Summary Plan Description

Transcription

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2 FOOD & BEVERAGE WORKERS UNION LOCAL 32 AND EMPLOYERS BENEFITS FUND Summary Plan Description January/2002

3 FACTS ABOUT THE PLAN Name of Plan: Food and Beverage Workers Union Local 32 & Employers Benefits Fund About the Fund: The Fund provides benefits to certain employees and their families who are covered by Collective Bargaining Agreements between Hotel & Restaurant Employees Local 25 or Parking Attendants & Service Workers Local 27 and employers. Although Local 25 succeeded to the interests of the Food and Beverage Workers Union Local 32, the name of the Fund remains the Food and Beverage Workers Union Local 32 & Employers Benefits Fund. Plan Sponsor: Board of Trustees, Food and Beverage Workers Union Local 32 & Employers Benefits Fund, 4301 Garden City Drive, Suite 201, Landover, Maryland , (301) or (800) A list of Participating Employers is inserted into this booklet. Employer Identification Number Plan Number Type of Plan This is a welfare, scholarship, and tuition payment Plan maintained to provide medical, dental, optical, prescription drug and tuition reimbursement benefits. The Plan also awards scholarships to children and grandchildren of eligible Plan Participants. Type of Administration Contract administration. The Board of Trustees has contracted with Associated Administrators, Inc. for administrative management services. Name of Plan Administrator Board of Trustees for the Food & Beverage Workers Union Local 32 and Employers Benefits Fund. Agent for Service of Legal Process Service may be made on the Trust or the Plan or any Trustee at this address: Board of Trustees, Food and Beverage Workers Union Local 32 & Employers Benefits Fund, 4301 Garden City Drive, Suite 201, Landover, Maryland Phone (301)

4 Source of Contribution Participating Employers make Contributions pursuant to the terms of their Collective Bargaining Agreements. Funding Medium All assets are held in trust by the Board of Trustees. Fees are paid to the companies which provide Life Insurance, Accidental Death and Dismemberment, Medical, Optical, Dental, and Prescription Drug services to Plan Participants. A current Summary Annual Report (available from the Plan Administrator, or Fund Office ) gives details of Plan funding of benefits. The Fund s assets are held by Mercantile Bank. The Fund has entered into contracts with Kaiser Permanente at 201 East Jefferson Street, Rockville, MD and with Optimum Choice, Inc. HMO at 4 Taft Court, Rockville, MD for health and prescription drug benefits. The Fund has entered into contracts with The Standard Insurance Company at 900 SW Fifth Avenue, Portland, OR for life, accidental death and dismemberment, accident and sickness/disability pay. These benefits are guaranteed and paid through the insurance contracts and the insurance and insurance companies provide claims processing services for these benefits. Plan Year January 1 - December 31 Collective Bargaining Agreements This Fund is maintained pursuant to Collective Bargaining Agreements between your employer and the Hotel and Restaurant Employees Union Local 25 or Parking Attendants and Service Workers Local 27. Many different companies participate in the Plan and the terms of the Collective Bargaining Agreements vary from employer to employer. You can get a copy of the Collective Bargaining Agreement that applies to you upon written request to the Fund Office at: Associated Administrators, Inc Garden City Drive, Suite 201 Landover, Maryland Phone (301)

5 CONTENTS Facts About the Plan Dear Participant.. 4 Notice No Fund Liability.. 5 Board of Trustees.. 6 Definitions Schedule of Benefits ELIGIBILITY.. 12 Eligibility for Life/AD&D/Accident & Sickness, Prescription Drug & Medical ( Monthly Benefits). 12 Eligibility for Optical/Dental/Scholarship ( Hourly Benefits ) 13 Dependent Coverage Continuation of Coverage under the Family and Medical Leave Act ( FMLA ) Continuation of Coverage under the Consolidated Omnibus Budget Reconciliation Act of 1985 ( COBRA ) 19 Continuation of Coverage under the Uniformed Services Employment and Re-employment Rights Act of 1994 ( USERRA )..22 Qualified Medical Child Support Orders 25 Certificate of Coverage. 26 DESCRIPTION OF BENEFITS Life/AD&D Accident & Sickness 30 Medical Benefit. 33 Prescription Drug Benefit 37 Dental Benefit (All Areas) Description of Dental Services and Fees (Washington, DC) Description of Dental Services and Fees (Richmond, VA) Optical Benefit. 55 Scholarship Awards Benefit.. 57 Tuition Reimbursement Program ADMINISTRATIVE PROCEDURES Claims Filing and Review Your Rights Under ERISA Participating Employers Numbers and Addresses... Inside Back Cover 3

6 Dear Participant, This booklet describes the benefits provided to eligible employees and Dependents under the Food and Beverage Workers Union Local 32 & Employers Benefits Fund ( Fund ) Plan of benefits ( Plan ). The benefits provided under this Plan include Life Insurance, Accidental Death & Dismemberment, Accident and Sickness ( Disability ), Medical, Optical, Dental, Prescription Drug and Scholarship benefits. However, whether you can receive benefits depends upon the Collective Bargaining Agreement between your employer and the Union and upon whether you have met the eligibility requirements as specified. There is a chart included with this booklet which shows each employer and the benefits for which its employees are covered. The chart is updated through the date shown on the bottom right corner. If you are not sure which benefits apply to you, call the Fund Office. Although this booklet is a detailed summary of the Plan provisions, it is not a contract. It does not contain the detailed Agreement and Declaration of Trust or the related Collective Bargaining Agreements. Those documents govern the operation and administration of this Plan. The Plan must be interpreted in accordance with those documents, which are available for your inspection at the Fund Office. Please read this booklet carefully so you will be familiar with your benefits and the Plan's eligibility and coverage requirements. We hope that you will share our pride in your Plan and the security and protection it provides to those who work in the industry. Sincerely, BOARD OF TRUSTEES 4

