Health Maintenance Organizations (HMOs) and Insured Health Plans Participating in: The Dow Chemical Company Insured Health Program (ERISA Plan #601)

Transcription

1 Summary Plan Description Wrapper for: Health Maintenance Organizations (HMOs) and Insured Health Plans Participating in: The Dow Chemical Company Insured Health Program (ERISA Plan #601) Applicable to eligible active employees Amended and Restated February 27, 2012 Effective January 1, 2012 and thereafter until superseded This Summary Plan Description (SPD) is updated annually on the Dow Intranet and supersedes all prior SPD s. Content Steward: Theis January 1, 2012 Literature #

2 Section Table of Contents Page Section 1. ERISA Information... 1 Section 2. Summary Plan Description Wrapper... 3 Section 3. A. About HMOs How HMOs Operate Dow and HMOs Information that Your HMO Should Provide You Secova, the HMO Network Manager Grandfathered HMOs... 6 B. Employee Assistance Plan ( EAP )... 6 Section 4. Eligibility HMO Availability Employee Eligibility... 7 Benefit Protected Leave of Absence International Medical and Dental Program 4.3 Dependent Eligibility... 8 Dropping or Adding a Domestic Partner The Working Spouse/Domestic Partner Rule Exception to the Working Spouse/Domestic Partner Rule Dependent Child(ren) Qualified Medical Child Support Orders Other Dependent Child Exclusions 4.4 Eligibility Determinations of Claims Administrator are Final and Binding Section 5. Enrollment Levels of Participation Enrolling at the Beginning of Employment Enrolling During Annual Enrollment Dual Dow Coverage Special Enrollment Provisions Change of Elections to Prevent Discrimination If You Move During the Plan Year Section 6. Mid-Year Election Changes Change in Status Consistency Rule Exceptions 6.3 Documentation of Eligibility Required to Make Election Change Deadline to Enroll for Mid-Year Changes i

3 Section 7. Premiums Your Contribution Excess Premium Payments Premiums During a Benefits Protected Leave of Absence Section 8. Survivor Benefits Survivor Benefits General Rule Exception for Vested Participants of the Dow Employees Pension Plan or Union Carbide Employees Pension Plan Exception for Vested Participants of the Rohm and Haas Company Retirement Plan Surviving Children without Surviving Spouse/Domestic Partner Section 9. HIPAA and Other Laws Health Insurance Portability and Accountability Act (HIPAA) and Other Legislation Women s Health and Cancer Rights Act of 1998 Maternity Stays Certificates of Coverage Information Exchanged by the Program s Business Associates Section 10. Filing a Claim Filing Claims and Appealing Claims Denials Section 11. Fraud Against the Program Fraud Against the Program Section 12. Ending Coverage When Coverage Ends COBRA Continuation Coverage What is COBRA Continuation Coverage? When is COBRA Continuation Available? How is COBRA Coverage Provided? Medicare Extension for Spouse and Dependent Children Disability Extension of 18-Month Period of Continuation Coverage Second Qualifying Event Extension of 18-Month Period of Continuation Coverage Termination of COBRA Continuation Coverage Before the End of the Maximum Coverage Period Cost of Continuation Coverage First Payment of Continuation Coverage Periodic Payments for Continuation Coverage Grace Periods for Periodic Payments More Information About Individuals Who May Be Qualified Beneficiaries Governmental Assistance from Trade Act of 2002 Section 13. Your Legal Rights Under ERISA ii

4 Section 14. Plan Administrator s Discretion Section 15. Welfare Benefits Section 16. Dow s Right to Terminate or Amend the Program Section 17. Disposition of Plan Assets If the Program is Terminated Section 18. Class Action Lawsuits Section 19. Funding Section 20. Payment of Unauthorized Benefits Section 21. For More Information Section 22. Definition of Terms Section 23. Claims Procedures General Who Will Decide Whether to Approve or Deny My Claim? Authority of Administrators and Your Rights Under ERISA 23.3 An Authorized Representative Can Act on Your Behalf Claims for Benefits Filing a Claim for Benefits Appealing a Denial of a Claim for Benefits 23.5 Eligibility Determination Claims Initial Determination Appealing the Initial Determination Section 24. For More Information APPENDIX A Important Notice of Creditable Coverage for Medicare-Eligibles iii

5 Section 1. ERISA Information The Dow Chemical Company Insured Health Program SPD Wrapper for HMOs and Insured Plans applicable to Eligible Active Employees Plan Sponsor: The Dow Chemical Company Employee Development Center Midland, Michigan Employer Identification Number: Plan Number: 601 Claims Administrator With respect to claims and questions concerning benefits coverage: The applicable HMO or insured health plan With respect to eligibility to participate in the Program: N.A. Health and Welfare Leader The Dow Chemical Company Employee Development Center Midland, Michigan ) or (989) Plan Administrator: N.A. Health and Welfare Leader The Dow Chemical Company Employee Development Center Midland, Michigan (877) or (989) To Apply for or to Appeal Denial of a Claim: See Claims Procedures in Section 23 To Serve Legal Process File with: The applicable HMO or insured health plan at the address provided by the HMO or insured health plan. COBRA Towers Watson BenefitConnect COBRA Service Center PO Box San Diego, CA (877) HMO Network Manager Secova, Inc. (formerly known as UltraLink) is the HMO Network Manager for HMOs offered to Employees and their Dependents. Page 1

