NATIONAL ALLIED WORKERS UNION INSURANCE TRUST FUND PREMIUM PPO PLAN DOCUMENT

Transcription

1 NATIONAL ALLIED WORKERS UNION INSURANCE TRUST FUND PREMIUM PPO PLAN DOCUMENT & SUMMARY PLAN DESCRIPTION Effective April 1, 2011 Plan II

2 1. APPLICATION AND ENROLLMENT IMPORTANT HIGHLIGHTS In order to become covered under the Plan, each Employee must complete and deliver an application approved by the Plan. The application may require you to disclose information about yourself and your dependents. Your coverage under the Plan is contingent upon providing honest and complete information in the application, and thus, your benefits under the Plan may be denied if they relate to information that you dishonestly or incompletely reported on the application. 2. MANDATORY PRE-CERTIFICATION YOU MUST OBTAIN PRE-CERTIFICATION FOR HOSPITAL ADMISSIONS AND OTHER SPECIFIED SERVICES. Refer to page 27 of this Summary Plan Description for more information. 3. YOU MUST NOTIFY THE THIRD PARTY ADMINISTRATOR WHEN ONE OF THE FOLLOWING EVENTS OCCUR. Birth of child. Your covered child turns age 26. Your covered child who is age 19 or older but under age 26, becomes eligible for other employer-provided health coverage. Divorce or marriage. Adoption of child. Failure to notify the Third Party Administrator of these events could result in loss of eligibility and claims being denied. 4. YOU MUST BE SURE NETWORK PROVIDERS HAVE CURRENT BILLING INSTRUC- TIONS PROVIDED ON YOUR IDENTIFICATION CARD. FAILURE TO SUBMIT CLAIMS PROPERLY WILL RESULT IN DELAYED CLAIMS PROCESSING. 5. BILLS SHOULD BE SUBMITTED FOR PAYMENT IN A TIMELY BASIS. Claims filed more than 12 months after the date of service will not be eligible for payment. 6. NOTICE OF GRANDFATHERED PLAN STATUS. The Board of Trustees of the National Allied Workers Union Local 831 Insurance Trust believes that the Plan is a grandfathered health plan under the Patient Protection and Affordable Care Act (the Affordable Care Act). Being a grandfathered health plan means that your plan does not include certain consumer protections of the Affordable Care Act. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the Plan Administrator at the address listed in the section of the Plan entitled Information About the Plan. You may also contact the U.S. Department of Health and Human Services at

3 TABL E OF CONT E NT S INTRODUCTION... 1 SCHEDULE OF BENEFITS... 2 ELIGIBILITY PROVISIONS... 5 EMPLOYEES... 5 DEPENDENTS... 5 FUNDING... 7 Contribution Determinations... 7 Employee Obligations... 7 Employer Obligations... 7 ENROLLMENT... 7 Special Enrollment Period Based on Loss of Other Coverage... 7 Dependent Special Enrollment Period... 8 Children s Health Insurance Program Reauthorization Act Special Enrollment Period... 8 OPEN ENROLLMENT PERIOD... 9 EFFECTIVE DATE... 9 Effective Date of Employee Coverage... 9 Effective Date of Dependent Coverage... 9 FAMILY AND MEDICAL LEAVE ACT... 9 IF YOU LEAVE FOR MILITARY SERVICE... 9 COVERAGE FOR EMPLOYEES AND DEPENDENTS OVER THE AGE OF TERMINATION OF BENEFITS Coverage for an Employee will terminate on the earliest of the following dates: Coverage for a Dependent will terminate on the earliest of the following dates: Loss of Eligibility Due to Fraud Certificates of Creditable Coverage CONTINUATION OF COVERAGE (COBRA) WHAT IS COBRA CONTINUATION COVERAGE? WHO IS ENTITLED TO ELECT COBRA? WHEN IS COBRA COVERAGE AVAILABLE? YOU MUST GIVE NOTICE OF SOME QUALIFYING EVENTS AND MAXIMUM COVERAGE PERIODS ELECTING COBRA CONTINUATION COVERAGE Newborns and Adopted Children Special considerations in deciding whether to elect COBRA Special second election period under the Trade Act for certain eligible employees who did not elect COBRA TERMINATION OF COBRA COVERAGE HOW MUCH DOES COBRA CONTINUATION COVERAGE COST? WHEN AND HOW MUST PAYMENT FOR COBRA CONTINUATION COVERAGE BE MADE? First payment for COBRA continuation coverage Monthly payments for COBRA continuation coverage Grace periods for monthly payments HOW LONG DOES COBRA CONTINUATION COVERAGE LAST? Disability extension of 18-month period of continuation coverage Second qualifying event extension of COBRA continuation coverage i