7 Notice -- Limit of Fund Liability Use of the services of any hospital, clinic, doctor, or other provider rendering health care, whether designated by the Fund or otherwise, is the voluntary act of the Participant or Dependent. Some benefits may only be obtained from providers designated by the Fund. This is not meant to be a recommendation or instruction to use the provider. You should select a provider or course of treatment based on all appropriate factors, only one of which is coverage by the Fund. Providers are not employees of the Fund. The Fund cannot guarantee the quality of service or treatment of any provider and is not responsible for any acts of commission or omission of any provider in connection with Fund coverage. The provider is solely responsible for the services and treatments rendered. 5

8 BOARD OF TRUSTEES Union Trustees Employer Trustees John Boardman, Chairman Pamela Wilson, Secretary Executive Secretary/Treasurer Dir. Labor Relations Mgr. HERE Local 25 Compass Group, Inc K Street, NW, 7 th Fl Washington Blvd. Washington, DC Baltimore, MD Minor Christian Holly Burke HERE Local 25 Guest Services, Inc K Street, NW, 7 th Fl Prosperity Avenue Washington, DC Fairfax, VA Roxie Herbekian John Rebstock, Trustee Local 27, PARC C/O Associated Administrators, Inc. Parking & Service Workers Union 4301 Garden City Drive, Ste. 201 Local 25, AFL-CIO Landover, MD th Street, NW, 2 nd Fl. Washington, DC Muriel Patterson HERE Local K Street, NW, 7 th Fl. Washington, DC Marcia Allen HERE Local K Street, NW Washington, DC

9 DEFINITIONS Below are some of the terms used in this booklet. Other terms are defined as they are used. Beneficiary. Someone other than a Participant who is eligible to receive benefits under the Plan. A Beneficiary for the Life Benefit is someone specifically named on the Life Benefit enrollment form to receive the Life Benefit. Collective Bargaining Agreement ( CBA ). A contract entered into between Hotel and Restaurant Employees Union Local 25, or Parking Attendants and Service Workers Local 27, and an employer for determining wages, hours, rules, and other working conditions, including benefits. COBRA ( Consolidated Omnibusman Budget Reconciliation Act of 1985 ). A federal law which permits Covered Persons who would otherwise lose their coverage to elect to continue to self-pay for their coverage, under certain circumstances. Contribution. The amounts Participating Employers must pay to the Fund based on the applicable Collective Bargaining Agreement to provide Plan benefits to its covered employees. Co-Payment. An amount required to be paid by a Covered Person for medical benefits. Covered Person. A Participant and/or his or her eligible Dependent(s). Dependent. A Participant s spouse, natural child, stepchild, legally adopted child, or a child placed for adoption with the Participant. ERISA. The Employee Retirement Income Security Act of 1974 and regulations thereunder, as amended from time to time. FMLA. The Family and Medical Leave Act of 1993 and regulations thereunder, as amended from time to time. Fund. The Food & Beverage Workers Union Local 32 and Employers Benefits Fund. Fund Office. Associated Administrators, Inc., located at 4301 Garden City Drive, Suite 201, Landover, MD Local 25. Local 25, Hotel and Restaurant Employees Union. 7

10 Local 27. Local 27, Parking Attendants & Service Workers. Medicare. A federal program that provides medical and hospital benefit for the aged. Benefits are provided under Title XVIII of the Social Security Act of 1965, as amended from time to time. Open Enrollment Period. A period of time during which Participants and eligible Dependents can enroll for medical benefits. Participant. An employee of a Participating Employer on whose behalf Contributions are made to the Fund and who has satisfied the Plan s eligibility rules. Participating Employer. An employer who participates in the Food & Beverage Workers Union Local 32 & Employers Benefits Fund by making Contributions on behalf of its covered employees. Plan. The Food and Beverage Workers Union Local 32 & Employers Benefits Fund and Plan of benefits. Trustees. The Board of Trustees of the Fund as constituted from time to time. Union. Local 25 and Local 27. USERRA ( Uniformed Services Employment and Re-employment Rights Act of 1997 ). A federal law that allows employees who leave employment for military duty to continue their employer s health coverage under certain circumstances. 8

11 COVERAGE AND ELIGIBILITY REQUIREMENTS Covered Employment To receive benefits under the Plan, two requirements must be met. 1. Your employer must offer the particular benefits you are seeking. The benefits described in this booklet include all the benefits available under the Plan. However, not every Participating Employer offers coverage for every benefit described. To determine the benefits which apply to you, see the chart inserted in this booklet, check your Collective Bargaining Agreement, or contact your employer. 2. Even if your employer offers a particular benefit, you must be eligible for benefits under the Plan. To be eligible, you must be employed by a Participating Employer and you must work in a job classification which requires Contributions to be made to this Fund on your behalf. The benefits you are eligible for are determined by the Contributions to be made to this Fund on your behalf and on the Collective Bargaining Agreement ("CBA") in place between your employer and the Union. If the benefits are provided through an insurance company, the insurance company may also have its own eligibility requirements. For instance, with regard to medical benefits, you should see the Evidence of Coverage booklet for Kaiser Permanente HMO or Optimum Choice, Inc. HMO (whichever is applicable) to be sure that you satisfy the HMO s eligibility requirements. 9