6 Secova, Inc. 535 Anton Boulevard, Suite 900 Costa Mesa, California (800) 7DOWDOW or (800) Plan Year Fiscal records are kept on a plan year basis beginning January 1 and ending December 31. Funding Participating Employers share the premium costs with Employees. Employee contributions are made through payroll deduction. Benefits are underwritten by the applicable HMO or insured plan. The applicable HMO or insured plan is liable to pay the benefits, not the Participating Employer. Any assets of the Program can be used at the discretion of the Plan Administrator to pay for any benefits provided under the Program, as the Program is amended from time to time, as well as to pay for any expenses of the Program. Such expenses can include, and are not limited to, consulting fees, actuarial fees, attorney fees, thirdparty administrator fees and other administrative expenses. EAP Aetna Employee Assistance Program 151 Farmington Avenue Mailstop RS 32 Hartford, CT Page 2

7 Section 2. Summary Plan Description Wrapper This is the Summary Plan Description ("SPD") Wrapper ("SPD Wrapper") for Health Maintenance Organizations (HMOs) and insured health plans (except The Dow Chemical Company International Medical and Dental Program) that are offered through The Dow Chemical Company Insured Health Program ( Program ) as applicable to eligible active Employees. The HMOs and insured plans, except The Dow Chemical Company International Medical and Dental Program, offered by the Program are listed each Fall in the annual enrollment materials. This SPD Wrapper addresses: ERISA Information EAP Eligibility for Coverage Enrollment Premiums Your Rights under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other legislation Information Exchanged by the Plan s Service Providers Filing and Appealing Claims for an Eligibility Determination Fraud Against the Program Survivor Benefits Ending Coverage and your rights under COBRA Your Legal Rights under ERISA The Program provides Welfare Benefits Dow s Right to Terminate or Amend the Program Disposition of Plan Assets if the Program is Terminated This SPD Wrapper does NOT address the information listed below. Such information can be found in the materials provided to you by the applicable HMO or insured plan. The SPD Wrapper, when combined with the materials provided to you by the HMO or insured plan are intended to constitute the Summary Plan Description for the HMO plan or insured plan. The materials provided by the HMO or insured plan should address the following: Benefits covered under the applicable HMO or insured plan and the coverage levels Terms and Conditions for benefits coverage under the applicable HMO or insured plan Copays, deductibles, out of pocket maximums and coverage limitations Filing and appealing Claims for Benefits Precertification or preauthorization requirements In-network and out-of-network provisions, if any Primary care physician requirements, if any Any other provisions of the applicable HMO or insured plan HIPAA notice of privacy practices Page 3

8 This SPD Wrapper, together with the material provided by the applicable HMO or insured plan, is intended to constitute the Summary Plan Description for the applicable HMO or insured plan. This SPD is an integral part of the Plan Document for The Dow Chemical Company Insured Health Program ( Program ). However, it does not contain all of the information. Further information can be found in the Plan Document for The Dow Chemical Company Insured Health Program, a copy of which is available from the Plan Administrator. You may request a copy of the Plan Document from the Plan Administrator. See the ERISA Information section of this SPD for the Plan Administrator s name and address. The Dow Chemical Company reserves the right to amend, modify or terminate The Dow Chemical Company Insured Health Program (and/or its inclusion or exclusion of any HMO or insured plan) at any time at its sole discretion. This SPD and the Plans do not constitute a contract of employment. Your Employer retains the right to terminate your employment or otherwise deal with your employment as if this SPD and medical benefits had never existed. The provisions of this SPD Wrapper only apply to HMOs and insured plans offered through The Dow Chemical Company Insured Health Program. For information about the self-insured plans applicable to eligible active Employees that are offered through The Dow Chemical Company Medical Care Program, check the Dow Intranet or call the Human Resources (HR) Service Center at (877) or (989) Words that are capitalized are either defined in the Plan Document for The Dow Chemical Company Insured Health Program in the Definitions of Terms section. When used in this Summary Plan Description and communications to Employees, Dow refers to The Dow Chemical Company and its subsidiaries and affiliates that it has authorized to participate in the Program. A pronoun or adjective in the masculine gender includes the feminine gender, and the singular includes the plural, unless the context clearly indicates otherwise. Section 3 (A) About HMO s 3.1 How HMOs Operate Section 3. HMOs are a form of prepaid medical assistance designed to help keep you and your family healthy by encouraging regular checkups and early detection of medical problems. Some HMOs provide services in an HMO-owned facility, perhaps with satellite facilities, staffed by their own physicians, specialists, and other health care professionals. Others offer services through independent medical offices or through physicians and specialists under contract with the HMO. The intent of an HMO is to maintain the health of its members while ensuring medical coverage when needed. The HMO provides services for emergencies and medical conditions, but the emphasis is on preventive medicine. In addition, HMOs try to reduce medical expenses by conducting, when possible under one roof, routine health maintenance services that are most commonly used by members. Page 4