4 IF YOU HAVE QUESTIONS Keep Your Plan Informed of Address Changes/Keep Copies of Notices MEDICAL EXPENSE BENEFIT PROVISIONS DEDUCTIBLE OUT-OF-POCKET MAXIMUM ANNUAL MAXIMUM ON ESSENTIAL HEALTH BENEFITS UTILIZATION REVIEW (UR) PROGRAM Pre-Certification Requirements Large Case Management Alternative Care COVERED MEDICAL EXPENSES MEDICAL EXCLUSIONS AND LIMITATIONS OTHER BENEFIT LIMITATIONS PRE-EXISTING CONDITION LIMITATION Prior Creditable Coverage COORDINATION OF BENEFITS PROVISION SUBROGATION, REIMBURSEMENT & THIRD PARTY RECOVERY Action Required of Claimant CLAIM FORMS AND CLAIM FILING IN-NETWORK (PPO) CLAIMS PROCEDURE NON-NETWORK CLAIMS PROCEDURE CLAIM PROCEDURES CLAIM PROCESSING Authorized Representatives Notice to Claimant of Adverse Benefit Determinations APPEALS EXHAUSTION OF ADMINISTRATIVE REMEDIES LIMITATION ON LAWSUITS CHOICE OF LAW/VENUE RIGHT TO RECEIVE AND RELEASE NEEDED INFORMATION DEFINED TERMS GENERAL PROVISIONS YOUR RIGHTS UNDER ERISA RECEIVE INFORMATION ABOUT YOUR PLAN AND BENEFITS CONTINUE GROUP HEALTH PLAN COVERAGE PRUDENT ACTIONS BY PLAN FIDUCIARIES ENFORCE YOUR RIGHTS ASSISTANCE WITH YOUR QUESTIONS HOW TO READ OR GET PLAN MATERIAL INFORMATION ABOUT THE PLAN ii

5 INTRODUCTION This Plan Document and Summary Plan Description describes the medical benefits in effect as of April 1, 2011 that are available to members of a collective bargaining unit under an agreement with the National Allied Workers Union Local 831 who become eligible to participate in the Plan. This document describes the rights and benefits provided for participants under the Plan. Contact the Third Party Administrator or the Claims Administrator if there are any questions concerning coverage. When you become a participant, you will be given information about how to find Providers that participate in the Plan s Preferred Provider Organization (PPO), through the PPO website or the PPO 800-number. It is your responsibility to confirm with the medical provider and/or facility that he/she/it continues to participate in the PPO. A telephone number is provided on the back of your Identification Card to contact the network to assist you with locating providers in your area. If you use the services of network providers, the Plan will provide higher levels of benefits to you. Also, the participating hospitals and physicians of the network have agreed to extend a discount to those participants that utilize their facilities. Stated another way, PPO providers may not charge you more than the negotiated or network rate and must discount their services to this rate. When your claims for hospital services are processed, you will see the amount of the discount on the Explanation of Benefits (EOB). This, of course, helps reduce your liability for the cost of the services. It s your decision whether to use a PPO or non-ppo Provider. You always have the final say about the Providers you and your family use. The fact that certain Providers are PPO Providers should not be construed as a recommendation, referral or any other statement as to the ability or quality of such Providers. The Plan bears no liability for any act or omission of such Providers. Conversely, the fact that certain Providers are non-ppo Providers should not be construed as a statement, negative or positive, as to the skill or quality of such Providers. 1

6 SCHEDULE OF BENEFITS MEDICAL BENEFITS PPO NON-PPO Annual Maximum for Essential Health Benefits Deductible per calendar year per person - does not apply to charges with fixed co-pays unless stated otherwise Plan Payment Percentage unless a different percentage is shown in the Special Benefits and Limitations section below Out-of-Pocket Maximum per person - Deductibles, fixed co-pays and penalty reductions for failure to pre-certify do not apply, nor do charges for mental health, substance abuse, PPO urgent care facilities, and PPO emergency rooms. Penalty for Failure to Pre-Certify Hospital Admissions and Other Specified Services ALL COVERED SERVICES $2,000,000 per person Benefits determined to be non-essential will not count toward the $2,000,000 annual limit. $300 $1,500 80% (participant pays 20%) 70% (participant pays 30%) $6,000 $9,000 50% reduction in expenses covered by the Plan; regular fixed co-pays, deductibles and Plan payment percentages apply to remaining 50% BENEFITS AND LIMITATIONS BY TYPE OF PROVIDER Deductible applies unless stated otherwise HOSPITALS AND MEDICAL CARE FACILITIES Hospital Services (facility charges only, does not include professional fees) Inpatient services, including semi-private room and ICU Outpatient surgical services, including charges for surgery and anesthesia Emergency Room Services (facility charge only, does not include professional fees) Skilled Nursing Facility Services Urgent Care Facility (facility charge only, does not include professional fees) Diagnostic testing facilities (outpatient hospital or independent facility) $800 co-pay per confinement, Plan pays 100% of balance Pre-certification required $500 co-pay Plan pays 100% of balance Pre-certification required $200 co-pay Plan pays 100% of balance $100 co-pay Plan pays 100% of balance $1,600 co-pay per confinement, Plan pays 70% of balance Pre-certification required $750 co-pay Plan pays 70% of balance Pre-certification required $200 co-pay Plan pays 70% of balance not covered $100 co-pay Plan pays 70% of balance X-ray, lab, other than MRIs and CT scans 80% 70% MRIs 100% 70% Limited to 6 annually Pre-certification required CAT/CT scans 100% 70% Limited to 3 annually Pre-certification required 2