12 SCHEDULE OF BENEFITS The benefits described on the following pages are ALL the benefits available under the Plan. Remember, not every Participating Employer provides coverage for every benefit described. To determine which benefits apply to you, see the chart inserted in this booklet, check your Collective Bargaining Agreement, or contact your employer. BENEFIT Life and Accidental Death and Dismemberment Benefits Participant Only COVERAGE Benefits provided through The Standard Insurance Company. See page 27. Accident and Sickness ( Disability ) Benefits Participant Only Benefits provided through The Standard Insurance Company. See page 27. Medical Benefits Participant and Eligible Dependents Fund Sponsored Medical coverage as described on pages 33 of this Summary Plan Description and in the Evidence of Coverage booklet from either Kaiser Permanente HMO or Optimum Choice, Inc. HMO (whichever is applicable). If your medical coverage is not Fund Sponsored, the medical benefits described in this booklet do not apply to you. See your Collective Bargaining Agreement or contact your employer for more information. 10

13 Prescription Drug Benefits Participant and Eligible Dependents Vision/Optical Benefits Participant and Eligible Dependents Dental Benefits Participant and Eligible Dependents Scholarship Award Benefit Children, stepchildren, and grandchildren of Participants Prescription Drugs covered through Kaiser Permanente for some Participants; other Participants have this coverage provided through Optimum Choice, Inc. Benefits provided through United Optical. Benefits for glasses and eye examinations available once every two years see the Optical Benefit section on page 55. Benefits provided through Group Dental Service. Coverage for periodic check-ups, routine care, and cleanings at no charge; other services covered with Co-Payment payable by the Participant. See the Dental Benefit section on page 39. Awarded by the Scholarship Committee based on established criteria. See the Scholarship Award section on page 57. Tuition Reimbursement Benefit See the Tuition Reimbursement Participant Only section on page 62. Important Note: The benefits described by employer on the chart included with this booklet are correct as of the effective date on the chart (bottom right corner). Because benefits and benefit levels may change with each new Collective Bargaining Agreement or with each amendment to an existing Collective Bargaining Agreement, it is important that you check with your employer to be sure which benefits, and in what level, apply to you and/or your eligible Dependents. 11

14 ELIGIBILITY Eligibility for Life, Accidental Death & Dismemberment ( AD&D ), Accident & Sickness ( A&S ), and Medical/Prescription Drug Benefits Monthly Benefits If your employer offers a particular benefit, you must then make sure you have met the eligibility requirements in order to receive that benefit. Initial Eligibility You will generally become eligible for Life, AD&D, Medical/Prescription Drug and A&S benefits on the first day of the month in which your Participating Employer makes a Contribution on your behalf. However, Contributions may not be made for you as soon as you start working and the waiting periods before the Contributions begin vary by Participating Employer. Please see your Collective Bargaining Agreement to determine the applicable waiting period. In order to receive Medical/Prescription Drug benefits through Kaiser Permanente or Optimum Choice, Inc., you must complete an enrollment application and return it to the Fund Office. If you do not submit your application within 30 days from the date you first became eligible, you must wait until the Open Enrollment Period to enroll for Medical/Prescription Drug benefits. Ongoing Eligibility Your continuing eligibility for these benefits is determined on a monthly basis. You will be eligible for Life, AD&D, Medical/Prescription Drug, and A&S benefits only for each month in which a Contribution is received. Some Participating Employers require a minimum number of hours of work per month in order to maintain eligibility. Again, this varies by employer. Please see your Collective Bargaining Agreement for the requirements which apply to you. 12

15 Eligibility for Optical, Dental, and Scholarship Benefits ( Hourly Benefits ) Your eligibility for these benefits is determined by the number of hours you work because your employer makes Contributions to the Fund based on your hours of covered work. Initial Eligibility You will become eligible for Optical, Dental, and Scholarship benefits on the first day of the month following three consecutive months in which you have worked a minimum of 60 hours per month and your Participating Employer has made Contributions on your buehalf. Your Collective Bargaining Agreement will determine when Contributions are due on your behalf. Example: You are hired on January 15. Your Collective Bargaining Agreement calls for Contributions to begin with the first month of employment in which you work at least 60 hours. Because you worked at least 60 hours between January 15th - January 31st, Contributions on your behalf begin with the month of January. You work at least 60 hours in February and March, so Contributions are also made for these months, making three consecutive months of Contributions. Based on this example, you would become eligible for Optical, Dental, and Scholarship benefits on April 1st. Tuition Reimbursement You will be eligible for Tuition Reimbursement after your employer has made monthly Contributions on your behalf for 12 consecutive months. Local 27 Parking Lot Attendants Participants who are eligible for benefits as a result of a Collective Bargaining Agreement between Local 27 and Participating Employers are covered for Scholarship benefits only. Eligibility begins when you meet the eligibility requirements set forth in your Collective Bargaining Agreement. Loss of Eligibility All Benefits A Participant will lose eligibility when any of the following events occurs: 1. termination of employment; 2. transfer to a job classification that is not covered by a Collective Bargaining Agreement; 3. layoff; 4. military leave; 5. leave of absence; 13