9 Generally, when you join an HMO, you select a Primary Care Physician (PCP) from the HMO staff. You agree to use the HMO s facilities and staff, or those under contract to the HMO, instead of obtaining services from physicians, specialists or facilities not affiliated with the HMO. Your PCP will be responsible for managing health care for you and your family. However, the HMO physician can, on occasion, refer you to a non-affiliated provider. Services obtained from any Physician or facility not affiliated with the HMO will not be covered by the HMO unless authorized by an HMO physician, or provided under emergency conditions. An HMO concentrates its resources in a specific geographic area, sometimes a county or an area defined by residential zip codes. Most HMOs do not provide coverage outside their service area other than for emergencies, life-threatening conditions or referrals by the PCP. HMOs should not refuse to provide services or coverage because of a labor dispute involving employees of the HMO. Generally, you will not be billed directly by the HMO for any medical services except for charges such as Copayments for services only partially covered by the HMO. Any charge not paid by the HMO becomes your responsibility not Dow s. If an HMO fails to pay a charge directly to a health care provider or fails to provide coverage for an expense you feel should be covered, the disagreement should be settled between you and the HMO. In general, if you leave Dow employment, you can convert to an individual policy with your HMO. Also, under certain circumstances, you can continue coverage for you and your Dependents for a limited time under the rules established in the Federal Consolidated Omnibus Budget Reconciliation Act (COBRA). See the section of this SPD Wrapper entitled Your Right to Continuation Coverage Under COBRA for details, or contact the Dow HR Service Center at (877) or (989) in Midland, Michigan, for details about COBRA. For details about converting your HMO coverage to an individual policy, contact your HMO or Secova. 3.2 Dow and HMOs When you enroll in an HMO, you are not enrolled in a benefit plan designed or administered by Dow except for Dow s involvement in determining whether you meet the Program s eligibility rules described in this SPD Wrapper. Instead, you are enrolled in an independent medical plan that is operated by an HMO entity separate from Dow. By joining an HMO you agree to obtain your health care coverage through the HMO. Dow s primary contact with the HMO is the payment of premiums, your portion through payroll deduction and Dow s. Any disagreement between you and the HMO becomes a matter to which you and the HMO should respond. For example, if you disagree with the HMO over a settlement of a Claim, or have any questions concerning a Physician referral, you should follow the review and appeals procedures of that HMO. Any charge not paid by the HMO is your responsibility, not Dow s. If an HMO fails to pay a charge directly to a health care provider or fails to provide coverage for an expense you feel should be covered, the disagreement should be settled between you and the HMO. 3.3 Information that Your HMO Should Provide You Each HMO will supply you, upon written request, written materials concerning: the nature of services provided the HMO s members; conditions pertaining to eligibility to receive such services, other than general conditions pertaining to eligibility required by Dow described in this SPD Wrapper; the circumstances under which services can be denied; the procedures to be followed in obtaining such services and the procedures available for the review of the Claims for Benefits that are denied in whole or in part. Page 5

10 Secova can assist you in obtaining these HMO materials if you need help getting them from the HMO. 3.4 Secova, the HMO Network Manager Dow has hired Secova, Inc. (formerly known as UltraLink) to manage the HMOs that participate in The Dow Chemical Company Insured Health Program. If you would like more information regarding the availability of HMOs in your area, or do not know how to contact your HMO, contact Secova, Dow s HMO Network Manager, at (800) 7DOWDOW. In addition, your open enrollment materials also will provide you with further details. 3.5 Grandfathered HMO s Dow believes that the HMO s offered under the Program are grandfathered health plans under the Patient Protection and Affordable Care Act (PPACA). Contact the HMO directly if you want to know whether the HMO plan is grandfathered. Being a grandfathered health plan means that this specific HMO s plan does not include certain consumer protections of PPACA. 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 Human Resources (HR) Service Center, Employee Development Center, Midland, Michigan 48674, telephone (877) or (989) You may also contact the Employee Benefits Security Administration, U.S. Department of Labor at or Section 3 (B). Employee Assistance Plan ( EAP ) All active Employees and their Dependents who are enrolled in any of the HMO s are eligible for free EAP services. EAP provides professional and confidential counseling on emotional, social and mental health issues for employees and dependents experiencing personal difficulties. Participation is voluntary and typically self-referred. EAP support is available on a 24-hour per day, 7-day per week basis. EAP provides up to six visits to an EAP counselor for assessment and referral or short-term counseling. The types of problems supported by EAP include: Interpersonal relationships Anxiety/stress Depression/mental health issues Teen/Parent relationships Separation/Divorce Financial/legal problems Grief/loss Anger management/violence When the EAP services are not medical in nature, they are called EAP Direct Services. The part of EAP that provides EAP Direct Services is not part of any HMO Plan. 1 Sometimes, during the EAP counseling sessions, a limited amount of mental health counseling occurs, which is medical in nature. The part of EAP that provides these limited mental health 1 EAP Direct Services are not offered under Dow ERISA Plan #501 or Dow ERISA Plan #601, or any other Dow-sponsored ERISA plan. Page 6

