as well as
You should also know that if you drop or lose your current coverage children that are under the legal guardianship and dependent upon • Your spouse’s employment ends for any reason other than his or
The Marketplace is designed to help you find health insurance that
with Forever 21 and don’t join a Medicare drug plan within 63 for support of our regular full-time employees. This coverage meets her gross misconduct;
meets your needs and fits your budget. The Marketplace offers “one-
continuous days after your current coverage ends, you may pay a stop shopping” to find and compare private health insurance options. the minimum value standard, and the cost of this coverage to you is • Your spouse becomes entitled to Medicare benefits (under Part A,
higher premium (a penalty) to join a Medicare drug plan later. You may also be eligible for a new kind of tax credit that lowers your intended to be affordable** based on employee wages. Part B, or both); or
monthly premium right away. Open enrollment for health insurance • You become divorced or legally separated from your spouse.
coverage through the Marketplace begins in October 2013 for
coverage starting as early as January 1, 2014.
13 Forever 21 – Your Style, Your Benefits! 2017-2018 Open Enrollment Guide 14
LEGAL NOTICES information of a person living or deceased (for a period of fifty years
after the death.)
For purposes of this Notice, all actions of the Company and the Business
Associates that are taken on behalf of the Plan are considered actions
Your dependent children will become qualified beneficiaries if they COBRA continuation coverage if the employee or former employee The Plan is required by law to provide notice to you of the Plan’s duties of the Plan. For example, health information maintained in the files of
lose coverage under the Plan because of the following qualifying dies; becomes entitled to Medicare benefits (under Part A, Part B, and privacy practices with respect to your PHI, and is doing so through the Claims Administrator is considered maintained by the Plan. So,
events: or both); gets divorced or legally separated; or if the dependent this Notice. This Notice describes the different ways in which the Plan when this Notice refers to the Plan taking various actions with respect
• The parent-employee dies; child stops being eligible under the Plan as a dependent child. This uses and discloses PHI. It is not feasible in this Notice to describe in to health information, those actions may be taken by the Company or a
extension is only available if the second qualifying event would have detail all of the specific uses and disclosures the Plan may make of PHI, Business Associate on behalf of the Plan.
• The parent-employee’s hours of employment are reduced; caused the spouse or dependent child to lose coverage under the Plan so this Notice describes all of the categories of uses and disclosures HOW THE PLAN MAY USE OR DISCLOSE YOUR PHI
• The parent-employee’s employment ends for any reason other had the first qualifying event not occurred. of PHI that the Plan may make and, for most of those categories, gives
than his or her gross misconduct; The Plan may use and disclose your PHI for the following purposes
ARE THERE OTHER COVERAGE OPTIONS BESIDES examples of those uses and disclosures.
• The parent-employee becomes entitled to Medicare benefits (Part without obtaining your authorization. And, with only limited exceptions,
A, Part B, or both);
COBRA CONTINUATION COVERAGE? The Plan is required to abide by the terms of this Notice until it is we will send all mail to you, the employee. This includes mail relating
Yes. Instead of enrolling in COBRA continuation coverage, there may replaced. The Plan may change its privacy practices at any time and, to your spouse and other family members who are covered under the
• The parents become divorced or legally separated; or if any such change requires a change to the terms of this Notice, the Plan. If a person covered under the Plan has requested Restrictions or
be other coverage options for you and your family through the Health
The child stops being eligible for coverage under the Plan as a “dependent Insurance Marketplace, Medicaid, or other group health plan coverage Plan will revise and re-distribute this Notice according to the Plan’s Confidential Communications, and if the Plan has agreed to the request,
child.” options (such as a spouse’s plan) through what is called a “special distribution process. Accordingly, the Plan can change the terms of the Plan will send mail as provided by the request for Restrictions or
enrollment period.” Some of these options may cost less than COBRA this Notice at any time. The Plan has the right to make any such change Confidential Communications.
continuation coverage. You can learn more about many of these effective for all of your PHI that the Plan creates, receives or maintains,
WHEN IS COBRA CONTINUATION COVERAGE even if the Plan received or created that PHI before the effective date of Your Health Care Treatment: The Plan may disclose your PHI for
options at www.healthcare.gov. treatment (as defined in applicable federal rules) activities of a health
AVAILABLE? the change.
IF YOU HAVE QUESTIONS care provider.
