General Dynamics Corporation

Transcription

1 Plan Name: Beacon Health Options EAP Active Plan Code(s): 631, 635 SPD Code: 1261 General Dynamics Corporation Employee Assistance Program Administered by Beacon Health Options Summary Plan Description For the following eligible employees: An American Overseas Marine (AMSEA) full-time nonrepresented employee. A Corporate Headquarters (CHQ) full-time or part-time nonrepresented employee. A General Dynamics Information Technology (GDIT) full-time nonrepresented or represented employee. A General Dynamics-OTS (formerly ATP) Vermont full-time represented hourly employee. A General Dynamics-OTS (formerly ATP) Lincoln full-time represented hourly employee who reaches 90 days of service with the Company. A General Dynamics-OTS (formerly ATP) Marion full-time represented hourly employee who reaches 90 days of service with the Company. A General Dynamics-OTS (formerly ATP) full-time or part-time nonrepresented salaried or nonrepresented hourly employee. A General Dynamics-OTS (formerly ATP) Saco full-time or part-time represented hourly employee who has completed 60 days of service with the Company. A General Dynamics-OTS (formerly ATP) Springboro full-time or part-time represented hourly employee who reaches 90 days of service with the Company. A Gulfstream Aerospace Corporation (GAC) full-time or part-time nonrepresented employee. A Jet Aviation Americas (JA) (except Jet Pro PEO, LLC) full-time nonrepresented employee. A Mission Systems full-time or part-time nonrepresented employee. A Mission Systems Greensboro full-time represented hourly employee. A Mission Systems Pittsfield full-time represented hourly employee.

2 A National Steel and Shipbuilding Company (NASSCO) full-time or part-time nonrepresented employee enrolled in a BCBS medical plan. A National Steel and Shipbuilding Company (NASSCO) San Diego full-time represented employee enrolled in a BCBS medical plan. A National Steel and Shipbuilding Company (NASSCO) Norfolk full-time nonrepresented or represented employee. A Shared Resources, Inc. (SRI) full-time or part-time nonrepresented employee. Effective January 1, General Dynamics Corporation

3 What You Should Know About This Plan This plan does not pay for every cost that you believe should be covered. This plan only pays for those costs or benefits that are described in this Summary Plan Description ( SPD ). As such, it is incumbent on you to carefully consider whether you should participate in this plan. In some cases, this plan may not provide you with any financial benefit or may not pay for an expense that is important to you. Only you can determine whether the coverage this plan provides will actually be beneficial for you and your family. Again, this plan only pays for those expenses that are described in this SPD or other official plan documents. It will not pay for any expenses that are not covered. In addition, if for any reason a benefit is paid in error or is larger than the amount allowed by the plan, the plan has the right to recover that payment. To ensure that you and your dependents (if applicable) receive the appropriate coverage, please review this SPD carefully. Intentionally providing false information or enrolling a dependent you know to be ineligible or willfully falsifying the documentation needed to prove a relationship with your dependent constitutes fraud and may be considered grounds for rescission of coverage, termination of employment or other legal action. If this SPD describes a plan that provides In-Network benefits, please understand that even though your doctor, hospital or other provider is currently listed as an In-Network Provider," there is absolutely no guarantee that they will remain an In-Network Provider" during your participation in this plan. Once you elect coverage under this plan, you will not be allowed to change your coverage solely due to the fact that your doctor, hospital, or other provider has withdrawn from the In-Network Provider list. The Company has the right to designate which Company-sponsored plan you and your eligible dependents (see the section titled Who Is Eligible: Dependents) can participate in based on your eligibility for Medicare. You and/or your covered dependents may not be eligible to participate in the same plan, and you and/or your covered dependents may be covered under different plans if any of you become eligible for Medicare either due to age or disability. This SPD is updated from time-to-time. This SPD replaces all prior versions. If you are not certain that you have the most recent SPD, please call the General Dynamics Service Center at GDBENEFITS ( ) to confirm whether you have the most up-to-date version. EAP Program Beacon Health Options