11 services is an adjunct component of each of the HMO Plans because this portion of EAP provides services that are medical in nature. This part of EAP is called Medical EAP. Medical EAP is an adjunct component each HMO Plan. Regardless of the HMO carrier, EAP is administered by Aetna: Aetna Employee Assistance Program 151 Farmington Avenue Mailstop RS 32 Hartford, CT To contact a local EAP provider, go to: While Medical EAP provides limited mental health benefits offered as an adjunct component of the HMO Plan at no cost to you, if you are enrolled in the HMO Plan, the HMO Plan also provides more extensive mental health coverage and that coverage and the costs of coverage are described in the materials provided by the HMO you are enrolled in, which are a part of this SPD. Am I Still Eligible for EAP If I Am Not Enrolled In an HMO? Yes. If you decided not to enroll in an HMO, but instead enrolled in one of the other medical plans offered by Dow to active employees, you are still eligible for free EAP benefits. Your Medical EAP benefits are provided by the active employee medical plan that you are enrolled in. Regardless of which active medical plan you are enrolled in, your EAP benefits are administered by Aetna at the Farmington Ave. address above. Even if you did not enroll in any medical plan offered by Dow to active employees, you are still eligible for free EAP benefits. If you did not enroll in any Dow medical plan, your Medical EAP benefits are provided by the MAP Plus Plan. Your EAP benefits are administered by Aetna at the Farmington Ave. address above. 4.1 HMO Availability Section 4. Eligibility Besides meeting the eligibility criteria described in this SPD Wrapper, in order to participate in a particular HMO or insured plan, you must be located where the HMO or insured plan is available. 4.2 Employee Eligibility Employee Eligibility: Except as otherwise provided in this Section 4.2, an eligible Employee is defined as: an active, regular, Full-Time or Less-Than-Full-Time Salaried U.S. Employee of The Dow Chemical Company or entity that The Dow Chemical Company has authorized to participate in the Program (The Dow Chemical Company and the other authorized entity are each a Participating Employer ), who is not covered by the Dow International Medical and Dental Program; or an active, regular, Full-Time Bargained-for U.S. Employee of a Participating Employer whose Bargaining Unit and the Participating Employer have agreed to the Program. However, if the terms Page 7

12 of the collective bargaining agreement specifically address which Employees are eligible or not eligible for this Plan, then the terms such collective bargaining agreement shall govern as to whether an Employee is eligible. If you are a Rohm and Haas Company Employee who has been approved for disability payments under the Rohm and Haas Company Health and Welfare Plan s Short Term Disability Program 2, you are eligible for medical coverage until you are no longer eligible to receive disability payments under the Rohm and Haas Company Health and Welfare Plan s Short Term Disability Program. You must pay the same premiums active Employees are required to pay. If you are a Rohm and Haas Company Employee who has been approved for disability payments under the Rohm and Haas Company Health and Welfare Plan s Long Term Disability Program or you are a Morton International, Inc. Employee who was approved for disability payments under the Rohm and Haas Company Health and Welfare Plan s Long Term Disability Program due to a qualifying disability incurred prior to October 1, 2009, you are eligible for medical coverage until you are no longer eligible to receive disability payments under the Rohm and Haas Company Health and Welfare Plan s Long Term Disability Program. Except as otherwise specified in a collective bargaining agreement, you must pay the same premiums active employees of Dow pay for comparable coverage. If you do not meet the eligibility requirements above, you still may be eligible if you live in Hawaii, and the Participating Employer is required to provide you coverage under the Hawaii Pre-Paid Health Care Act of A regular Employee is an Employee who is classified by the Employer as regular. Benefit Protected Leave of Absence: Eligibility for benefits under the Program may continue during certain leaves of absences approved by the Participating Employer such as under the Company's Military Leave Policy, Family Leave Policy or Medical Leave Policy. The benefits under the Program shall be administered consistent with the terms of such approved leaves of absences. International Medical and Dental Program: Expatriates and their eligible Dependents should refer to the Dow International Medical and Dental Plan Summary Plan Description to determine their eligibility and coverage under that plan. Those who are eligible for coverage under The Dow International Medical and Dental Plan are not eligible for coverage under HMOs or other insured plans offered under The Dow Chemical Company Insured Health Program. 4.3 Dependent Eligibility Eligible Employees can enroll their eligible Dependents. A Dependent may be an Employee s Spouse, an Employee s Domestic Partner or an eligible child. An Employee must be enrolled in order to enroll a Dependent Spouse/Domestic Partner or Dependent child. If you enroll your Spouse/Domestic Partner or Dependent Child, you are required to provide their social security number to the Plan if requested to do so by the Plan. Dropping or Adding a Domestic Partner: You must file a Termination of Domestic Partnership form with the Plan Administrator by using the Dow Benefits web site or calling the HR Service Center, and wait at least twelve (12) months after filing the Termination of Domestic Partnership form before you can add a new Domestic Partner as your 2 If you are a Morton Salt Employee, this paragraph does not apply to you. You are not eligible for coverage under The Dow Chemical Company Insured Health Program. Page 8