7 MEDICAL BENEFITS PPO NON-PPO PROFESSIONAL SERVICES (PHYSICIANS AND THERAPISTS) Physician Services Hospital visits 80% Pre-certification required for hospitalization Office visits with primary care Physician (not including labs & x-rays) Specialist office visits (not including labs & x-rays) Allergy testing Allergy treatment $25 co-pay per visit Plan pays 100% of balance $40 co-pay per visit Plan pays 100% of balance $25 co-pay per visit Plan pays 100% of balance $25 co-pay per visit Plan pays 100% of balance 70% Pre-certification required for hospitalization $40 co-pay per visit Plan pays 70% of balance $55 co-pay per visit Plan pays 70% of balance $40 co-pay per visit Plan pays 70% of balance $40 co-pay per visit Plan pays 70% of balance Lab and x-ray, in-office expenses 80% 70% Minor surgery in office 80% 70% Chiropractic Services Podiatry Services Rehabilitation Therapy (outpatient) Occupational Therapy Physical Therapy Speech Therapy Speech Testing not covered not covered $40 co-pay per visit $55 co-pay per visit Plan pays 100% of balance Plan pays 70% of balance Maximum 10 visits per calendar year $40 co-pay per visit $55 co-pay per visit Plan pays 100% of balance Plan pays 70% of balance Maximum 20 visits per calendar year $40 co-pay per visit $55 co-pay per visit Plan pays 100% of balance Plan pays 70% of balance Maximum 10 visits per calendar year $40 co-pay per visit Plan pays 100% of balance $55 co-pay per visit Plan pays 70% of balance Radiation Therapy 80% 70% Chemotherapy 80% 70% OTHER MEDICAL PROVIDERS Ambulance Services Local ground transportation 80% (no deductible) 70% (no deductible) Air ambulance not covered Durable Medical Equipment 80% 70% Home Health Care 80% 70% Hospice Care Maximum 40 visits per calendar year not covered BENEFITS AND LIMITATIONS APPLICABLE TO TYPE OF TREATMENT Deductible applies unless stated otherwise 3

8 MEDICAL BENEFITS PPO NON-PPO Wellness Care (90-day waiting period -- no wellness benefits are payable until 90 days after your effective date) Well-baby/child care (under age 18) Office visits $25 co-pay per visit Plan pays 100% of balance (no deductible) $40 co-pay per visit Plan pays 70% of balance (no deductible) Immunizations, labs and x-rays 80% (no deductible) 70% (no deductible) Well adult care (age 18+) Office visits age 18+ Mammograms Routine tests, including pap, PSA, and other tests that are part of routine physical Immunizations, including flu shots Maternity Care - pre- and post-natal, hospital services for mother and child, Birthing Center and premature births Mental Health and Substance Abuse Inpatient Services Outpatient Services $25 co-pay per visit Plan pays 100% of balance (no deductible) $25 co-pay Plan pays 80% of balance (no deductible) $40 co-pay per visit Plan pays 70% of balance (no deductible) $40 co-pay Plan pays 70% of balance (no deductible) 80% (no deductible) 70% (no deductible) $800 co-pay Plan pays 80% of balance not covered $1,600 co-pay Plan pays 70% of balance not covered $25 co-pay per visit $50 co-pay per visit Plan pays 100% of balance Plan pays 70% of balance Maximum 20 visits per calendar year Sleep Apnea not covered HIV/STD Treatment 80% 70% PRESCRIPTION DRUG BENEFITS DENTAL BENEFITS VISION BENEFITS Discounts provided through a separate discount program Discounts provided through a separate discount program Discounts provided through a separate discount program 4

9 ELIGIBILITY PROVISIONS EMPLOYEES You are an Eligible Employee if you are an active, full-time Employee belonging to a class of employees covered under this Plan pursuant to a collective bargaining agreement between an Employer and National Allied Workers Union Local 831 (the Union ) or an active, full-time Employee of the Union. Your effective date of coverage is the first day of the month following your date of hire subject to any waiting periods under the applicable collective bargaining agreement. Full-time employment means regularly working at least the number of hours in the normal work week set by your Employer, but not less than 30 hours per week, at the Employer s place of business or at a location established by your Employer. Notwithstanding anything herein to the contrary, a seasonal employee may be afforded a short extension of eligibility during periods when he or she is not working full-time if so required under the terms of the applicable collective bargaining agreement. If you have any questions regarding eligibility, enrollment, contributions or termination of benefits, please contact the Third Party Administrator. DEPENDENTS If you are an Eligible Employee covered by the Plan, your eligible dependents are: 1. Your lawful spouse. Lawful spouse means the person recognized as your husband or wife under a legally existing marriage under the laws of the state where the Eligible Employee lives. You are required to submit documentation proving a legal marital relationship. 2. Your child(ren) who is: under the age of 26, and either your child, legally adopted child, step-child, child legally placed for adoption, Foster Child, or a child for whom you or your spouse is the Legal Guardian as documented by appointment from a court of competent jurisdiction. Children age 19 or older who are eligible for other employer-provided health coverage (i.e., either through their own employer s group health plan or their spouse s employer s group health plan) are not eligible for coverage under the Plan. 3. A child age 26 or older who is totally disabled, incapable of self-sustaining employment by reason of mental or physical handicap, receives over one-half of his/her support and maintenance from you, unmarried and covered under the Plan at the date he/she attains age 26. You may be required, at reasonable intervals during the two years following the dependent s 5