4 Table of Contents Terms You Need to Know... 1 Who Is Eligible: Employees... 2 Who Is Eligible: Dependents... 3 Who Is Not Eligible... 5 Cost of the Plan... 5 When Coverage Begins... 5 How the Plan Works... 6 Benefits Chart... 7 What Is Covered... 9 What Is Not Covered...10 Filing a Claim...10 Appealing a Denied Claim or Any Other Adverse Benefit Determination...10 Coverage for Disabled Adult Child(ren): Claim and Appeals Process...19 Plan Administration...24 When Coverage Ends for You...24 When Coverage Ends for Your Dependents...25 COBRA Continuation Coverage...26 Continuation of Coverage for Employees in the Uniformed Services...34 Family and Medical Leave Act (FMLA)...35 Leave of Absence...36 Your Rights Under ERISA...36 Plan Financing...37 HIPAA Privacy Regulations...38 Qualified Medical Child Support Order (QMCSO)...40 Official Plan Document...41 The Company s Right to Change (Amend) or Terminate This Plan...41 Limitation on Assignment...41 Unclaimed Benefits...41 Your Employment...42 Collective Bargaining Agreement...42 Disclaimer...42 EAP Program Beacon Health Options

5 Terms You Need to Know Here are important terms you need to know. These terms have the specified meaning when capitalized throughout this summary plan description. COBRA: The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA Administrator: General Dynamics Service Center. Company: This term refers to General Dynamics Corporation, and in any employment context, and elsewhere as appropriate, the subsidiary or affiliate of General Dynamics Corporation that is the employing unit of those eligible to participate in the plan. ERISA: Employee Retirement Income Security Act of FMLA: Family and Medical Leave Act of HIPAA: Health Insurance Portability and Accountability Act of In-Network or In-Network Provider: Providers who have a contract with the Claims Administrator to provide services to plan participants. Out-of-Network or Out-of-Network Provider: Any provider who does not have a contract with the Claims Administrator to provide services to plan participants. USERRA: The Uniformed Services Employment and Reemployment Rights Act of

6 Who Is Eligible: Employees You are eligible to participate in this plan if you are: An American Overseas Marine (AMSEA) full-time nonrepresented employee. A Corporate Headquarters (CHQ) full-time or part-time nonrepresented employee. A General Dynamics Information Technology (GDIT) full-time nonrepresented or represented employee. A General Dynamics-OTS (formerly ATP) Vermont full-time represented hourly employee. A General Dynamics-OTS (formerly ATP) Lincoln full-time represented hourly employee who reaches 90 days of service with the Company. A General Dynamics-OTS (formerly ATP) Marion full-time represented hourly employee who reaches 90 days of service with the Company. A General Dynamics-OTS (formerly ATP) full-time or part-time nonrepresented salaried or nonrepresented hourly employee. A General Dynamics-OTS (formerly ATP) Saco full-time or part-time represented hourly employee who has completed 60 days of service with the Company. A General Dynamics-OTS (formerly ATP) Springboro full-time or part-time represented hourly employee who reaches 90 days of service with the Company. A Gulfstream Aerospace Corporation (GAC) full-time or part-time nonrepresented employee. A Jet Aviation Americas (JA) (except Jet Pro PEO, LLC) full-time nonrepresented employee. A Mission Systems full-time or part-time nonrepresented employee. A Mission Systems Greensboro full-time represented hourly employee. A Mission Systems Pittsfield full-time represented hourly employee. A National Steel and Shipbuilding Company (NASSCO) full-time or part-time nonrepresented employee enrolled in a BCBS medical plan. A National Steel and Shipbuilding Company (NASSCO) San Diego full-time represented employee enrolled in a BCBS medical plan. A National Steel and Shipbuilding Company (NASSCO) Norfolk full-time nonrepresented or represented employee. A Shared Resources, Inc. (SRI) full-time or part-time nonrepresented employee. For the purposes of benefits eligibility, you are considered a full-time employee if you are regularly scheduled to work 30 or more hours per week. For the purposes of benefits eligibility, you are considered a part-time employee if you are regularly scheduled to work at least 20 but less than 30 hours per week. If you are in a location that offers this plan to other categories of employees, your Benefits Office will provide you with details. 2