16 6. your employer is no longer obligated to make Contributions; 7. Contributions fall below the minimum amount required under the applicable Collective Bargaining Agreement to maintain eligibility; 8. your Participating Employer fails to make the required Contributions to the Fund on the Participant s behalf; 9. the Participant s death. If Contributions due on your behalf are not made, your benefits are subject to suspension until your Participating Employer becomes current on its Contributions. Important: If loss of eligibility occurs, a Participant and his/her Eligible Dependents may be entitled to continue coverage under the Family and Medical Leave Act as described on page 18, COBRA as described on page 19, or under USERRA as described on page 22. Date Benefits Terminate: If your termination of employment is due to an involuntary discharge (not including layoff) or voluntary resignation of your employment, then your eligibility ceases on the last day of employment. If you lose eligibility as a result of any other reason, benefits will terminate on the last day of the second month following your last day of employment. For example, if your employment terminated any time during the month of September, for a reason other than resignation, or involuntary discharge, your eligibility for benefits would end on November 30. Reinstatement of Eligibility If your loss of eligibility is due to military service, layoff, working less than 60 hours for three consecutive months, or an approved leave of absence, eligibility will be reinstated on the first day of the month for which Contributions are received from your employer at (or above) the rate of 60 hours per month. If you lose eligibility for any other reason, but become actively employed again by the same or another Participating Employer within 30 days, you will be eligible again on the day you return to active employment. If the period of separation is 31 days or longer, then you must again meet the initial eligibility requirements as described in the eligibility section starting on page 12. NOTE: If you have elected continuation coverage under COBRA (see page 19) and have paid the COBRA premiums as required, then you will be reinstated immediately to eligibility status if you become actively employed again by the same or another Participating Employer within 30 days of the last date of COBRA coverage. 14

17 Additional Rules Relating to Loss of Benefits and Reinstatement of Eligibility for Medical Benefits Kaiser Permanente HMO and Optimum Choice, Inc. HMO may have additional rules which might affect your continuing eligibility for medical benefits. You should review the rules in the HMO Evidence of Coverage booklet which applies to you. DEPENDENT COVERAGE Eligible Dependents include only the spouse and children of the Participant. The children covered are the natural children, stepchildren, adopted children (or children placed for adoption), of the eligible Participant. Participants who have legal custody of a child may also add that child as a Dependent. In order to be eligible for dependent coverage, the child must be under the age of 19, not married, not employed on a regular and full time basis, and dependent upon the Participant for support. Dependent Eligibility and Adding New Dependents Your eligible Dependent(s) become eligible for coverage on the same date as you (the Participant) do. There is no waiting period. However, only those Dependents who are properly enrolled with the Fund Office will have dependent coverage. In order for coverage to be effective on the earliest possible eligibility date, you must submit an enrollment card to the Fund Office within 30 days of your initial eligibility. This is very important. Enrolling Your Dependents If you have a new Dependent (for example, you get married, adopt a child or have a baby), he or she may be added for benefit coverage. To do this, you must contact the Fund Office and complete a new enrollment card. If added within 30 days from the date of the marriage, birth, adoption, or placement for adoption, coverage will be effective as follows: for an eligible spouse, coverage will be effective on the first day of the calendar month following the date of marriage. Newborns will be covered from the date of birth and legally adopted children and children placed for adoption may be covered from the date of adoption or placement for adoption. Eligible stepchildren will be covered on the first day of the month following the date of marriage. Only those eligible Dependents who are properly enrolled with the Fund Office will have dependent coverage. If you fail to properly enroll your Dependent when he/she is first eligible, Optical and Dental coverage will begin on the first of the month following the Fund Office s receipt of a completed 15

18 enrollment card and the appropriate evidence of your Dependent s status (see below). For medical benefits through Kaiser Permanente or Optimum Choice, if Dependents are not added within 30 days from the date they become eligible, they can only be enrolled during the Open Enrollment Period each year. This applies to all Dependents, including newborns. Evidence of a Dependent s Status Evidence of a Dependent s status is required to be provided to the Fund Office in order for the Dependent to be added (for example, a copy of a marriage license, birth certificate, adoption certificate or court order placing the child for adoption). Loss of Eligibility for Dependents A Dependent's coverage will end automatically on the earliest of the following dates: 1. the Participant s loss of eligibility (except in certain cases under the Scholarship Benefit see the Scholarship Benefit section on page 57 for details). 2. the Dependent becomes eligible as an employee of a Participating Employer 3. a spouse's divorce or legal separation from the Participant 4. If the Dependent is a child, coverage will cease: a) at the end of the calendar month in which the child turns 19-- unless he/she is a full-time student as described in the following section; b) at the end of the month in which the child begins regular full - time employment; c) at the end of the month in which the child ceases to be dependent on the Participant for support; or d) at the end of the month in which the child is married. Coverage of Dependent Children Over 19 Children of an eligible Participant who will lose eligibility solely because they turn age 19 may continue to be eligible for benefits, provided they are enrolled as full time students in an accredited school. You must complete a student certification form and return it to the Fund Office before the child reaches age 19 in order for coverage to be continued. Students will be covered through the end of the calendar year in which they become age 23 or until they leave school, whichever comes first. An unmarried child age 19 or over who is incapable of self support because of physical or mental disability which began before age 19 and who is dependent on the Participant for support may continue to be covered as an eligible Dependent 16