10 reaching the limiting age, to submit subsequent proof of the child s total disability and dependency. After such two-year period, you may be required to submit subsequent proof not more than once each year. The Plan Administrator reserves the right to have such dependent examined by a physician of the Plan Administrator s choice, at the Plan s expense, to determine the existence of such incapacity. In order to continue coverage, you must furnish written proof within 30 days of the child s 26th birthday. For purposes of this section, total disability means the inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months. 4. Alternate recipients under qualified medical child support orders (QMCSOs) who are required to be covered according to the provisions of ERISA Section 609. Any child of a participant who is an alternate recipient under a qualified medical child support order shall be considered as having a right to dependent coverage under this Plan with no pre-existing conditions provision applied, provided the employee is an eligible employee and is covered. Under a QMCSO, the fact that the child is eligible for, is entitled to, or is provided benefits under Title XIX of the Social Security Act will not affect the child or children s receipt of benefits under the QMCSO. A qualified medical child support order (QMCSO) is a national medical support notice, or a medical child support order issued by a court which has jurisdiction under state law requiring a non-custodial parent to provide medical coverage for his or her children that specifies the individuals involved, the type of coverage to be provided and the plan that provides the coverage, which meets the other requirements of ERISA Section 609 to be a QMCSO. You may receive from the Plan, without charge, a copy of the Plan s QMCSO procedures. Please contact the Third Party Administrator for more information. These persons are excluded as dependents: any spouse who is on active duty in any military service of any country, or any person who is covered under the Plan as an Employee. The phrase legally placed for adoption refers to the placement of a child whom the Employee intends to adopt, whether or not the adoption has become final, who has not attained the age of 18 as of the date of such placement for adoption. The phrase refers to the assumption and retention by such Employee of legal obligation for total or partial support of the child in anticipation of adoption of the child. The child must be available for adoption and the legal process must have commenced. For purposes of this section, other employer-provided health coverage pertains to group health insurance available to an eligible child and provided through an employer-sponsored health plan other than a parent s group health plan. This other employer provided health coverage exception does not apply for Plan Years beginning on or after April 1, You will be asked to certify as to whether your dependent children have access to other employer-provided health insurance, and the Fund will have the right to verify such information. If your dependent children currently do not have access to other employer-provided health insurance, but later gain such access, you are obligated to notify the Plan Administrator of any such change within thirty days. 6

11 If a person covered under the Plan changes status from employee to dependent or dependent to employee, and the person is covered continuously under this Plan before, during and after the change in status, credit will be given for deductibles and all amounts applied to maximums. If your dependent should lose his or her dependent status, you must notify the Plan within 60 days of the loss of such dependent status. FUNDING C ontr ibution Deter minations The Plan Sponsor may, from time to time, evaluate the costs of the Plan and determine the amount to be contributed by the Employer and the amount to be contributed (if any) by you. E mployee Obligations Your coverage will be at least partially funded by the Employer but you may be required to make an employee contribution. If you elect to enroll dependents under the Plan, you may be responsible for payment of all or a portion of the dependent contributions suitable to cover such enrollment. Your Employer will deduct such costs on a regular basis from your wages or salary. E mployer Obligations The Employer will make contributions to the Plan towards the cost of health care coverage of employees and may contribute to the cost of dependent coverage. If your Employer fails to make the contribution required by the collective bargaining agreement for you, coverage for you and your eligible dependents will end effective as of the last day of the month for which Employer contributions have been received. E NR OL L ME NT You may obtain coverage for you and your eligible dependents by completing the enrollment form and contributing any amounts required by the collective bargaining agreement. If a husband and wife are Employees, they may both be covered as Employees, but any eligible children may be covered as dependents of one parent but not both. Special E nrollment Period B ased on L oss of O ther C over age Those individuals who do not enroll in the Plan at the first opportunity and subsequently lose coverage may enroll in the Plan in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Enrollment Date for anyone who enrolls under a special enrollment period is the first date of coverage. Thus, the time between the date a special enrollee first becomes eligible for enrollment under the Plan and the first day of coverage is not treated as a waiting period. You must request enrollment within 30 days after the other coverage ends (or after the Employer stops contributing toward the other coverage). 7