13 dependent. In addition, you must file a new Statement of Domestic Partner Relationship for the new Domestic Partner. Adding a New Domestic Partner after Termination of a Prior Domestic Partnership You must file a Termination of Domestic Partnership form with the Plan Administrator by using the Dow Benefits web site or calling the HR Service Center, and wait at least twelve (12) months after filing the Termination of Domestic Partnership form before you can add a new Domestic Partner as your dependent. In addition, you must file a new Statement of Domestic Partnership for the new Domestic Partner. Spouse and Domestic Partner Exclusions Your Spouse or Domestic Partner is not eligible for coverage under the Program if he is: eligible for coverage as a full-time employee or retiree under another employer s 3 plan, but not enrolled for personal coverage in that plan (see the Working Spouse/Domestic Partner Rule section for details), or enrolled for coverage as an Employee or Retiree under another Dow or Dow-affiliated Plan, or serving in the armed forces of any country. The Working Spouse/Domestic Partner Rule: If your Spouse/Domestic Partner is working full time or retired and your Spouse/Domestic Partner s employer offers subsidized group health coverage to its employees or retirees, you cannot cover your Spouse/Domestic Partner as a Dependent under the Program unless your Spouse/Domestic Partner has enrolled himself in his/her employer s group health plan. If your Spouse/Domestic Partner s employer does not subsidize the group health coverage, he/she is not required to enroll. However, if there is an employer subsidy, no matter how large or small the subsidy is, or what the premiums are, your Spouse/Domestic Partner must enroll to be eligible for coverage as a Dependent under the Program. If the Plan learns that an Employee has a Spouse/Domestic Partner who has inadvertently failed to enroll in the medical plan available to them through their own employer as a result of their full-time employment, the Program will offer coverage at 102% of Dow s cost. This coverage (at 102% of the full cost) will be retroactive to January 1 of the plan year in which the Plan learns that the Spouse/Domestic Partner failed to enroll in his/her employer s group health plan. If the Spouse/Domestic Partner incurred Claims during the year prior to such plan year, the Employee has the option to purchase coverage for the entire prior year at 102% of the full cost to insure. Therefore, the Employee can choose coverage for the current plan year (in which the Spouse/Domestic Partner s failure to enroll in his employer s group health plan was discovered by the Program), or the current plan year plus one prior year. The Plan will not allow retroactive coverage for partial years. The following is required in order to have such coverage on your Spouse/Domestic Partner: the Spouse/Domestic Partner was enrolled in the Program at the normal premium when the Plan learns that he/she was eligible for his/her employer s group health plan. the Spouse/Domestic Partner will be required to enroll in coverage through his/her employer s group health plan at the earliest possible date, which date you must provide to the Plan before being able to cover your Spouse/Domestic Partner at 102% of the cost of coverage. If the two previous bulleted items are met, and you cover your Spouse/Domestic Partner, and then drop him/her from your Dow coverage, or fail to pay the 102% premium, you cannot re-enroll your Spouse/Domestic Partner until the next Dow open enrollment period that occurs after your Spouse/Domestic Partner has enrolled in his/her plan. 3 As used in the Spouse/Domestic Partner Exclusions paragraphs of this SPD, employer means someone who employs another. It also includes the partner or owner of a business. As used in these sections, employees (without a capital e ) includes partners and owners, as well as those who are providing services in an employeremployee relationship. These definitions also apply to the paragraphs of this SPD entitled The Working Spouse/Domestic Partner Rule; Waiving Coverage Working Spouse/Domestic Partner and Mid Year Election Changes. Page 9

14 If your Spouse s/domestic Partner s employer offers more than one group health plan, your Spouse/Domestic Partner must enroll himself/herself in the group health plan that is most comparable to the Dow Plan in which you are enrolled. If your Spouse/Domestic Partner is enrolled for the Dow Plan, the Dow Plan will be coordinated according to the plan offered by your Spouse s/domestic Partner s employer that is most comparable to the Dow Plan you are enrolled in, regardless of the plan in which your Spouse/Domestic Partner is actually enrolled. If the 102% of premium option described above is either not applicable or not elected by the Employee/Retiree, then during the period of time when the Spouse of Record/Domestic Partner of Record did not satisfy the Working Spouse/Domestic Partner Rule, coverage under the Dow Plan is cancelled. There is not a requirement that your Dependent children must enroll in your Spouse/Domestic Partner s plan to be eligible under the Program. If you decide to enroll your eligible Dependent child(ren) under the Program, and your Spouse/Domestic Partner also enrolls them under his employer s group health plan, the benefits for the child(ren) will be coordinated between the two health plans. Please note that you may want to consider carefully whether it is advantageous to enroll your Spouse/Domestic Partner as a Dependent under the Dow Plan if the coverage offered by his or her employer is as comprehensive or better coverage than the Dow Plan. The Dow Plan would be secondary to your Spouse/Domestic Partner s medical plan under the Dow Coordination of Benefits rules. You may choose to waive coverage for him /her under the Dow Plan in order to save premium dollars. If you waive Dow coverage, then no coordination of benefits will occur. Exception to the Working Spouse/Domestic Partner Rule: Dual Dow Active Employee and Retiree Spouse/Domestic Partner If your Spouse/Domestic Partner is a Dow Retiree (or 60 Point or 65 Retiree Medical Severance Plan Participant or LTD Participant) who is eligible for coverage under the Program because of his or her prior employment with Dow and is eligible for active medical coverage under another employer s plan, your Spouse/Domestic Partner is not required to enroll in that coverage in order to have coverage under the Plan. Dependent Child(ren): A child is eligible if the child meets the definition of Dependent child. A Dependent child is a child who must be: your birth or legally adopted child, or your Spouse s or Domestic Partner s natural or adopted child; or, a child for whom you or your Spouse/Domestic Partner have the permanent legal guardianship or permanent legal custody as those terms are defined under the laws of the state of Michigan. Child(ren), including grandchild(ren), not specifically identified in the first two bullets above, are not eligible for coverage as Dependents unless both their biological parents are deceased, or have permanently legally relinquished all of their parental rights in a court of law. Legally relinquished all of their parental rights, means that the biological parents permanently do not have the: authority to consent to the child s Marriage or adoption, and authority to enlist the child in the armed forces of the U.S.; and right to the child s services and earnings; and power to represent the child in legal actions and make other decisions of substantial legal significance concerning the child, including the right to establish the child s primary residence. Page 10