19 for all Dependent benefits offered by the Plan. A Disability Certificate must be completed annually and returned to the Fund Office. 17

20 CONTINUATION OF COVERAGE UNDER THE FAMILY AND MEDICAL LEAVE ACT ( FMLA ) The Family and Medical Leave Act of 1993 ( FMLA ) requires Participating Employers with 50 or more employees to provide eligible employees with up to 12 weeks per year of unpaid leave in the case of the birth, adoption, placement for adoption, foster care of an employee s child or for the employee to care for his/her own sickness or to care for a seriously ill child, spouse, or parent. In compliance with the provisions of the FMLA, your Participating Employer is required to maintain pre-existing coverage under the Plan during your period of leave under the FMLA just as if you were actively employed. Your coverage under the FMLA will cease once the Fund Office is notified or otherwise determines that you have terminated employment, exhausted your 12 week FMLA leave entitlement, or do not intend to return from leave. Your coverage will also cease if your employer fails to maintain coverage on your behalf by making the required Contribution to the Fund. Once the Fund Office is notified or otherwise determines that you are not returning to employment following a period of FMLA leave, you may elect to continue your coverage under COBRA, as described in the following section. You may elect COBRA continuation coverage within 60 days from the last day of your FMLA leave. If you return to active employment for at least 30 days following your FMLA leave, your employer may not seek to recover the value of any benefits paid. However, if you fail to return to covered employment following your leave, the Participating Employer may recover the value of Contributions it paid to maintain your health and welfare coverage during FMLA leave, unless your failure to return was based on the continuation, recurrence, or onset of a serious health condition which affects you or a family member and which would normally qualify for leave under the FMLA. If you fail to return from FMLA leave for impermissible reasons, the Fund may offset payment of outstanding medical claims incurred prior to the prior to the period of FMLA leave against the value of benefits paid on your behalf during the period of FMLA leave. 18

21 CONTINUATION OF COVERAGE UNDER COBRA (CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT OF 1985) The Consolidated Omnibus Budget Reconciliation Act of 1985 ("COBRA") requires that the Plan offer eligible Participants and their families the opportunity to continue their health coverage for a certain period of time at group rates in instances where coverage under the Plan would otherwise end. Participants must make self-payments to the Fund Office in order to continue their coverage. If you are a Participant, you and your Dependent(s) have the right to continue medical, prescription drug, optical, and dental coverage under this Plan on a selfpayment basis if coverage would otherwise have terminated due to a Qualifying Event (see below). This provision does not apply to Life Benefits, Accidental Death and Dismemberment Benefits, Accident and Sickness Benefits, Scholarship Benefits, or Tuition Reimbursement Benefits. Qualifying Event means one of the following occurances which would terminate a Participant s and/or Dependent s coverage unless he/she elects to continue coverage under COBRA: 1. termination of a Participant s employment (other than for gross misconduct); 2. reduction in the Participant s work hours; 3. the Participant s retirement; 4. the Participant s death; 5. The Participant s entitlement to Medicare; 6. the Participant s divorce or legal separation; or 7. a Participant s child ceasing to satisfy the Plan s definition of a Dependent. Notification and Election Period It is the responsibility of the Participant and Dependent(s) to notify the Fund Office of any of the following Qualifying Events: Participant s divorce or legal separation, or a Dependent Child ceasing to be a Dependent. The Participant and/or Dependent(s) must provide such notification within 60 days from the later of: the date of the Qualifying Event; or the date the Dependent(s) would otherwise lose coverage due to the Qualifying Event. 19

22 The Participant and/or Dependent(s) may elect to continue coverage within 60 days from the later of: the date the Participant and/or the Dependent(s) would otherwise lose coverage due to the Qualifying Event; or the date the Participant and/or the Dependent(s) would otherwise lose coverage due to the Qualifying Event; or the date the Participant and/or the Dependent(s) are notified of the right to elect COBRA coverage. Such election must be in writing. Elected benefits will be continued provided that the election form is completed and returned to the Fund Office within the 60-day period noted above and the required premium is paid to the Fund Office within 45 days from the Participant s and/or Dependent(s) election. Subsequent payments must be made on a timely basis to the Fund Office. Length of COBRA Coverage -- Continuation Period COBRA coverage may continue, on a self-payment basis, as follows: 1. Coverage for the Participant and/or the Dependent(s) may be continued for up to 18 months beginning on the first of the month following the date of the Qualifying Event if coverage terminated due to the Participant s: a. termination of employment (other than for gross misconduct); b. reduction in work hours, or c. retirement. The 18-month period of continuation may be extended an additional 11 months (for a total of 29 months) if, at the time of the Qualifying Event described in number (a) or (b) above, the Participant or Dependent(s) are disabled as determined by the Social Security Administration. Proof of such disability must be provided to the Fund Office within 60 days from the date the Social Security Administration makes its determination. 2. Coverage for Dependent(s) may be continued for up to 36 months from the first day of the month following the Qualifying Event if coverage terminated due to: a. the Participant s death b. divorce or legal separation, or c. with respect to a Participant s child, if the child ceases to satisfy the Plan s definition of a Dependent. 20