12 You are allowed to enroll under the special enrollment rules if: You (or your dependent) had been covered under another group health plan or had an individual health policy at the time coverage was initially offered. You stated at the time initial enrollment was offered under this Plan that other coverage was the reason for declining enrollment in the Plan. You lost coverage as a result of the loss of eligibility, expiration of COBRA continuation coverage, termination of employment, reduction in the number of hours of employment, or termination of Employer contributions towards such coverage. If you or your dependent lost the other coverage as a result of the failure to pay premiums or required contributions or for cause (such as making a fraudulent claim), then you do not have a special enrollment right. Dependent Special E nr ollment Per iod Since the Plan provides dependent coverage and a person becomes a dependent through marriage, birth or adoption, the Plan provides a dependent special enrollment period of not less than 30 days. If an individual seeks to enroll a dependent during the first 30 days, coverage must become effective: In the case of marriage, no later than the first day of the first month beginning after the date the request was completed. In the case of a dependent s birth, the date of birth. In the case of adoption or placement for adoption, the date of adoption or placement of adoption. A newborn child automatically will be covered for the first 30 days immediately following birth. The child s coverage will end 30 days after birth if the Plan does not receive an application from you to add the baby to your coverage and the appropriate payment (if any). If you agree to contribute any required amounts and complete an enrollment form within the initial 30-day period, coverage for the child will continue. C hildren s H ealth I nsur ance Progr am R eauthor ization Act Special E nrollment Period Effective April 1, 2009, if you or your dependent experience (1) a loss of eligibility for Medicaid or a state children s health insurance program (SCHIP), or (2) become eligible to participate in a premium assistance program under Medicaid or a SCHIP, you and/or your dependent will be entitled to receive coverage under the Plan. You must request such enrollment within 60 days of the loss of such eligibility or becoming eligible for such premium assistance. If you or your dependent lost the other eligibility for cause (such as making a fraudulent claim), then you do not have a special enrollment right. 8

13 OPEN ENROLLMENT PERIOD Each year during the annual open enrollment period, you and your dependents who are Late Enrollees will be able to enroll in the Plan. Also during this time you will be eligible to change some of your benefit decisions based on which benefits and coverage are right for you. Benefit choices made during the open enrollment period will become effective at the beginning of the Plan year and remain in effect until the next open enrollment period, unless there is a change in family status during the year or loss of coverage due to loss of a spouse employment. You will receive detailed information regarding open enrollment from the Third Party Administrator. EFFECTIVE DAT E E ffective Date of E mployee C over age You will be covered under this Plan as of the first day that you satisfy all of the eligibility requirements, Waiting Period and enrollment requirements. You may be subject to a Pre-Existing Condition limitation as explained on page 42. E ffective Date of Dependent C over age A dependent s coverage will take effect on the day that the eligibility requirements are met, the Employee is covered under the Plan, and all enrollment requirements are met. Dependents may be subject to the Plan s Pre-Existing Condition limitation only as explained on page 42. FAMILY AND MEDICAL LEAV E A C T Health coverage benefits (including medical coverage and discounted prescription drug, dental and vision coverage) during your approved leave of absence under the Family and Medical Leave Act ( FMLA ) (as determined by your Employer), will continue as long as you pay any required contributions. If you do not return to work at the end of an approved leave, you may be required to reimburse the Employer the difference between any required contributions and total monthly premium. If you have any questions concerning your rights under the FMLA, or your Employer s responsibilities under the FMLA, please contact the Third Party Administrator. IF YOU LEAVE FOR MILITARY SERVICE The Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) established requirements that employers must meet for certain employees who are called into military service (active duty or inactive duty training). In addition to the rights that you have under COBRA (described in the Continuation Of Coverage section), you are entitled under USERRA to continue the health coverage that you (and your covered dependents, if any) had under the Plan as long as you make any required self-payment. If your Employer is required to make a contribution for the month in which you are called into military service, your period of self-payment will begin on the first day of the following month. You may continue your coverage by making any required self-payments for up to 24 months under USERRA. 9

14 Your rights under COBRA and USERRA are similar but not identical. Any election that you make pursuant to COBRA also will be an election under USERRA, and COBRA and USERRA both will apply with respect to the continuation coverage elected. If COBRA and USERRA give you (or your covered spouse or dependent children) different rights or protections, the law that provides the greater benefit will apply. COBRA and USERRA coverage are concurrent. This means that COBRA coverage and USERRA coverage begin at the same time. However, COBRA coverage usually continues for up to 18 months in the case of a leave of absence (it may continue for a longer period and is subject to early termination, as described in the Continuation of Coverage section). In contrast, USERRA coverage can continue for up to 24 months. Your coverage under USERRA will continue until the earliest of the following: the date you or your dependents do not make the required self-payments; the date you lose your rights under USERRA as a result of a dishonorable discharge or other conduct specified in USERRA; the date you reinstate your eligibility for coverage under the Plan as an active employee; the end of the period during which you are eligible to return to work or apply for reemployment following the completion of your service in the uniformed services in accordance with USERRA when you do not actually return to work or apply for reemployment as required; the last day of the month after 24 consecutive months; the date the Fund no longer provides any group health benefits; or the date you become covered under another group health plan. You need to notify the Third Party Administrator in writing when you enter the military. For more information about continuing coverage under USERRA, contact the Plan Administrator. If you do not continue coverage under USERRA, your coverage will end immediately when you enter active military service. Your dependents still may have the opportunity to elect COBRA continuation coverage as described in the Continuation Of Coverage section. When you are discharged or released from military service and return to work for an Employer, you will be eligible for benefits under the Plan as of the date you return to employment. COVERAGE FOR EMPL OYEES AND DEPENDENTS OVER THE AGE OF 65 If you, as a regularly scheduled and Eligible Employee, or your covered spouse are beyond age 65, and you choose to remain covered under the Plan, this Plan will be the secondary payer of benefits and Medicare will be the primary payer. Upon becoming eligible for age-based Medicare coverage, you must enroll immediately in Medicare Parts A and B. Thereafter, you may submit any unpaid portion of your medical bills to this Plan. Even if you fail to enroll in Medicare on a timely basis when first eligible to do so, the Plan will pay as if Medicare coverage were in effect. If you choose to drop 10

