2021 BENEFITS GUIDE - RepcoLite Paints
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2021
BENEFITS
GUIDE
1Welcome Inside
Medical Plans
Whether you are new to our organization or an existing member, Health Reimbursement
we are excited that you have made us your employer of choice. Account
Your role is critical in fulfilling the mission of our organization.
This guide is to help inform you of the benefits available. Please Flexible Spending Account
see the Human Resource Department whenever questions
Health Savings Account
arise.
Dental Plan
Use this guide to:
Vision Plan
Learn who you can cover
What benefits are available to you and your family Basic Life / AD&D
Cost of benefits provided
Voluntary Life / AD&D
Short Term Disability
Additional Information
Cost of Benefits
Toll Free
(800) 936-4236
Jamie Lange
Account Manager
(269) 982-3885
jamie.lange@hubinternational.com
Cindy Payne
Associate Account Manager
(269) 982-3887
cynthia.payne@hubinternational.com
We’re committed to caring for YOU!
Take care of yourself and your family. HUB International is here to help
you with any questions that you have regarding your benefits, claims
issues, enrollment questions and more. Please feel free to contact any one
of your benefit service team members.
2Carrier Contact Information
Refer to this list when you need to contact one of your benefit vendors. For general information contact the Human Resources
Department.
Coverage Carrier Phone Number Website
Medical Priority Health 800-446-5674 www.priorityhealth.com
Dental Flex Administrators 800-968-3539 www.flexadministrators.com
Voluntary Vision EyeMed 866-299-1358 www.eyemedvisioncare.com
Flexible Spending Accounts (FSAs) Flex Administrators 800-968-3539 www.flexadministrators.com
Basic Life / AD&D
Lincoln Financial 800-423-2765 www.lfg.com
Voluntary Life / AD&D
Short Term Disability Lincoln Financial 800-423-2765 www.lfg.com
www.guidanceresources.com
Employee Assistance Program Employee Connect 888-628-4824 Username: LFGsupport
Password: LFGsupport1
Enrollment Considerations
Eligibility Choose Carefully
Employees must be working a minimum of 30 hours Due to IRS regulations, you cannot change your elections
per week (full-time) to be eligible for all benefits. until the next annual Open Enrollment period, unless you
Employees regularly scheduled to work a minimum of have a qualified life event during the year. Following are
20 hours per week are eligible to enroll in the FSA, examples of the most common qualified life events:
Voluntary Vision and Voluntary Life plans. Marriage or divorce
Birth or adoption of a child
Effective Date
Child reaching the maximum age limit
The elections you make are effective first of the month
following your date of hire. Death of a spouse, RDP, or child
Due to IRS regulations, once you have made your You lose coverage under your spouse’s/RDP’s plan
selections for the 2020-2021 Plan Year, you won’t be You gain access to state coverage under Medicaid or
able to change your benefits until the next enrollment CHIP
period unless you experience a Qualifying Life Event.
Making Changes
Termination Date To make changes to your benefit elections, you must
Coverage will terminate as of midnight on the last day of contact Human Resources within 31 days of the
work following termination. qualified life event (including newborns). Be prepared
to show documentation of the event such as a marriage
Dependent Coverage license, birth certificate or a divorce decree. If changes
are not submitted on time, you must wait until the next
Dependents eligible for coverage in benefit plans include:
Open Enrollment period to make your election changes.
Your legal spouse
Children up to age 26 (includes natural children, What Happens If You Don’t Enroll?
stepchildren, legally adopted children, children placed If you miss the deadline, you wont be able to make
for adoption, foster children, and children for whom changes for most benefits until next Annual Enrollment
legal guardianship has been awarded to you or your period, unless you have a qualified life event change.
spouse).
Coverage will end at the end of the month in which
they turn 26 regardless of student status for medical,
dental, and vision. Voluntary life coverage will end at
age 19 or on the 25th birthday if a full time student.
