The Chemours Company. BeneFlex Vision Care Plan

Transcription

1 The Chemours Company BeneFlex Vision Care Plan Originally Adopted July 1, 2015 Effective January 1, 2017 The Chemours Company

2 BENEFLEX VISION CARE PLAN I. PURPOSE The purpose of this Plan is to provide Employees with the opportunity to participate in a managed vision care program. II. VISION CARE ADMINISTRATOR This is a fully-insured benefit plan provided through Vision Benefits of America VBA ). This document, along with the certificate of insurance and any accompanying benefits booklet provided by VBA make up the Plan s Summary Plan Description. The Company shall have the right to enter into a contract with one or more Vision Care Administrators for the purposes of providing any benefits under this Plan, and to replace any of such companies at its sole discretion. III. DEFINITIONS 1. The term "Company" means The Chemours Company FC, LLC, any wholly owned subsidiary or part thereof and any partnership or joint venture in which The Chemours Company FC, LLC is joined which adopts this Plan with the approval of the Company, or such person or persons as the Company may designate. 2. The term "Plan" means The Chemours Company BeneFlex Vision Care Plan as set forth herein, with any and all amendments hereto. The Plan is a Component Benefit Plan of The Chemours Company Health and Welfare Benefit Plan. 3. The term "Employee" means a "Full Service Employee" as such term is defined in the Company's Continuity of Service Rules. 4. The term "dependent" means: a. the lawful spouse of the Employee. b. the Employee s natural child, step-child, adopted child (including a child legally placed with Employee for adoption), foster child, or child for whom the Employee has court-appointed, legal guardianship, who is: (i) (ii) under age 26; or a federal tax dependent of Employee, regardless of age, and is mentally or physically incapable of earning a living, due to a medical condition established prior to reaching age 26, and the Employee submits proof of the child s incapacity and dependency to the Company at reasonable intervals upon request, incapacity and dependency to the Company at reasonable intervals upon request, or

3 (iii) the natural or legally adopted unmarried child under age 26 who, as the result of a court order, must be provided coverage by the Employee. A person shall not be covered as both an Employee and as a dependent of an Employee, or as a dependent of more than one Employee. 5. The term "Plan Year" means the calendar year January 1 through December 31. IV. ELIGIBILITY Employees are eligible to participate in this Plan as of their date of hire by the Company. Dependents shall become eligible for benefits under this Plan only when such dependent is enrolled as a dependent in this Plan by the Employee. V. PARTICIPATION Participation in this Plan shall become effective only if the Employee elects to participate in this Plan in connection with The Chemours Company BeneFlex Flexible Benefits Plan (the Flexible Benefits Plan ). An Employee who fails to make an election under the Flexible Benefits Plan for the succeeding Plan Year will have no coverage under the Plan. A new Employee will have no coverage under this Plan until an election is made. VI. COVERAGE A participating Employee may elect Employee-only coverage, Employee and spouse coverage, Employee and dependent child(ren) coverage, or family coverage. VII. VISION CARE BENEFITS Subject to the limits set forth below, a participating Employee and covered dependents will be entitled to the following benefits. The amount of benefit payable per service and copayments applicable during a Plan Year for each covered service will be determined by the Company: 1. Vision Care through a vision care provider affiliated with the Vision Care Administrator a. Eye Examination not more than once in any Plan Year b. Lenses not more than once in any Plan Year subject to a copayment determined by the Company, excluding the following items which may be purchased by the Employee at the Employee's cost: (i) (ii) (iii) (iv) The laminating of a lens or lenses A frame that costs more than the Plan allowance Contact lenses in excess of the Plan allowance Rimless frames c. Frames standard frames not more than once in every Plan Year, subject to a copayment -3-

4 d. Contact Lenses 100% reimbursement with advance approval of the Vision Care Administrator for necessary contact lenses following cataract surgery, to correct extreme visual acuity problems, to correct for significant anisometropia, to correct keratoconus; reimbursement of up to an amount determined by the Company for cosmetic or elective contact lenses and eye examination. 2. Vision care through a vision care provider not affiliated with the Vision Care Administrator, up to an amount determined by the Company a. Eye Examination b. Lenses reimbursement for the following types of lenses up to an amount determined by the Company: (i) (ii) (iii) (iv) Single vision Bifocal Trifocal Lenticular c. Frames d. Contact Lenses reimbursement for necessary contact lenses following cataract surgery, to correct extreme visual acuity problems, to correct for significant anisometropia, to correct keratoconus; or reimbursement for cosmetic or elective contact lenses and eye examination. 3. Vision care through a vision provider not affiliated with the Vision Care Administrator when a vision care provider is not available within 35 miles of the participant s home address: a. Eye Exam Plan pays 100% b. Eyeglass lenses and/or frames (one time per year) (i) Includes polycarbonate lenses, scratch-resistant coatings, optional lens tints, blended bifocals, progressive lenses, and trifocal Lenticular Plan pays 100% after $20 copayment per person for the materials (ii) Frames will be reimbursed up to $130 (iii) Additional Lens Options such as 1-year scratch, UV Coatings, polycarbonate lenses, pressives (except digital) and tints will be reimbursed in full. c. Cosmetic contact lenses (in in lieu of glasses, including exam) up to $175 allowance toward the total cost d. VBA-approved, medically necessary contact lenses (in lieu of glasses, including exam 100% reasonable and customary charges VIII. EXCLUSIONS The following items shall in no event be considered benefits provided by this Plan: -4-