15 coverage under the Plan, Medicare will be your primary plan, and you will have no secondary coverage. T E R MINAT ION OF BE NE FITS C over age for an E mployee will terminate on the earliest of the following dates: The date of the termination of the Plan, or the date your Employer terminates its participation in the Plan; The last day of the month in which you cease to be an Employee regularly scheduled to work full-time, except if you are on an approved leave allowing an extension of benefits under the Plan during such leave, a seasonal employee on a temporary layoff of no longer than four months, and/or leave under Family and Medical Leave Act (FMLA), your coverage may continue up to any limit imposed by the Plan or required by law; The last day of the month you are no longer a member of the eligible class of employees; The date of your entry into the military service of any country or international organization on a full-time active duty basis other than scheduled drill or other training not exceeding one month in any calendar year; The date determined by the Fund if you commit an act of fraud or a material misrepresentation with respect to Plan benefits or coverage, in which case coverage may be terminated retroactively; The end of the period for which the required contribution has been paid if the charge for the next period is not paid when due; or The last day of an approved leave of absence under the FMLA, if you do not return to work. C over age for a Dependent will ter minate on the earliest of the following dates: The last day of the month that dependent ceases to meet the definition of a dependent as defined in the Plan; The last day of the month the Employee s coverage is terminated; the date determined by the Fund if there is an act of fraud or a material misrepresentation with respect to Plan benefits or coverage, in which case coverage may be terminated retroactively; The end of the period for which the required contribution has been paid if the charge for the next period is not paid when due; or 11

16 The date the Plan is changed to end coverage for a class to which the dependent belongs. The Plan will not rescind coverage on a retroactive basis with respect to medical benefits. However, the Plan will retroactively terminate coverage of either active employees or retirees and their dependents if benefits were provided due to fraud or intentional misrepresentation of material fact. You will receive 30 days advance notice if your coverage will be retroactively terminated. Neither termination of coverage due to the failure to pay a premium nor termination of coverage due to fraud or misrepresentation is considered a rescission. L oss of E ligibility Due to Fraud A failure to complete any enrollment forms or questionnaires accurately, completely and honestly, may result in a denial of benefits or a termination of coverage under the Plan with respect to all covered family members. Likewise, any attempt otherwise to defraud or mislead the Plan about the eligibility of yourself or your dependents, may cause you and your covered family members to become ineligible for benefits effectively immediately. Coverage under this Plan is expressly non-assignable and nontransferable and will be forfeited if you attempt to assign or transfer coverage or aid or attempt to aid any other person in fraudulently obtaining coverage. C er tificates of Creditable C over age When you or a dependent are no longer eligible for coverage, you will receive a certificate of coverage from the Plan. Certificates of creditable coverage will be issued within the time periods specified in federal regulations following loss of coverage in compliance with the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This certificate provides evidence of your prior health care coverage. You may need to furnish this certificate if you become eligible under another group health plan that excludes coverage for pre-existing conditions. You may also need this certificate in order to buy an individual insurance policy with a pre-existing condition exclusion or limitation. If your (or your dependent s) coverage terminates, the Plan will automatically send a certificate of coverage to your (or your dependent s) last known address. If you do not receive a certificate because of a change of address, or because the Plan was not notified that a dependent s coverage has terminated, or if you would like a certificate for any other reason, you have the right to request one just contact the Third Party Administrator. You may request a certificate of coverage any time within 24 months of when you were last covered under the Plan. NOTE: For purposes of electing continuation coverage under COBRA, it is your responsibility to notify the Third Party Administrator in writing within 60 days of you or your dependent experiencing a qualifying event which results in a loss of coverage under the Plan (see Continuation of Coverage (COBRA) section that follows). Failure to notify the Third Party Administrator will result in coverage being terminated as of the original date of the occurrence without entitlement to COBRA. Any claims paid after that date must be reimbursed to the Plan and the Plan reserves 12

17 the right to utilize all available means to collect such monies, including offset against any future benefits. 13