Required InformaƟon—When you enroll, you will be required to enter a Social Security number (SSN) for all covered dependents. The Affordable Care Act (ACA), otherwise known as health care reform,
requires the company to report this informa on to the IRS each year to show that you and your dependents have coverage. This informa on will be securely submi ed to the IRS and will remain 3
confiden al.Medical Plan - Priority Health
We offer two medical plans through Priority Health, a Traditional Plan and a High Deductible Health Plan (HDHP) with a Health Savings
Account (HSA). The plans for the Michigan employees are HMOs; the plans for the Indiana employees are PPOs. Please keep in mind that
the option you select will be in place for all of the 2021 Plan Year, unless you have a Qualifying Life Event. The chart below gives a
summary of the 2021 Medical coverage . All covered services are subject to medical necessity as determined by the Plan. Employees are
encouraged to search for in-network providers by visiting the carrier website. Please reference page 3 for the web address and
follow the link ”Find a Doctor”.
TRADITIONAL HDHP/HSA
In-Network In-Network
Frequently Used Services
Primary Care Physician $30 copay 30% after deductible
Specialist $45 copay 30% after deductible
Urgent Care Facility $50 copay 30% after deductible
Emergency Room $250 copay 30% after deductible
Routine Preventive Care Covered 100% Covered 100%
Hospitalization 30% after deductible 30% after deductible
Surgery 30% after deductible 30% after deductible
Employee Deductible (per calendar year)
Single $1,000 $2,000
Family $2,000 $4,000
Employer HRA/HSA Reimbursement/Contributions
Single $4,000 $1,020 (annual)
Family $8,000 $2,280 (annual)
Coinsurance Maximum (per calendar year)
Single $2,500 N/A
Family $5,000 N/A
Out-of-Pocket Maximum (per calendar year)
Single $8,150 $3,000
Family $16,300 $6,000
Retail RX (30-Day Supply)
Generic $20 copay $20 copay after deductible
Preferred Brand $60 copay $60 copay after deductible
Non Preferred Brand $80 copay $80 copay after deductible
Preferred Specialty 20% to $200 max 20% to $200 max after deductible
Non Preferred Specialty 20% to $400 max 20% to $400 max after deductible
Traditional Plan Deductible: the individual deductible amount must be satisfied by each member enrolled under your Medical coverage. If
you have several covered dependents, all charges used to apply toward a “per individual” deductible amount will be applied toward the “per
family” deductible amount. When the family deductible amount is reached, no further individual deductibles will have to be satisfied for the
remainder of that calendar year. No member may contribute more than the individual deductible amount to the “per family” deductible
amount.
HDHP/HSA Plan Deductible: each covered individual is not required to meet the individual deductible. This Plan has an aggregate
deductible, meaning the family deductible amount will include all combined eligible expenses that you and your covered dependents incur.
The family deductible amount may be satisfied by one member or a combination of two or more members covered under your medical plan. 4Health Savings Account How To Enroll
Your HSA can be used for qualified expenses, including those of your spouse and/or tax YOU MUST ENROLL EACH
dependent(s), even if they are not covered by your plan. If you are not enrolled in an YEAR TO PARTICIPATE
HDHP but you have unused HSA funds from a previous account, those funds can still be
You must elect the HDHP Plan. You
used for qualified medical expenses.
will need to open an HSA at the bank
Banks will usually issue you a debit card giving you direct access to your account
of your choice and provide the bank
balance. You must have a balance to use your debit card. There are no receipts to submit
routing and account numbers to
for reimbursement.
RepcoLite Paints, Inc. who will make
Eligible expenses include doctors’ office visits, eye exams, prescription expenses, laser
your payroll deduction contributions.
eye surgery and more. IRS Publication 502 provides a complete list of eligible expenses
and can be found on www.irs.gov.
Eligibility
You are eligible to open and fund an HSA if:
You are enrolled in the RepcoLite Paints, Inc. HDHP Plan.
You are not covered by your spouse’s non-HSA health plan.
Your spouse does not have a health care Flexible Spending Account or Health
Reimbursement Account.
You are not eligible to be claimed as a dependent on someone else’s tax return.
You are not enrolled in Medicare or TRICARE.
You have not received Department of Veterans Affairs medical benefits in the past 90
days for non-service-related care. (Service-related care will not be taken into consideration.)
Individually Owned Account
You own and manage your Health Savings Account. You determine how much you’ll contribute to the account, when to use the money
to pay for qualified medical expenses, and when to reimburse yourself. HSAs allow you to save and roll over money if you do not spend
it in the calendar year. The money in this account is portable, even if you change plans or jobs. There are no vesting requirements or
forfeiture provisions.