23 If the Qualifying Event is the Participant s entitlement to Medicare, coverage for Dependents may be continued for up to 36 months from the date the Participant becomes entitled to Medicare. If a Dependent s coverage is continued for a reason listed under number (1) on the preceding page, and during that initial Continuation Period, a Qualifying Event occurs which entitles the Dependent to continue coverage under number (2), the Dependent may elect to continue coverage for a combined maximum of 36 months. You or your Dependent(s) who elect to continue coverage under COBRA shall be solely responsible for the payment of the premium for such coverage. If you elect COBRA continuation coverage, premium payment for continuation coverage for the period preceding the election must be made within 45 days from the date of the election. Thereafter, the premium may be paid in monthly installments. Termination of COBRA Coverage The continued coverage will cease on the first of the following dates: a) the date the Plan terminates; b) the date a required premium payment is due and unpaid after any applicable grace period; c) the date the Participant and/or the Dependent(s) become insured under another group health plan. This may not apply if the Participant or Dependent has a pre-existing condition which is not covered under the new plan. Contact the Fund Office for additional information when you and/or your Dependents become insured become insured under another group plan; d) the date the Dependent(s) becomes eligible for Medicare; e) the date the applicable period of continuation coverage is exhausted; or f) the first day of the month which begins 30 days after the Participant or Dependent(s) are no longer disabled, in situations where the Qualifying Event was termination of employment or reduction in hours and where coverage was being continued for an additional 11 months. Contact the Fund Office as soon as possible when a Qualifying Event has occurred for additional information about you and your Dependent(s) right to continuation coverage. Failure to notify the Fund Office in a timely manner may eliminate you or your Dependent(s) opportunity to continue coverage. 21

24 CONTINUATION OF COVERAGE UNDER THE UNIFORMED SERVICES EMPLOYMENT AND RE-EMPLOYMENT RIGHTS ACT OF 1997 ( USERRA ) USERRA requires that the Fund provide you the right to elect continuous health coverage for you and your eligible Dependent for up to 18 months, beginning on the date your absence begins from employment due to military services, including National Guard Duty and Reserve Duty. If you are absent from employment by reason of service in the uniformed services, you can elect to continue coverage for yourself and your eligible Dependent(s) under the provisions of USERRA. The period of coverage for you and your Dependent(s) ends on the earlier of: 1. the end of the 18-month period beginning on the date on which your absence begins; or 2. the day after the date on which you are required but fail to apply for or return to a position of employment for which coverage under this Plan would be extended (for example, for periods of military service over 180 days, generally you must re-apply for employment within 90 days of discharge). You may be required to pay a portion of the cost of your benefits. If your military service is considered an approved Leave of Absence, your Participating Employer must pay the cost of the premium for the first 12 months that you are eligible for coverage. You are responsible for paying 100% of the cost of coverage for the remaining 6 months of eligible coverage. If your military service is not considered to be an approved Leave of Absence, there is no charge for the cost of the premium for the first 31 days of coverage. Beyond 31 days, you must pay 100% of the cost of the coverage. The cost you must pay to continue benefits will be determined in accordance with the provisions of USERRA. You must notify the Fund Office or the Participating Employer that you will be absent from your job due to military service, unless you cannot give notice because of military necessity or unless, under all relevant circumstances, such notice is impossible or unreasonable. You also must notify the Fund Office that you wish to continue coverage for yourself or your eligible Dependent under the provisions of USERRA. If you have satisfied the Plan s eligibility requirements at the time you enter the uniformed services, and you qualify for coverage under USERRA, you will not be subject to any additional exclusions or a waiting period for coverage under the Plan when you return from uniformed service. 22

25 Special Note For Military Personnel Participants who are retired from active military service are entitled to benefits under this Plan for themselves and their eligible Dependents even though they may also have benefits provided under the CHAMPUS Program. Participants married to active duty military personnel are entitled to benefits under this Plan for themselves and any eligible Dependents not in active military service. COORDINATION OF BENEFITS A Participant under this Plan may also be eligible for similar benefits under another group benefit plan. If this happens, the two plans will coordinate their benefit payments so that the combined payments of both plans will not exceed the actual expenses incurred. The primary plan normally pays its benefits to the full extent set forth in the schedule of benefits, and the other plan pays a reduced amount. The Plan will pay either its benefits in full or a reduced amount which, when added to the benefits payable by the other plan for the same service, will equal not more than 100% of the usual, customary, and reasonable charge. Coordination of benefits saves the Fund money by making sure other plans pay benefits where they are available. The Fund is authorized to obtain information about benefits and services available from other plans in order to recover payments from those plans. The order of payment is determined as follows: 1. If one plan does not have a coordination of benefits provision, it is primary. Otherwise, the plan which covers the person as an employee is the primary plan. 2. The plan which covers the person as a Dependent is the secondary plan. 3. Where both parents are insured and have Dependent coverage and the claim is for a Dependent child, the primary plan is the plan of the parent whose birthday falls earliest in the year. However, if the other plan coordinates benefits based on gender, the Fund will also coordinate with that plan so that the plan covering the male pays the benefit first. 4. When the parents are divorced or separated, benefits for a Dependent child will be coordinated as follows: If a court determines financial responsibility for a child's health care expenses, the plan of the parent having that responsibility pays first. If that determination has not been made, the plan of the parent with custody pays before the plan of the other parent. 23