7 Who Is Eligible: Dependents For purposes of the plan, your spouse and children are eligible for coverage under the plan, so long as that person meets the defined requirements set out in this section. You may be required to prove that your spouse and children are eligible for coverage under the plan as described in the Dependent Verification section below. Your legal spouse: The person to whom you are legally married (including as a result of common-law marriage) under applicable law. Your natural-born child, legally adopted child, stepchild or legal guardian child: The child is your natural-born child, legally adopted child (or the child has been placed in your home for adoption), stepchild or the court has appointed your legal guardian, and The child is under age 26. Your disabled adult child: The child is your natural-born child, legally adopted child (or the child has been placed in your home for adoption), or legal guardian child, or the child is your stepchild, The child is age 26 or older, The child is unmarried, The child is dependent on you for a majority of his or her financial support, The child was covered under a General Dynamics-sponsored EAP plan immediately prior to turning age 26, The child became disabled prior to turning age 26, The child was your dependent at the time he or she first became disabled and continues to be your dependent, The child is incapable of self-sustaining employment, and The child continuously meets all of the plan s requirements for a disabled child. To enroll a disabled adult child, you must provide satisfactory evidence of disability (i.e., proof that the disabled adult child meets all of the above requirements) no later than the date of the child s 26th birthday. If you provide evidence of disability after this date, the disabled adult child will be ineligible for coverage. Qualified Medical Child Support Order (QMCSO) child: The child is your natural-born child or legally adopted child (or the child has been placed in your home for adoption), or your stepchild, You have a current QMCSO order that is in effect, and The child is under age 26. Your dependents must have a Social Security Number or other Taxpayer Identification Number in order to be covered by this plan. A Social Security Number or other Taxpayer Identification Number is not required for newborns during the Social Security application period. Upon receipt of the Social Security Number or other Taxpayer Identification Number for your newborn, you 3

8 must submit the number to the General Dynamics Service Center at GDBENEFITS ( ). If you have never provided a Social Security Number or other Taxpayer Identification Number for your covered dependents, the Company may make a solicitation for such numbers as needed. Dependent Verification From time to time, you may be asked to verify the eligibility of your dependents under the plan. Failure to comply with this request may lead to a loss of coverage for your dependents. In order to verify the eligibility of covered dependents, the Plan Administrator or its designee may perform routine eligibility verification checks. The Plan Administrator performs these eligibility verifications for your protection to ensure that benefits are reserved for eligible participants and their eligible dependents. If you are asked to verify your dependents, the Plan Administrator or its designee will send you an inquiry specifying the documents needed for dependent verification. The following is a list of the information that may be required in verifying dependent status. Your spouse. Proof of marital status. Proof of joint ownership. Your natural-born child, legally adopted child, stepchild or legal guardian child. Proof of relationship. Your disabled adult child. Proof of relationship. Proof of financial support. Proof of disability. QMCSO child. Proof of relationship. The Company may update or revise this list from time to time in its sole discretion without any prior notification to employees, participants and any dependents. If you do not submit adequate documentation to confirm eligibility of your dependent(s) when the Plan Administrator or its designee requests it, your dependent(s) will be deemed ineligible and will be removed from coverage. The Plan Administrator or its designee will provide you with notice of termination of such coverage. Intentionally providing false information, enrolling a dependent you know to be ineligible or willfully falsifying the documentation required to enroll a dependent constitutes fraud and may be considered grounds for rescission of coverage, termination of employment or other legal action. In the event the Plan Administrator determines that the plan has covered an ineligible person as a result of fraud, you will be responsible for paying back to the plan any costs for services provided to that ineligible person. 4

9 Who Is Not Eligible Any individual classified by the Company as an independent contractor. Any individual who is classified by the Company as an intern and who is employed by the Company for less than 90 days. Any individual whose compensation for services to the Company is reported on IRS Form Any individual whose compensation for services to the Company is paid from a payroll or other account of another employer under contract with the Company. Any individual who is not paid from the Company s payroll account or with respect to whom the Company does not issue an IRS Form W-2 (or any replacement form). The above exclusions shall not be affected by the Company s misclassification of the individual s employment status, or a determination by a court, government agency, arbitrator, or other authority that the individual is or was a common-law employee of the Company, or that the Company is or was a common-law employer, joint employer, single employer, or co-employer of the individual. For example, workers commonly referred to as contract employees, job-shoppers, independent contractors, consultants, and leased employees (including leased employees as that term is used in Code Section 414(n) regardless of whether such leased employees have completed the 12-month waiting period described in Code Section 414(n)) are excluded from participation in the plan. Any employee represented by a collective bargaining agent, unless the applicable collective bargaining agreement specifically allows for participation. Cost of the Plan The Company pays the full cost of coverage. Information about the cost of your coverage (if applicable) is available on the General Dynamics Service Center web site at It can also be found in the enrollment materials posted on your work intranet or that you receive from your General Dynamics business unit (by mail or delivered at work). If you don t have access to the enrollment materials, you can get cost information by calling the General Dynamics Service Center at GDBENEFITS ( ). When Coverage Begins You do not enroll in this plan; you automatically participate. Coverage begins for you and your eligible dependents (see the section titled Who Is Eligible: Dependents) on your date of hire or the day after you complete your waiting period, if applicable. If you have a 90-day waiting period, your coverage begins on the 90 th day. (See the section titled Who Is Eligible for information about waiting periods.) 5