Maximize Your Tax Savings
Contributions to an HSA are tax-free (they can be made through payroll deduction on a pre-tax basis when you open an account ). The
money in this account (including interest and investment earnings) grows tax-free. As long as the funds are used to pay for qualified
medical expenses, they are spent tax-free.
Per IRS regulations, if HSA funds are used for purposes other than qualified medical expenses and you are younger than age 65, you
must pay federal income tax on the amount withdrawn, plus a 20% penalty tax.
HSA Funding Limits
Each year, the IRS places a limit on the maximum amount that can be contributed to HSA accounts. Please see the chart below for
2021 contribution limits (which include any employer contributions).
HSA contributions in excess of the IRS annual contribution limits ($3,600 for individual coverage and $7,200 for family coverage for
2020) are not tax deductible and are generally subject to a 6% excise tax.
If you’ve contributed too much to your HSA this year, you can do one of two things:
Remove the excess contributions and the net income attributable to the excess contribution before you file your federal income tax
return (including extensions). You’ll pay income taxes on the excess removed from your HSA.
Leave the excess contributions in your HSA and pay 6% excise tax on excess contributions. Next year you may want to consider
contributing less than the annual limit to you HSA to make up for the excess contribution during the previous year.
HSA Funding Limits Employer HSA Annual Contribution*
Employee $3,600 Employee $1,020
Double/Family $7,200 Double/Family $2,280
Catch‐Up Contribu on (Ages 55+) $1,000
*RepcoLite Paints, Inc. will make their deposits into the employee’s
HSA on a monthly basis. The monthly deposit will be $85 for those
enrolled with single coverage, and $190 for those enrolled in
double/family coverage.
Employee deposits will be made pre-tax from their weekly pay.
For any employee that enrolls into the HSA plan during the year, 5
the company match will be prorated.Health Reimbursement Account
The Traditional Plan has a $5,000/$10,000 deductible, but it is enhanced with a Health Reimbursement Account. RepcoLite Paints, Inc. will reimburse
the following expenses: Annual Deductible AFTER the insured has paid an in-network deductible of $1,000 for individual and $2,000 for double/family.
The maximum reimbursement will not exceed $4,000 for an individual and $8,000 for a double/family unit during the plan year.
In-Network
Calendar Year Deductible Maximum Reimbursement Your Net Deductible
Individual $5,000 $4,000 $1,000
Double/Family $10,000 $8,000 $2,000
Flexible Spending Account
You can contribute up to $2,750 for qualified medical expenses (deductibles, copays and coinsurance, for example) with pre-tax dollars, which will
reduce the amount of your taxable income and increase your take-home pay. You can even pay for eligible expenses with an FSA debit card at the
same time you receive them, so you don’t have to wait for reimbursement.
Please note: Over-the-counter (OTC) drugs are now eligible for reimbursement through an FSA without a doctor’s prescription.
How to Use the Account
You can use your FSA debit card at locations such as doctor and dentist offices, pharmacies, and vision service providers. The card cannot be used
at locations that do not offer services under the plan, unless the provider has also complied with IRS regulations. The swipe transaction will be
denied if you attempt to use the card at an ineligible location.
General Rules and Restrictions
In exchange for the tax advantages that FSAs offer, the IRS has imposed the following rules and restrictions for both Health Care Flexible Spending
Account (FSA) and Dependent Care Reimbursement Account (DCRA):
Your expenses must be incurred during the 2021 plan year.
Your dollars cannot be transferred from one FSA/DCRA to another.
You cannot change your FSA/DCRA election in the middle of the plan year unless you experience a qualifying life event like marriage, divorce
or birth of a child.
If you have remaining funds in your Health Care FSA account at the end of the plan year and are still eligible for the FSA, you will be able to roll
over $550 from your current plan to the new plan year. Any amount over $550 remaining will be forfeited.
Dependent Care Reimbursement Account
Dependent Care Reimbursement Account
Through the use of a Dependent Care Reimbursement Account (DCRA), you can reduce your tax burden by using pre-tax dollars to pay for eligible child or
dependent care expenses. Federal law also allows you to claim a direct credit against federal income taxes for eligible child or dependent care expenses.
You may use a DCRA or take a federal tax credit - but not both.