26 If the parent remarries, the payment order will be as follows: 1. The plan of the natural parent who has custody pays first. 2. The plan of the step-parent married to the parent who has custody pays second. 3. The plan of the natural parent who does not have custody pays third. If none of the above applies, then the plan in which the patient has been enrolled the longest will be primary. When an eligible Dependent under the Plan is eligible under another program of dental, drug, and/or vision benefits and the Dependent has the option of selecting the other employer health coverage or receiving cash, this Plan coordinates its benefits as if the other health coverage were applicable. It does so even when the Dependent does not elect coverage under another plan. Before the Fund will pay benefits to an employed Dependent, he or she must provide the Fund Office with information explaining the other employer's health coverage, if any. If the Dependent fails to notify the Fund Office of the availability of other health coverage, the Plan has the right to collect any excess payment it makes directly from the parties involved, or to offset future benefit payments from the Plan on the Dependent's behalf. This right of offset does not keep the Plan from recovering erroneous payments in any other manner. If a Participant is employed by a Participating Employer, is between the ages of 65 and 70, and is eligible for Part A of Medicare, or if the Participant's spouse is between the ages of 65 and 70, and is eligible for Part A of Medicare, the Participant or Participant's spouse may elect to make coverage under Medicare primary. If the Participant or Participant's spouse does so, this Plan will not provide secondary coverage for Medicare for that individual. However, if the Participant or spouse is age 65 through 69, and does not elect Medicare as primary payor, the Plan shall continue to be the primary payor of the Participant s health benefits. In addition, if the Participant is actively employed, and the Participant s spouse or Dependent child is under age 65, totally and permanently disabled and therefore eligible for Medicare, the Plan will provide primary coverage and Medicare will be secondary, unless elected otherwise. If you decide to select Medicare as your primary payor of medical benefits, you may do so in writing, on forms supplied by the Fund Office. End Stage Renal Disease (ESRD) If you or your eligible Dependent(s) are entitled to Medicare on the basis of age or disability and you then become entitled to Medicare based on ESRD, and the Plan 24

27 is currently paying benefits as primary, the Plan will remain primary for the first 18 months of your entitlement to Medicare due to ESRD. If the Plan is currently paying benefits secondary to Medicare, the Plan will remain secondary upon your entitlement to Medicare due to ESRD. QUALIFIED MEDICAL CHILD SUPPORT ORDERS There have been several important changes to federal law regarding coverage of children by the Plan, as explained below. (a) The Fund will provide coverage to a Participant s child if required to do so by what is called a Qualified Medical Child Support Order ( QMCSO ). The Fund will provide coverage to a child under QMCSO even if the Participant does not have legal custody of the child, the child is not dependent on the Participant for support, the child does not reside with the Participant, and regardless of any waiting period that otherwise may exist for dependent coverage. If the Fund receives a QMCSO and if the Participant does not enroll the affected child, it will allow the custodial parent or state agency to complete the necessary enrollment forms on behalf of the child. A copy of the Fund s procedures for determining whether an order is a QMCSO can be obtained from the Fund Office. (b) A QMCSO may require that the Accidental Death and Dismemberment benefits payable by the Fund be paid to satisfy child support obligations with respect to the child of a Participant. If the Fund receives such an order and benefits are currently payable or become payable while the order is in effect, the Fund will make payments either to the child support agency or directly to the recipient listed in the order. (c) If a QMCSO is in effect, the Fund will also provide dependent coverage for a child that is placed for adoption with a Participant, regardless of whether the adoption is finalized. A child will be considered placed for adoption with a Participant if the Participant assumes a legal obligation for the total or partial support of a child in anticipation of adopting that child. The child s placement will be considered terminated when the Participant no longer has a legal obligation to support the child. A Participant will be required to supply evidence to the Fund that a child for whom dependent coverage is requested has actually been placed with the Participant for adoption. Additionally, any pre-existing conditions that would otherwise be excluded from coverage will not apply to a child that is adopted or placed for adoption with the Participant. 25

28 CERTIFICATE OF COVERAGE In certain circumstances, federal law requires that the Plan provide Participants or Dependents with evidence of coverage under the Plan. This certificate of coverage can be used as proof of prior coverage when beginning coverage under another plan. Effective October 1, 1996, the Fund will provide a Certificate of Coverage to Covered Persons under the Fund within a reasonable time after any of the following events occurs: 1. Loss of coverage under the Fund; 2. Loss of COBRA coverage; or 3. Upon written request, within two years from the date you lost coverage under the Fund. 26