15 In addition to meeting the above requirements, in order to be a Dependent child, the child must be less than age 26, except that a child who is age 26 or older and incapable of self-sustaining employment because of a physical or mental disability, and is covered under the Plan prior to the child s 26 th birthday, may continue coverage. If you enroll your Domestic Partner's child(ren), you must have the Plan Administrator's "Statement of Domestic Partner Relationship" on file with the Plan, and your Domestic Partner must meet the Plan's definition of Domestic Partner. In addition, your Domestic Partner's child(ren) must meet all of the eligibility criteria outlined in this SPD. Qualified Medical Child Support Orders: A child who does not qualify as a dependent child above, may still be eligible for coverage if the Employee has a qualified medical child support order for that child. A Qualified Medical Child Support Order (QMCSO) is a court order that meets the Program s requirements. It gives a child the right to be covered under one of the Dow Plans. Typically, a divorce decree that orders the Employee to provide medical coverage for a specific child is a QMCSO, as long as the divorce decree also provides the following information. The Plan will also deem a divorce decree that orders the Employee to provide medical coverage for a specific child a QMCSO if the following information is also provided with the divorce decree in a document signed by either the Employee or the custodial parent (as long as such document contains information consistent with the divorce decree): clearly specifies the name and last known mailing address of each child for whom the Employee must provide medical coverage, and gives a reasonable description of the type of coverage to be provided to the child, and states the period for which the coverage is to be provided (within Dow s rules). In order to provide coverage to a child under a QMCSO, the Employee must be eligible for coverage under the Program. Note that if there is any ambiguity in, or between, the document(s) signed by the Employee or custodial parent, the Plan reserves the right to require the Employee and/or custodial parent to obtain a court order to clear the ambiguity. If a QMCSO applies, the child is eligible for coverage as your Dependent. You can obtain a free copy of the Program s QMCSO procedures, which explain how the Program determines whether a court order meets the Plan s requirements, by requesting a copy from the Plan Administrator (listed in the ERISA Information section of this SPD). Other Dependent Child Exclusions Your Dependent child will not be eligible for coverage under the Program if he: is covered as a Dependent under a Dow-sponsored or UCC-sponsored retiree medical plan all eligible child(ren) in a family must be covered by the same parent (exceptions can be made as necessary in stepchild situations). reaches age 26 coverage ends on the child s 26 th birthday. Children age 26 or older are not eligible. However, coverage can continue beyond age 26 if, prior to age 26, he/she is incapable of self-sustaining employment because of a physical or mental handicapping condition and is covered under the Plan on the day prior to reaching age 26. The child must be principally dependent upon you for support. Proof of the child s initial and continuing dependency and incapacity must be provided to the Program prior to age 26 in order for coverage to continue. You must make any contribution required by the Program to continue coverage for your child. Once the coverage is terminated, it cannot be reinstated. Contact the Dow HR Service Center at (877) or in Midland at (989) for more information if this applies to you. Page 11

16 When your child is no longer is eligible for Dependent coverage because of one of these events, you must make a new enrollment within 90 days of the loss of eligibility. You may qualify for a reduction in your monthly premium. If you are an active Employee, complete a make a new enrollment on the Dow Benefits web site or call the HR Service Center. If you fail to enroll within 90 days, according to government regulations for pre-tax deductions, you cannot make the change until the following annual enrollment period, with any reduction in premium effective at the beginning of the next calendar year. The loss of coverage for your Dependent, however, will occur on the date your Dependent becomes ineligible, whether or not a reduction in your monthly premium occurs. For information about rights your child may have for continuation of coverage under the Program as provided by the federal COBRA law, see section entitled Your Right to Continuation Coverage Under COBRA. 4.4 Eligibility Determinations of Claims Administrator are Final and Binding The Dow N.A. Health and Welfare Leader is the Claims Administrator that determines eligibility. The N.A. Health and Welfare Leader is a fiduciary of the Program and with respect to Eligibility Determinations, has the full discretion to interpret provisions of the SPD Wrapper and the Plan Document and to make findings of fact. Interpretations and eligibility determinations by the N.A. Health and Welfare Leader are final and binding on Participants. If you would like the N.A. Health and Welfare Leader to determine whether you are eligible for coverage, you can file a Claim for an Eligibility Determination. See Claims Procedures in Section 23. Section 5. Enrollment 5.1 Levels of Participation Levels of Participation The levels of participation available are: Employee Only Employee plus Spouse Employee plus Domestic Partner Employee plus Child(ren) Employee plus Spouse and Child(ren) Employee plus Domestic Partner plus Child(ren) The Employee must be enrolled in order to enroll a Dependent Spouse/Domestic Partner or Dependent child. The Employee may only enroll the Dependent in same plan that the Employee is enrolled in. A Dependent may not be enrolled in a Dow plan that is different than the Employee. For example, if the employee is enrolled in Kaiser HMO, the Dependent cannot be enrolled in Blue Care Network or MAP Plus. The Dependent may only be enrolled in the same plan that the Employee is enrolled in, in this example, Kaiser HMO. 5.2 Enrolling at the Beginning of Employment Page 12