The Plan will offer COBRA continuation coverage to qualified
beneficiaries only after the Plan Administrator has been notified that Questions concerning your Plan or your COBRA continuation The Plan is distributing this Notice, and will distribute any revisions, only Example: If your doctor requested information from the Plan about
a qualifying event has occurred. The employer must notify the Plan coverage rights should be addressed to the contact or contacts to participating employees and COBRA qualified beneficiaries, if any. previous claims under the Plan to assist in treating you, the Plan could
Administrator of the following qualifying events: identified below. For more information about your rights under If you have coverage under the Plan as a dependent of an employee, disclose your PHI for that purpose.
• The end of employment or reduction of hours of employment; the Employee Retirement Income Security Act (ERISA), including or COBRA qualified beneficiary, you can get a copy of the Notice by Example: The Plan might disclose information about your prior
COBRA, the Patient Protection and Affordable Care Act, and requesting it from the contact named at the end of this Notice. prescriptions to a pharmacist for the pharmacist’s reference in
• Death of the employee; or
other laws affecting group health plans, contact the nearest Please note that this Notice applies only to your PHI that the Plan determining whether a new prescription may be harmful to you.
• The employee’s becoming entitled to Medicare benefits (under Regional or District Office of the U.S. Department of Labor’s maintains. It does not affect your doctor’s or other health care
Part A, Part B, or both). Making or Obtaining Payment for Health Care or
Employee Benefits Security Administration (EBSA) in your area provider’s privacy practices with respect to your PHI that they maintain. Coverage: The Plan may use or disclose your PHI for payment
For all other qualifying events (divorce or legal separation of the or visit www.dol.gov/ebsa. (Addresses and phone numbers of (as defined in applicable federal rules) activities, including making
employee and spouse or a dependent child’s losing eligibility for RECEIPT OF YOUR PHI BY THE COMPANY AND
Regional and District EBSA Offices are available through EBSA’s BUSINESS ASSOCIATES payment to or collecting payment from third parties, such as health care
coverage as a dependent child), you must notify the Plan Administrator providers and other health plans.
website.) For more information about the Marketplace, visit
within 60 days after the qualifying event occurs. You must provide this The Plan may disclose your PHI to, and allow use and disclosure of your
notice to: Forever 21 Human Resources Department www.HealthCare.gov. Example: The Plan will receive bills from physicians for medical care
PHI by, the Company and Business Associates without obtaining your
KEEP YOUR PLAN INFORMED OF ADDRESS CHANGES authorization. provided to you that will contain your PHI. The Plan will use this PHI, and
HOW IS COBRA CONTINUATION COVERAGE create PHI about you, in the course of determining whether to pay, and
PROVIDED? To protect your family’s rights, let the Plan Administrator know about Plan Sponsor: paying, benefits with respect to such a bill.
any changes in the addresses of family members. You should also
Once the Plan Administrator receives notice that a qualifying event The Company is the Plan Sponsor and Plan Administrator. The Plan Example: The Plan may consider and discuss your medical history
keep a copy, for your records, of any notices you send to the Plan
has occurred, COBRA continuation coverage will be offered to each may disclose to the Company, in summary form, claims history and with a health care provider to determine whether a particular treatment
Administrator.
of the qualified beneficiaries. Each qualified beneficiary will have an other information so that the Company may solicit premium bids for which Plan benefits are or will be claimed is medically necessary as
independent right to elect COBRA continuation coverage. Covered PLAN CONTACT INFORMATION for health benefits, or to modify, amend or terminate the Plan. This defined in the Plan.
employees may elect COBRA continuation coverage on behalf of their Forever 21 Human Resources Department summary information omits your name and Social Security Number
The Plan’s use or disclosure of your PHI for payment purposes may
spouses, and parents may elect COBRA continuation coverage on and certain other identifying information. The Plan may also disclose