5 1. Orthoptics or vision training, subnormal vision aids, or nonprescription lenses. 2. Plano lenses. 3. Two pairs of glasses in lieu of bifocals. 4. Medical or surgical treatment of the eyes. 5. Any eye examination, or corrective eyewear, required by an employer as a condition of employment. 6. Services or materials provided as a result of any Worker's Compensation Law or similar legislation. 7. Glasses and contacts during the same eligibility period. 8. Replacement of lost or broken lenses and frames furnished under this Plan except at the normal intervals when services are otherwise available. 9. Charges above the fees charged by a vision care provider affiliated with the Vision Care Administrator if a participant fails to obtain a claim form in advance and visits the provider as a private patient. IX. PRICE OF COVERAGE The Employee s share of the cost of coverage under this Plan for each Plan Year will be determined annually by the Company. The price of coverage will be deducted from the participating Employee's compensation pursuant to the terms of the Flexible Benefits Plan. X. TERMINATION OF COVERAGE An Employee's coverage under this Plan shall terminate on the last day of the calendar month in which employment terminates. A dependent's coverage under this Plan will terminate on the last day of the calendar month in which such individual ceases to be a dependent, or if earlier, the last day of the calendar month in which the Employee terminates employment. XI. CONTINUATION OF COVERAGE Continuation of coverage under this Plan will be provided to Qualified Beneficiaries in compliance with applicable laws and according to the following terms: 1. An Employee may elect COBRA continuation coverage if coverage under this Plan is lost because of a reduction in hours of employment or termination of employment (for reasons other than gross misconduct on the Employee s part). 2. An Employee s spouse and/or dependent child(ren) may elect COBRA continuation coverage if benefits coverage under the Plan is lost as a result of the occurrence of any of the following qualifying events: -5-

6 a) the death of the Employee while employed by the Company and currently covered; b) the Employee terminates employment (for reasons other than gross misconduct) or experiences a reduction in hours of employment; c) a divorce or separation from the Employee; d) the Employee becomes entitled to Medicare; e) loss of dependent status under the Plan (applies to dependent child(ren) only). 3. If the qualifying event is a divorce or legal separation, or a child ceasing to be a dependent under the terms of the Plan, the Employee, Qualified Beneficiary or legal representative must inform the Plan Administrator of the qualifying event within 60 days of the occurrence of such event. For all other qualifying events, the Company must notify the Plan Administrator no later than 30 days after the occurrence of such event. 4. Within 14 days of receiving notice of a Qualifying Event, the Plan Administrator must furnish each Qualified Beneficiary with written notification of the termination of health benefits coverage and the right to elect COBRA continuation coverage. Notification to a Qualified Beneficiary who is a spouse of an Employee is considered notification to all other Qualified Beneficiaries residing with that person at the time notification is made. 5. A Qualified Beneficiary who elects COBRA continuation coverage shall pay 102 percent of the full cost of such coverage on an after-tax basis or the percentage determined by the Plan Administrator as hereinafter described. The first premium payment must be made within 45 days from the date the Qualified Beneficiary elects COBRA continuation coverage. The Plan Administrator may, however, at its discretion; set the required premium payment amount at any other percentage permissible under applicable law, provided such other percentage is applied on a uniform basis to similarly situated Employees. -6-

7 6. If the applicable qualifying event is death, divorce or legal separation from the Employee, the Employee s entitlement to Medicare, or, in the case of a dependent, his or her ineligibility for dependent coverage, a Qualified Beneficiary s continuation coverage may continue for 36 months. If the applicable qualifying event is the Employee s termination or reduction in hours of employment, a Qualified Beneficiary s continuation coverage may continue for 18 months. An Employee s entitlement to Medicare shall not be a qualifying event for family members if they remain covered under the Plan because the Employee still is employed. However, if family members later lose coverage due to the Employee s termination or reduction in hours of employment, their continuation coverage period shall be 36 months from the date that the Employee previously became entitled to Medicare, if that would be longer than the 18- month period measured from the date of the Employee s termination or reduction in hours of employment. 7. Extension of Continuation Coverage. a) The 18-month continuation coverage period for dependents may be extended to 36 months if a second qualifying event (death, divorce or legal separation, Medicare entitlement which would result in loss of coverage, or ineligibility for dependent coverage) occurs during the initial 18-month period. b) If a Qualified Beneficiary is eligible for 18 months of COBRA continuation coverage, such coverage may be extended for up to 11 months more if it is determined, under the Social Security Act, that the Qualified Beneficiary was disabled on or within 60 days of the date of the Employee s termination or reduction in hours of employment. To extend health coverage, the Employee, Qualified Beneficiary, or a legal representative must notify the Plan Administrator of a determination of disability within 60 days after the date the determination is made and before the end of the first 18 months of COBRA continuation coverage. 8. Continuation coverage may be terminated for any of the following reasons: a) the Company ceases to provide coverage to all its employees; b) the premium for the Qualified Beneficiary s COBRA continuation coverage is not paid on a timely basis; c) the Qualified Beneficiary becomes covered under another group health plan ( other plan ); d) the Qualified Beneficiary becomes entitled to Medicare; e) the maximum period of continuation coverage ends; or -7-