How to Use the Account
The DCRA operates much like a bank account. Deposits are made into your account through pre-tax payroll deductions. Withdrawals from the account are
made using a reimbursement form, which is available through your Human Resources Department. The reimbursement form, along with a copy of your
receipt and/or bill and a description of the expense should be submitted to Flex Administrators.
General Rules and Restrictions
Dependent care expenses are expenses incurred by you to enable you to work. If you are married, the expenses must be to enable you and your spouse
to work, or your spouse to attend school on a full time basis. The expenses must be for the care of your dependent that is under age thirteen and for whom
a personal-exemption deduction is allowed for federal income tax purposes; or for the care of your dependent or spouse who is physically or mentally
incapable of self-care, or for household services in connection with the care of such a person.
If you are single or married filing a joint return, the maximum amount that can be reimbursed (i.e., deposited) is the lowest of your earned income or your
spouse's earned income, or $5,000. If you are married and you file a separate tax return, the maximum amount that can be reimbursed (i.e., deposited) is
the lower of 100% of your spouse's income or $2,500. If your spouse is a full-time student or is incapable of self-care, your spouse's earned income is
assumed to be not less than $3,000 if you provide care for one person and $6,000 if you provide for two or more people.
The IRS does not allow you to carry over any unused funds in your DCRA. Any remaining funds in your DCRA account at the end of the year will be
forfeited.
Plan Carefully
Since funds going into your account are free from taxes, the IRS imposes some restrictions on the operation of this account. If any funds remain in your
DCRA account at the end of the plan year, according to IRS regulations, you will forfeit this amount. You will receive a statement from Flex
Administrators before the end of the plan year to help you manage this account. 6Dental Benefits
The Single benefit is available to non-seasonal full-time employees. The Double and Family benefit is only available to employees who elect
coverage under a RepcoLite medical insurance. For these employees, the level of dental insurance coverage (Double or Family) will be
determined based on enrollment in the RepcoLite medical insurance plan.
For any employee who qualifies for the Dental Benefit during the year, the amount of the dental benefits will be calculated as 10% of the
appropriate annual dental benefit ($300/$600/$900) multiplied by the number of months of coverage (rounded to the nearest month) for the
months of January - October. No dental benefit will accrue for the month of November and December.
RepcoLite Paints, Inc. provides reimbursement towards dental/orthodontic expenses each
Plan pays 100% of dental claims up to: plan year:
Single $300 Dental receipts must be sent to Flex Administrators in order to receive reimbursement
into your bank account on file.
Double $600
Dental services reimbursement will only be made for the current plan year.
Family $900 Orthodontia services reimbursement is based on payment plan for current plan year.
Voluntary Vision Plan - EyeMed
The following is a high‐level overview of your Vision coverage. For complete coverage details, please refer to the benefit summary.
Employees are encouraged to search for in-network providers by visiting the carrier website. Please reference page 3 for the web
address and click “Find an Eye Doctor” to get started.
Key Vision Benefits In-Network Coverage Copay Frequency
Well Vision Exam $10 copay Once every 12 months
Lined Single/Bifocal/Trifocal $25 copay
Lenses
Progressive Lenses $110-$135 copay Once every 12 months
Lenticular $25 copay
$130 allowance +20% off any
Frames $0 Once ever 24 months
amount over the allowance
Contact Lenses $130 allowance +15% $0
Once every 12 months
(instead of glasses) Standard contact lens exam Up to $55
Employee Assistance Program
Employee Connect Services (Employer Paid) In-person help for short-term issues (up to four sessions with a
Unlimited 24/7 assistance: You can access the following services counselor per person, per issue, per year)
anytime, online or with a toll-free call: In-person consultations with network lawyers, including one free
Information, resources, and referrals on family matters, such as 30-minute in-person consultation per legal issue, and subsequent
child and elder care; kennels and pet care; event and vacation meetings at a reduced fee
planning; moving and relocation; car buying; college planning;
and more Online Resources: Find a wide range of information and resources
Legal information and referrals for situations requiring expertise in that you can research and access on your own just by visiting
family law, estate planning, landlord/tenant relations, consumer www.GuidanceResources.com. (See Contact Page at the front of this
and civil law, and more guide.)