3880 N. Mission Road, Los Angeles, CA 90031 include uses and disclosures for the following purposes, among others.
behalf of their children. information about your participation and enrollment status in the Plan
(213) 741-5100 to the Company and receive similar information from the Company. Obtaining payments required for coverage under the Plan
COBRA continuation coverage is a temporary continuation of coverage
NOTICE OF PRIVACY PRACTICES If the Company agrees in writing that it will protect the information Determining or fulfilling its responsibility to provide coverage and/or
that generally lasts for 18 months due to employment termination
against inappropriate use or disclosure, the Plan also may disclose to benefits under the Plan, including eligibility determinations and claims
or reduction of hours of work. Certain qualifying events, or a second THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT the Company a limited data set that includes your PHI, but omits certain adjudication
qualifying event during the initial period of coverage, may permit a YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET direct identifiers, as described later in this Notice. • Obtaining or providing reimbursement for the provision of
beneficiary to receive a maximum of 36 months of coverage. There ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
are also ways in which this 18-month period of COBRA continuation The Plan may disclose your PHI to the Company for plan administration health care (including coordination of benefits, subrogation, and
The effective date of this Notice of Forever 21’s Health Information functions performed by the Company on behalf of the Plan, if the determination of cost sharing amounts)
coverage can be extended:
Privacy Practices (the “Notice”) is October 1, 2016. Company certifies to the Plan that it will protect your PHI against
DISABILITY EXTENSION OF 18-MONTH PERIOD OF • Claims management, collection activities, obtaining payment
Forever 21 Group Health Plan (the “Plan”) provides health benefits to inappropriate use and disclosure. under a stop-loss insurance policy, and related health care data
COBRA CONTINUATION COVERAGE eligible employees of Forever 21 (the “Company”) and their eligible
Example: The Company reviews and decides appeals of claim denials processing
If you or anyone in your family covered under the Plan is determined dependents as described in the summary plan description(s) for the
Plan. The Plan creates, receives, uses, maintains and discloses health under the Plan. The Claims Administrator provides PHI regarding an • Reviewing health care services to determine medical necessity,
by Social Security to be disabled and you notify the Plan Administrator
information about participating employees and dependents in the appealed claim to the Company for that review, and the Company uses coverage under the Plan, appropriateness of care, or justification of
in a timely fashion, you and your entire family may be entitled to get
course of providing these health benefits. PHI to make the decision on appeal. charges
up to an additional 11 months of COBRA continuation coverage, for
a maximum of 29 months. The disability would have to have started For ease of reference, in the remainder of this Notice, the words “you,” Business Associates: The Plan and the Company hire third parties, • Utilization review activities, including precertification and
at some time before the 60th day of COBRA continuation coverage “your,” and “yours” refers to any individual with respect to whom such as a third party administrator (the “Claims Administrator”), to preauthorization of services, concurrent and retrospective review
and must last at least until the end of the 18-month period of COBRA the Plan receives, creates or maintains Protected Health Information, help the Plan provide health benefits. These third parties are known of services
continuation coverage. including employees and COBRA qualified beneficiaries, if any, and as the Plan’s “Business Associates.” The Plan may disclose your PHI to The Plan also may disclose your PHI for purposes of assisting other
their respective dependents. Business Associates, like the Claims Administrator, who are hired by health plans (including other health plans sponsored by the Company),
SECOND QUALIFYING EVENT EXTENSION OF the Plan or the Company to assist or carry out the terms of the Plan. In
The Plan is required by law to take reasonable steps to protect your health care providers, and health care clearinghouses with their
18-MONTH PERIOD OF CONTINUATION COVERAGE addition, these Business Associates may receive PHI from third parties payment activities, including activities like those listed above with
Protected Health Information from inappropriate use or disclosure.
If your family experiences another qualifying event during the 18 or create PHI about you in the course of carrying out the terms of the respect to the Plan.
months of COBRA continuation coverage, the spouse and dependent Your “Protected Health Information” (PHI) is information about your Plan. The Plan and the Company must require all Business Associates to
children in your family can get up to 18 additional months of COBRA past, present, or future physical or mental health condition, the agree in writing that they will protect your PHI against inappropriate use Health Care Operations: The Plan may use and disclose your PHI
continuation coverage, for a maximum of 36 months, if the Plan is provision of health care to you, or the past, present, or future payment or disclosure, and will require their subcontractors and agents to do so, for health care operations (as defined in applicable federal rules) which
properly notified about the second qualifying event. This extension for health care provided to you, but only if the information identifies too. includes a variety of facilitating activities.
may be available to the spouse and any dependent children getting you or there is a reasonable basis to believe that the information
could be used to identify you. Protected health information includes
15 Forever 21 – Your Style, Your Benefits! 2017-2018 Open Enrollment Guide 16You can also read