18 CONTINUATION OF COVERAGE (COBRA) The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 ( COBRA ). COBRA continuation coverage is a temporary extension of group health coverage under the Plan under certain circumstances when coverage would otherwise end. Under federal law, COBRA would apply to this Plan only if at least one Employer had 20 or more employees. The Fund believes that all Employers have under 20 employees, and, consequently, that COBRA does not apply. Nevertheless, the Fund has elected to voluntarily extend COBRA-like coverage on the same basis as if COBRA applied. Of course, because the Fund is not legally obligated to do so, this policy might be changed at any time. This section generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. COBRA (and the description of COBRA continuation coverage contained here) applies only to the group health benefits offered under the Plan and not to any other benefits that may be offered under the Plan or another plan in which you participate (such as life insurance, disability benefits, or accidental death or dismemberment benefits). COBRA continuation coverage can become available to you when you would otherwise lose your group health coverage under the Plan. It also can become available to your spouse and dependent children who are covered under the Plan when they would otherwise lose their group health coverage. For additional information about your rights and obligations under the Plan, you should contact the Third Party Administrator. The Plan provides no greater COBRA rights than what the COBRA federal law itself would require if it applied, and nothing in this notice is intended to expand your rights beyond COBRA s requirements. WHAT IS COBRA CONTINUATION COVERAGE? COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a qualifying event. Specific qualifying events are listed later in this section. After a qualifying event occurs and any required notice of that event properly is provided to the Third Party Administrator, COBRA continuation coverage must be offered to each person losing coverage who is a qualified beneficiary. You and your dependents could become qualified beneficiaries and be entitled to elect COBRA if coverage under the Plan is lost because of the qualifying event. (Certain newborns, newly adopted children, and alternate recipients under qualified medical child support orders also may be qualified beneficiaries with the same rights as all other qualified beneficiaries.) Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay the entire cost of the COBRA continuation coverage plus an administrative fee. COBRA continuation coverage is the same coverage that the Plan gives to other similarly situated persons under the Plan who are not receiving continuation coverage. This means, for example, that if the Plan changes benefits for active employees or their family members, your COBRA coverage will change accordingly. Each qualified beneficiary who elects COBRA continuation coverage will have the same rights under the Plan as other persons covered under the Plan. 14

19 WHO IS ENTITL ED TO ELECT COBRA? Employee. If you are an Employee of a Employer, you will be entitled to elect COBRA if you lose your group health coverage under the Plan because either one of the following qualifying events happens: Your hours of employment are reduced, or Your employment ends for any reason other than your gross misconduct. Spouse. If you are the spouse of an Employee of a Employer, you will be entitled to elect COBRA if you lose your group health coverage under the Plan because any of the following qualifying events happens: Your spouse s hours of employment are reduced; Your spouse s employment ends for any reason other than his or her gross misconduct; Your spouse dies; Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both);3 or You become divorced or legally separated from your spouse. (Also, if the employee reduces or eliminates a spouse s group health coverage in anticipation of a divorce or legal separation, and a divorce or legal separation occurs, the divorce or legal separation may be considered a qualifying event for the employee s spouse though the coverage was reduced or eliminated before the divorce or separation.) Dependents. Your children who are dependents (as defined by the Plan) will be entitled to elect COBRA if they lose group health coverage under the Plan because any of the following qualifying events happens: The parent-employee s hours of employment are reduced; The parent-employee s employment ends for any reason other than his or her gross misconduct; The parent-employee dies; The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both) (applicable only to retiree coverage); The parents become divorced or legally separated; or The child stops being eligible for coverage under the Plan as a dependent as defined by the Plan. 15

20 You do not have to show that you are insurable to elect COBRA continuation coverage. However, COBRA coverage is provided subject to your eligibility for such coverage. In particular, you must have been both eligible for coverage and actually covered by the Plan on the day prior to the date of the qualifying event. The Plan Administrator reserves the right to terminate your COBRA coverage retroactively if you are determined to have been ineligible. WHEN IS COBRA COVERAGE AVAILABLE? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Third Party Administrator has been notified that a qualifying event has occurred. When the qualifying event is the end of employment or reduction of hours of employment, death of the employee, or the employee s becoming entitled to Medicare benefits (under Part A, Part B, or both; applicable only to retiree coverage), the Employer must notify the Plan Administrator of the qualifying event. However, because Employers contributing to multi-employer funds may not be aware of all qualifying events, the Third Party Administrator also may rely on its records for determining whether eligibility is lost under certain circumstances. Y OU MUST GIVE NOTICE OF SOME QUAL IFYING EVENTS AND MAXIMUM COVERAGE PE R IODS For the other qualifying events (divorce or legal separation of the employee and spouse or a dependent child s losing eligibility for coverage as a dependent child), you will not be entitled to COBRA unless you notify the Plan Administrator in writing within 60 days after the later of (i) the date of the qualifying event, and (ii) the date on which the qualified beneficiary would lose coverage under the terms of the Plan as result of the qualifying event. The notice must be mailed or hand-delivered. Oral notice, including notice by telephone, is not acceptable. If mailed, the notice must be postmarked no later than the deadline. If hand-delivered, the notice must be received no later than the deadline. Notice sent via facsimile is also acceptable, but notice that is sent via is not. The notice may be provided by the covered employee, another qualified beneficiary who would lose coverage as a result of the event, or a representative acting on behalf of either one. The notice must contain the Plan name, the name of the Employer, the employee s name, address, birth date, and social security (or other identification) number, the name and address of any impacted spouse or dependent, a description of the qualifying event, the date of the event, and adequate documentation of the event (such as divorce decree or decree of legal separation, a copy of the dependent s birth certificate, or a transcript showing the last date of the dependent s enrollment in an educational institution, as applicable). If you provide a written notice that does not contain all of the information and documentation required, such a notice will nevertheless be considered timely if all of the following conditions are met: the notice is mailed or hand-delivered to the individual and address specified; the notice is provided by the deadline; 16