17 To enroll for Program coverage upon hire, enroll on the Dow Benefits web site within 90 days of beginning to work or call the HR Service Center. If you are enrolling your Spouse/Domestic Partner and/or child(ren), you must provide proof of their eligibility within the 90-day period (for example: Marriage certificate, Domestic Partner signed statement, birth certificate, adoption papers or any other proof the Plan Administrator deems appropriate). If your enrollment and proof of Dependent eligibility are received within 30 days of your first day at work, coverage is effective on your first day on the job. Otherwise, except as specified below, coverage begins on the date your enrollment is received if the proofs of Dependent eligibility are received within 90 days of your first day at work and you are actively at work. If you enrolled and submitted the required documentation during the 90-day period and you want your enrollment to be made retroactively effective to your date of hire, then you can request retroactive coverage. In order for your coverage to be made retroactive, you must pay 102% of the full cost to insure with post-tax dollars for the period from your date of hire until your date of enrollment. Failure to provide proof of Dependent eligibility will result in no coverage for your Dependents. After enrolling you will receive an identification card showing the phone number to call with questions you may have, or to verify coverage. 5.3 Enrolling During Annual Enrollment Enrollment is typically held during the last quarter of the year and is handled electronically. You can enroll for coverage, switch plans or waive coverage at this time. If you wish to add a Dependent, either a Spouse/Domestic Partner or a child, during annual enrollment, you must make sure that your coverage level is appropriate when you enroll. Complete the Dependent Enrollment Change Form on the Dow Benefits web site or call the HR Service Center to add your Dependent, and submit it with proof of Dependent eligibility no later than March 31 of the applicable plan year. The Program reserves the right at any time to request proof of Dependent eligibility, such as birth certificates, passports, Marriage certificates, Domestic Partner signed statements or any other form of proof the Plan Administrator deems appropriate. Failure to provide proof of Dependent eligibility will result in no coverage for your Dependents. If your Spouse is enrolled in a plan, you may not dis-enroll your Spouse in anticipation of a divorce. You are required to continue coverage for your Spouse and pay the applicable premium. Under the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (COBRA), when your legal separation or divorce is final, your Spouse has a right to continue coverage under the Plan at 102% of the full cost of coverage for a certain period of time. See Your Rights to Continuation Coverage Under COBRA in this SPD for more information about COBRA coverage. 5.4 Dual Dow Coverage If you and your Spouse/Domestic Partner are each independently eligible for coverage under a Dowsponsored medical plan (which includes heritage Rohm and Haas) or Union Carbide-sponsored medical plan, the following rules apply: You may each enroll separately, or one of you may enroll the other as a Dependent; except that an active Employee may not be enrolled as a Dependent in a Retiree Medical plan. If you each enroll separately, either of you, but not both, may enroll your eligible Dependent children (this rule also applies to divorced parents who are independently eligible for coverage) Page 13

18 If you each enroll separately, your Deductibles and Out-of-Pocket Maximums will be calculated separately (this rule also applies to divorced parents who are independently eligible for coverage) 5.5 Special Enrollment Provisions If you decline enrollment in Dow coverage for yourself or your Dependents (including your Spouse/Domestic Partner) because you have other health insurance coverage, you may in the future enroll yourself or your eligible Dependents outside of Dow s usual open enrollment period if you or your Dependent lose eligibility for the other coverage or the other employer ceases to make employer contributions for the other coverage. In order to have Dow sponsored HMO/insured plan coverage, you or your eligible Dependent must enroll in the Dow sponsored HMO/insured plan coverage within 90 days after the other coverage ends. However, if you or your Dependent declined Dow sponsored HMO/insured plan coverage because of other coverage provided through COBRA, you or your Dependent must wait until Dow s open enrollment period unless the entire period of coverage available under the COBRA coverage has been exhausted. An individual need not elect COBRA coverage under another health plan in order to use these special enrollment provisions. Proof of eligibility is required within the 90-day period. If you have a new Dependent as a result of Marriage, Domestic Partnership, birth, adoption or placement for adoption, you may receive Dow coverage for yourself and your Dependent if you enroll in the Dow coverage within 90 days after the Marriage, Domestic Partnership, birth, adoption or placement for adoption. For new births, the date of birth will be the effective date of coverage. For adoptions, the date of adoption or date of placement for adoption, whichever is earlier, will be the effective date of coverage. For Marriage and Domestic Partnership, coverage is effective on the date the Plan Administrator receives the enrollment papers. Proof of eligibility is required within the 90-day period. If you or your Dependent either (i) lose coverage under Medicaid or a State Child Health Insurance Plan ( SCHIP ) or (ii) become eligible for premium assistance under the Plan through Medicaid or SCHIP, you may receive coverage under the Plan for yourself and your Dependent if you enroll in the Plan within 90 days. Contact the HR Services Center, Employee Development Center, Midland, Michigan 48672, telephone (877) or (989) Plan coverage will be effective on the date the Plan Administrator receives the enrollment papers. Proof of eligibility is required within the 90-day period. 5.6 Change of Elections to Prevent Discrimination The Plan Administrator has the authority to change the benefit elections of certain Participants if such a change is necessary to prevent the Program from becoming discriminatory within the meaning of Code Section 125(b). If the Plan Administrator determines or is informed by the plan administrator of The Dow Chemical Company Flexible Spending Plan ( Cafeteria Plan ) before or during any plan year that the cafeteria plan may fail to satisfy, for such plan year, any nondiscrimination requirement imposed by the Code, or any limitation on benefits provided to key Employees or highly compensated Employees, the Plan Administrator shall take such action as the Plan Administrator deems appropriate, under rules uniformly applicable to similarly situated Participants, to assure compliance with such requirement or limitation. Such action may include, without limitation, a modification of elections by highly compensated Employees or key Employees with or without the consent of such Employees. Page 14