8 f) the Qualified Beneficiary extends health coverage for up to 29 months due to a disability and there has been a final determination that the Qualified Beneficiary is no longer disabled. (The Employee, Qualified Beneficiary, or a legal representative must notify the Plan Administrator within 30 days of the date of any final determination that the disability has ended. Extended coverage shall be terminated beginning with the first month that begins more than 30 days after the date of the final determination that the Qualified Beneficiary is no longer disabled.) XII. APPLICATION FOR BENEFITS Application for benefits under this Plan must be filed with the Vision Care Administrator on the forms provided. Filing any claim for benefits under this Plan will constitute an authorization to any provider, insurance company, employer or organization to release any information regarding the claim for the purpose of validating and determining benefits payable or for audit or statistical purposes. XIII. CLAIMS FOR BENEFITS This Plan is fully insured. Participants should refer to the insurance certificate and benefits booklet provided by the insurance company for information on how to file claims and appeals for benefits under this Plan. This information is available Vision Benefits of America (VBA) online at vbaplans.com or by calling VBA at (80) XIV. IRREVOCABLE ELECTIONS Elections made under this Plan (or deemed to have been made) shall be irrevocable and binding for the balance of the Plan Year, provided, however, that such elections may be revoked or changed in such manner as the Plan Administrator may prescribe, but only in the event of, and consistent with, a qualifying change in the Employee s family status or benefit coverage related to employment. XV. ADMINISTRATION The Company is the Plan Administrator. The Company shall have the authority to control and manage the operation and administration of this Plan and to designate one or more persons to carry out the responsibilities of the operation and administration of this Plan. The Company shall have the discretionary right to determine eligibility for benefits hereunder and to construe the terms and conditions of this Plan. The decision of the Company shall be final with respect to any questions arising as to the interpretation of this Plan. XVI. MODIFICATION OR TERMINATION OF THE PLAN The Company reserves the sole right to change, terminate, modify, amend or discontinue this Plan. If any provision of this Plan is or in the future becomes contrary to any applicable law, rule, regulation or order issued by competent government authority, the Company reserves the sole right to amend or discontinue this Plan in its discretion without notice. XVII. YOUR RIGHTS UNDER ERISA -8-

9 As a participant in this Plan you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all Plan participants shall be entitled to: 1. Examine, without charge, at the Plan Administrator's office and at other specified locations, such as worksites and union halls, all documents governing the Plan, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration. 2. Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The Plan Administrator may make a reasonable charge for the copies. 3. Receive a summary of the Plan's annual financial report. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report. 4. Continue health care coverage for yourself or your dependents if there is a loss of coverage under the Plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review the Summary Plan Description and the documents governing the group health plans for the rules governing your COBRA continuation coverage rights. In addition to creating rights for Plan participants ERISA imposes duties upon the people who are responsible for the operation of the Plan. The people who operate your Plan, called fiduciaries of the Plan, have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries. No one, including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a benefit or exercising your rights under ERISA. If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of Plan documents or the latest annual report (Form 5500) from the Plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the Plan Administrator. If you have a claim for benefits that is denied or ignored, in whole or in part, and you have exhausted the claims procedures available to you under the Plan, you may file suit in a state or Federal court. In addition, if you disagree with the Plan s decision or lack thereof concerning the qualified status of a medical child support order, you may file suit in Federal court. If it should happen that Plan fiduciaries misuse the Plan s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in Federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If -9-

10 you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous. If you have any questions about your Plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration (EBSA), U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration (EBSA), U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration. -10-

11 XVIII. PLAN INFORMATION Plan Name: Plan Sponsor: The Chemours Company BeneFlex Vision Care Plan. The Plan is a Component Benefit Plan of The Chemours Company Health and Welfare Benefit Plan. The Chemours Company FC, LLC EIN: Plan Administrator: The Chemours Company FC, LLC 1007 Market Street P. O. Box 2047 Wilmington DE