29 DESCRIPTION OF BENEFITS The benefits described on the following pages are ALL the benefits available under the Plan. Not all Participating Employers programs provide all benefits. Refer to the sections under coverage and eligibility. Also, see your Collective Bargaining Agreement and/or contact your employer to determine which benefits apply to you. LIFE BENEFIT, ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT, ACCIDENT & SICKNESS BENEFIT Benefits provided through The Standard Insurance Company Participant Only NOTE: Some Participants have Life and/or Accidental Death and Dismemberment (AD&D) Benefits, and/or Accident & Sickness Benefits directly through their employers, and not through the Plan. In that case, contact your employer or see your Collective Bargaining Agreement for the benefit amounts, claims information, and other provisions of the coverage. The information below does not apply to you. Life Benefit In the event of your death while insured, the amount of Life Benefit you are eligible for (shown on the chart inserted into this booklet) is payable to the person you have named as your Beneficiary. The amount of the Life Benefit is shown on the attached chart. Beneficiary You may name any person you choose to be your Beneficiary. You may change the named Beneficiary at any time. To name (or to change) a Beneficiary, you should: 1. Contact the Fund Office for an enrollment form; 2. Complete and sign the enrollment form; and 3. Return the completed form to the Fund Office. Only enrollment forms which are properly completed, signed, and received by the Fund Office prior to a Participant s death will be honored. The Fund will assume that the most recently named Beneficiary who was properly named with an enrollment card is correct. 27

30 If the Beneficiary you designate dies before you and/or you fail to designate a Beneficiary, the Life benefits will be paid to the first survivor in the following order: 1. Your surviving spouse 2. Your children 3. Your surviving parents 4. Your surviving brothers and sisters 5. The executor or administrator of your estate If you and your spouse or designated Beneficiary die at the same time, or simultaneously as determined by relevant state law, as a result of injuries sustained or resulting from the same accident or event, your spouse or designated Beneficiary will be deemed to have pre-deceased you for purposes of this Life benefit. To File A Claim To file a claim for Life Benefits, your Beneficiary or family member should notify the Fund Office within 180 days from the date of loss. Benefit amounts vary by Participating Employer. See the enclosed chart to determine the benefit amount which applies to you. Group Policy Information The group policy has been issued to the Trustees. The group policy is on file and may be examined at the Fund Office. The Policy number is A. This information is a description of the insurance issued under and subject to the terms and conditions of the group policy. The group policy controls in all cases. This description merely summarizes and explains the pertinent parts of the policy and it does not constitute a contract of insurance. Accidental Death and Dismemberment Benefit ( AD&D ) This benefit is payable if you suffer any of the losses listed below. If the loss is due to an accident, such loss must have occurred within 90 days from the date of the accident. You (or, in the case of death, a family member) must notify the Fund Office within 30 days from the start of the covered loss. To find out the benefit amount, consult the enclosed chart. A Participant will not be paid more then the full benefit amount shown for all losses which arise from the same accident. 28

31 Group Policy Information The group policy has been issued to the Trustees. The group policy is on file and may be examined at the Fund Office. The policy number is A. This information is a description of the insurance issued under and subject to the terms and conditions of the group policy. The group policy controls in all cases. This description merely summarizes and explains the pertinent parts of the policy and it does not constitute a contract of insurance. Exclusions Life Benefit The Life benefit may not be payable if your death is a result of suicide or selfinflicted injury. Contact the Fund Office if you have questions about this provision. Exclusions -- Accidental Death & Dismemberment ( AD&D ) Benefits No AD&D benefit will be paid for any loss resulting from directly or indirectly, in whole or in part: Intentional self-injury, suicide or attempted suicide, while sane or insane; War or acts of war, whether declared or undeclared, whether civil or international; Sickness or pregnancy existing at the time of the accident; Heart attack or stroke; Committing or attempting to commit an assault or felony, or actively participating in a violent disorder or riot. Actively participating does not include being at the scene of a violent disorder or riot while performing your official duties; Flight (boarding, leaving or being) in or on any type of aircraft unless travelling as a fare-paying passenger on a commercial aircraft; Medical or surgical treatment for any of the above. 29

32 Accident and Sickness ( A&S )/Disability Benefits If you become disabled and unable to work, you may qualify for A&S benefits. These benefits provide income to you while you are not working. Group Policy Information The group policy has been issued to the Trustees. The group policy is on file and may be examined at the Fund Office. The policy number is A. This information is a description of the insurance issued under and subject to the terms and conditions of the group policy. The group policy controls in all cases. This description merely summarizes and explains the pertinent parts of the policy and it does not constitute a contract of insurance. Benefit Amount If you are disabled and unable to work as certified by a doctor, you will receive a portion of your weekly pay. For example, you may receive 60% of your weekly salary, 50% of your salary, or 66 2/3 % of your salary--whatever percentage is specified in the applicable Collective Bargaining Agreement--up to a specified maximum weekly dollar amount. Your weekly maximum is also stated in your Collective Bargaining Agreement. Duration of Benefits Your benefits will be paid as long as you are disabled up to the maximum benefit period (a certain number of weeks). See your employer or your Certificate of Coverage (which your employer gives to you when you have served the waiting period and are eligible for this benefit) to identify the maximum benefit period which applies to you. Waiting Period Most Participating Employers have a waiting period for A&S benefits. Benefits will begin if you are still disabled after you have completed the waiting period. The length of the waiting period varies depending on your employer. See your Collective Bargaining Agreement for the waiting period, if any, which applies to you. You must be under the regular care of a physician for the duration of your disability in order to be covered. Successive periods of disability which are separated by less than two weeks of active work will be considered as one period of disability unless the second period of disability is due to an illness or injury entirely unrelated to the cause of the first one, and which begins after you returned to active employment. 30