Guidance with financial matters, including household budgeting,
and short and long term planning When you call the toll free line 888-628-4824, you’ll talk to an experi-
enced professional who will provide counseling, work-life advice, and
In-Person guidance: referrals. All counselors hold master’s degrees, with broad-based
Some matters are best resolved by meeting with a professional in clinical skills and at least three years of experience in counseling on a
person. With EmployeeConnect, you get: variety of issues. For face-to-face meetings, you will be referred to a
fully credentialed, state-licensed clinician. 7Basic Life / AD&D - Lincoln Financial
We help our eligible employees maintain financial security for their loved ones by providing a group life and accidental death and
dismemberment (AD&D) benefit. This benefit is provided at NO COST to you.
Employee Life and AD&D
Employee Employee Navigator will indicate the amount of coverage
Spouse Coverage $10,000
Dependent Children
$3,500
15 days old to age 19, or to age 23 if FT student
Benefit Reduction Schedule
Age: Percentage:
65 Reduce by 35% of original amount
70 Reduce an addi onal 25% of the original amount
75 Reduce an addi onal 15% of the original amount
Voluntary Life / AD&D - Lincoln Financial
If you determine you need more than the Company-paid Basic Life/AD&D coverage, you may purchase additional coverage for yourself and
your eligible family members.
Benefit Option Guarantee Issue*
In increments of $10,000 up to lesser of 5 times your
Employee $100,000
annual salary or $500,000
In increments of $5,000 to a maximum of $250,000
Spouse $10,000
not to exceed 50% of employee elected amount
Child(ren)
Age 14 days to 6 months: $250 $10,000
Age 19 or age 25 if a full
time student: $10,000
*Only during your new hire eligibility period, can you purchase coverage up to the Guarantee Issue amounts without having to provide
Evidence of Insurability (information about your health). Coverage amounts that require Evidence of Insurability (EOI) will not be effective
unless approved by the insurance carrier.
At each subsequent open enrollment period an employee may purchase one or two $10,000 increments up to the Guarantee Issue amount
on themselves; and one or two $5,000 increments up to the Guarantee Issue amount on their spouse without having to provide EOI.
Age Reduction: 35% at age 65; additional 15% at age 70, additional 15% at age 75; additional 15% at age 80. Spouse’s benefits also reduce
with employee’s age and terminate when employee reaches age 70.
Rates are based on employee and spouse’s age and the rates will increase as their ages increase.
Short Term Disability - Lincoln Financial
RepcoLite Paints, Inc. provides all full-time, active employees with Short Term Disability insurance, and pays the full cost of this coverage.
This benefit is for certain circumstances such as childbirth, surgery, and other types of non-work related injuries or illnesses, as confirmed
by medical documentation, which prevent an employee from performing their regular duties.
Short Term Disability Benefit
Benefit Percentage 66.67%
Weekly Benefit Maximum Up to $400
When Benefits Begin 1st day accident / 8th day illness
Maximum Benefit Duration 26 weeks
8Clothing & Shoe Allowance Policy
RepcoLite Paints, Inc. will reimburse all employees up to $100 per calendar year for work clothing including shirts and pants.
Employees not working in Manufacturing/Production, Warehouse, or Delivery, may be reimbursed for regular shoes within the
$100 annual clothing allowance. For all employees working in Manufacturing/Production, Warehouse, and Delivery, RepcoLite
Paints will reimburse an additional $150 per calendar year for safety shoes that meet ANSI minimum standards F2413-11 and
F2412-11.
Cost of Benefits
Your contributions toward the cost of benefits are automatically deducted from your pay check before taxes. The
amount will depend upon the plan you select and if you choose to cover eligible family members.
Medical
Employee Cost (Weekly)
Traditional HDHP/HSA
Single $30.00 $30.00
Double $71.00 $71.00
Family $90.00 $90.00
Voluntary Vision
Employee Cost (Weekly)
Single $1.80
EE + Spouse $3.41
EE + Child(ren) $3.59
Family $5.28
Please see Employee Navigator for cost of Voluntary Life for you and your family.
This is a brief summary of benefits prepared by HUB International Midwest, the employee benefits insurance broker for your employer.
This is not a certificate of coverage. For full coverage provisions, including a description of waiting periods, limitations and exclusions
refer to the benefit plan documents and contracts. If there is a conflict between this summary and the official plan documents, the
actual plan document will govern in all cases. 9You can also read