19 5.7 If You Move During the Plan Year If you move during the plan year and your HMO is not offered at your new location, you may switch your coverage to an HMO that is available at the new location or switch to a self-insured plan offered under The Dow Chemical Company Medical Care Program. Section 6. Mid-Year Election Changes 6.1 Change in Status You purchase your Employee, Spouse and Dependent Child coverage with premiums that are pre-tax dollars through The Dow Chemical Company Flexible Spending Plan, a plan intended to qualify under s.125 of the Internal Revenue Code as a Cafeteria Plan. Under Internal Revenue Service (IRS) rules, you may change your medical coverage level only during annual enrollment or if you have BOTH a change in status AND you meet all of the consistency rules. Because of IRS rules, Domestic Partner coverage is purchased with post-tax dollars. The Program administers changes in status events and the consistency rules the same way with respect to Domestic Partners as Spouses, regardless of the post-tax treatment by IRS, to the extent that such administration does not jeopardize the tax qualified status of the Program. A change in status is an event listed in one of the bullets below: Events that change your legal marital status, including Marriage, Domestic Partnership, death of Spouse/Domestic Partner, divorce or annulment or similar event with respect to a Domestic Partnership. Birth, adoption, placement for adoption or death of Dependent. A termination or commencement of employment by you or your Spouse/Domestic Partner. A reduction or increase in hours of employment by the Employee or Spouse/Domestic Partner. Dependent satisfies or ceases to satisfy the definition of Dependent child. A change in the place of residence or work for you or your Spouse/Domestic Partner. Spouse/Domestic Partner gains eligibility for coverage under the Spouse/Domestic Partner s employer s health plan. 6.2 Consistency Rule Consistency Rule: In addition to having a change in status, you also must meet all of the following consistency rules. 1. The change in status must result in you, your Spouse/Domestic Partner, or your Dependent gaining or losing eligibility for coverage under either the Dow sponsored plan or the parallel plan of your Spouse/Domestic Partner or Dependent s employer. 2. The election change to the Dow sponsored plan must correspond with that gain or loss of coverage. Exceptions: You may change your medical coverage levels mid-year without having met the change in status and consistency-rule requirements only under the following circumstances: Court Orders You may change your election mid-year if a court order resulting from a divorce, annulment, or change in legal custody (including a Qualified Medical Child Support Order QMCSO), requires a change in your medical plan election. Page 15

20 Entitlement to Medicare or Medicaid If you, your Spouse/Domestic Partner or Dependent are enrolled in the Program and become entitled to coverage (i.e., enrolled) under Medicare or Medicaid mid-year (other than for coverage consisting solely for distribution of pediatric vaccines), you may cancel your Program coverage. Significant Cost or Coverage Changes If your Spouse/Domestic Partner is covered by his/her employer s plan, and your Spouse/Domestic Partner s employer allows him/her to change his/her benefit plan election because of a significant change in cost or coverage under your Spouse/Domestic Partner s employer s plan, such change in your Spouse/Domestic Partner s election will allow you to change your Dow election. If your Spouse/Domestic Partner s employer s enrollment period is different from Dow s, your Spouse/Domestic Partner s election under his/her employer s plan may constitute a significant coverage change allowing you to change your Dow election. Special Enrollment Rights under the Health Insurance Portability and Accountability Act (HIPAA) You may change your Program election mid-year if you meet the special enrollment requirements addressed in HIPAA. See the HIPAA section for more details. 6.3 Documentation of Eligibility Required to Make Election Change Documentation is required to make an election change, such as birth certificates, passports, Marriage certificates, Domestic Partner signed statements, evidence of loss of Spouse/Domestic Partner or Dependent s employment, or any other form of proof the Plan Administrator deems appropriate. The Program reserves the right to, at any time, request proof of eligibility. Failure to provide proof of eligibility within the time required will result in no coverage. 6.4 Deadline to Enroll for Mid-Year Changes If you meet the requirements allowing you to make a mid-year election change, any change made at any time outside of open enrollment (typically in the Fall of each year), you must submit proof of eligibility and enroll within 90 days or 180 days for geographic relocation under the Participating Employer s relocation policy of the change in status event. Except for the birth or adoption of a child or a court order, if the Plan Administrator receives your enrollment and proofs within 31 days of the Change-in-Status event, the effective date of change in coverage will be the date of the Change in Status event. If the Plan Administrator receives your enrollment and proofs on day 32 through 90 after the Change in Status event, the effective date of the change in coverage will be the Plan Administrator s processing date. For the birth of a child, the date of birth will be the effective date of coverage. For adoption of a child, the date of adoption or date of placement for adoption, whichever is earlier, will be the effective date of coverage. For a court order, the date specified in the court order will be the effective date. Page 16