21 from the written notice provided, the Plan Administrator is able to determine that the notice relates to the Plan; from the written notice provided, the Plan Administrator is able to identify the covered employee and qualified beneficiary(ies), the qualifying event (the divorce, legal separation, or child s loss of dependent status), and the date on which the qualifying event occurred; and the notice is supplemented in writing with the additional information and documentation necessary to meet the Plan s requirements within 15 business days after a written or oral request from the Plan Administrator for more information (or, if later, by the deadline for this notice). If any of these conditions is not met, the incomplete notice will be rejected and COBRA will not be offered. If all of these conditions are met, the Plan Administrator will treat the notice as having been provided on the date that the Third Party Administrator receives all of the required information and documentation but will accept the notice as timely. E LECTING COBRA CONTINUATION COVERAGE Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees (and spouses if the spouse is a qualified beneficiary) may elect COBRA continuation coverage on behalf of all of the qualified beneficiaries, and parents may elect COBRA continuation coverage on behalf of their children. Any qualified beneficiary for whom COBRA is not elected within the 60-day election period described in the Plan s COBRA Election Notice will lose his or her right to elect COBRA continuation coverage. You may elect COBRA continuation coverage even if you are enrolled in Medicare or in another group health plan on or before the date on which COBRA is elected. However, as discussed below, your COBRA continuation coverage will terminate if you first become enrolled in Medicare or another group health plan (but only after you have exhausted or satisfied any applicable preexisting conditions exclusions under that other group health plan) after the date on which you elect COBRA. Your election must be provided to the Third Party Administrator via hand-delivery, U.S. Mail, or some form of express mail delivery. Newbor ns and A dopted C hildr en Under the Health Insurance Portability and Accountability Act of 1996 ( HIPAA ), if a child is born to the covered employee or placed for adoption with the covered employee during a period of COBRA coverage, that child will be eligible for COBRA coverage. In accordance with the terms of the Plan and the requirements of federal law, the newborn or child placed for adoption can be added to COBRA coverage and become a qualified beneficiary under COBRA upon proper notification to the Plan 17

22 Administrator within 30 days of the birth or adoption or during open enrollment (if the Plan offers open enrollment) and payment of any required additional premium. To be enrolled in the Plan, the child must satisfy the otherwise applicable Plan eligibility requirements (for example, regarding age). Special considerations in deciding whether to elect COBR A In considering whether to elect COBRA continuation coverage, you should take into account that a failure to continue your group health coverage will affect your future rights under federal law. First, you can lose the right to avoid having pre-existing condition exclusions applied to you by other group health plans if you have a 63-day gap or more in health coverage, and election of continuation coverage may help you to avoid such a gap. Second, you should take into account that you have special enrollment rights under federal law. You have the right to request special enrollment in another group health plan for which you are otherwise eligible (such as a plan sponsored by your spouse s employer) within 30 days after your group health coverage under the Plan ends because of the qualifying event indicated in this notice. You also will have the same special enrollment right at the end of continuation coverage if you get continuation coverage for the maximum time available to you. Special second election per iod under the T r ade A ct for cer tain eligible employees who did not elect C O B R A Under the Trade Act of 2002, special COBRA rights apply to certain employees and former employees who are eligible for federal trade adjustment assistance (TAA) or alternative trade adjustment assistance (ATAA). The process for determining individual eligibility for trade adjustment assistance begins when employees (or their representatives) petition the Department of Labor to recognize their Employer as being adversely affected by trade. Generally, an Employer may be found to be adversely affected by trade if the Employer meets the following criteria: Employees have been totally or partially laid off (a partial layoff means a reduction of hours and wages to 80% or less per week), Sales or production have declined due to trade, and Increased imports have contributed to employee layoffs. TERMINATION OF COBRA COVERAGE Eligible individuals are entitled to a second opportunity to elect COBRA for themselves and certain family members (if they did not already elect COBRA) during a special second election period. This special second election period lasts for 60 days or less. It is the 60-day period beginning on the first day of the month in which an eligible employee or former employee becomes eligible for TAA or ATAA, but only if the election is made within the six months immediately after the individual s group health plan coverage ended. If you are an employee or former employee and you qualify or may qualify for TAA or ATAA, promptly contact the Third Party Administrator after qualifying for TAA or ATAA or you will lose the right to elect COBRA during a special second election period. 18