10 For Jet Aviation, coverage begins for you and your eligible dependents (see the section titled Who Is Eligible: Dependents) on your date of hire if you are hired on the first business day of the month; otherwise, coverage begins on the first day of the following month. For NASSCO San Diego represented, coverage begins for you and your eligible dependents on your 60 th day of service with the Company. How the Plan Works The EAP offers the following benefits: Assessment, consultation, and problem solving. Risk screening and crisis intervention. Advocacy to help you address your situation. Referral to a licensed network practitioner for up to a specified number of counseling sessions at no charge per member and/or eligible dependent (see the section titled Who Is Eligible: Dependents) per unique problem per calendar year (based on clinical necessity). Referral to community resources. Educational materials specific to issue. Legal consultation from a licensed attorney (does not include consultation related to any dispute involving General Dynamics Corporation or any of its divisions, operating or business units, affiliates, employees, agents or directors, or any dispute against the EAP or any other employee benefit plan, or any employment-related matter). Mediation services. Financial counseling from a credentialed financial professional. In order to receive EAP benefits, all services must be precertified by the EAP Administrator and provided by the Administrator s network practitioners. When you call Member Services, you will speak with a licensed behavioral health professional who will refer you to a licensed practitioner in your area. The EAP provides both clinical care and non-clinical services. Your EAP benefit for up to the specified number of clinical care visits per unique problem, per calendar year is used to assess your treatment needs, and when clinically appropriate, provide for the resolution of short-term issues within the number of EAP visits available under the plan. For ongoing treatment issues and higher levels of care, contact your medical plan. 6

11 Benefits Chart Plan Identifying Information Plan Year Active Plan Code(s) Retiree Plan Code(s) Plan Summary , 635 Not applicable Plan Facts Member Services Web Site Claims Administrator Claims Fiduciary Claims Payor Insurer Beacon Health Options Beacon Health Options Beacon Health Options Not applicable Benefit Structure Clinical Care Non-Clinical Services Administrative Information Plan Records Plan Sponsor and Plan Administrator 100% up to 8 visits per unique problem per covered member per calendar year Services: Family mediation; child/elder care referral; adult/elder support services; child/parenting support services; chronic condition support; financial services; legal assistance; life learning. Benefit: You will be referred to verified resources that specialize in these services, and any fees are your responsibility Plan records are kept on a calendar-year basis: January 1 - December 31 General Dynamics Corporation 2941 Fairview Park Drive Suite 100 Falls Church, VA Employer Identification Number (EIN)

12 DOL Plan Name (Number) Plan Summary ~ ATP, DSI, GDIT, Mission Systems and NASSCO: General Dynamics Corporation Subsidiary Health and Welfare Plan (561) ~ AMSEA, CHQ, and SRI: Group Insurance and Health Benefits for Salaried Personnel (501) ~ GAC: Gulfstream Aerospace Corporation Health and Welfare Benefits (592) ~ JA: Jet Aviation Consolidated Welfare Plan (652) Plan Type Administration Type (Contract or Insured) Funding Type (Self- Funded or Insured) Insurer Agent for Service of Legal Process Welfare plan providing employee assistance benefits Contract Self-funded by General Dynamics Corporation Not applicable General Dynamics Corporation 2941 Fairview Park Drive Suite 100 Falls Church, VA Claims Fiduciary Beacon Health Options Important Addresses Claims Filing Address Appeals Filing Address Not applicable. Your EAP provider files claims for you. Beacon Health Options PO Box 1347 Latham NY Corporate Address: Claims Administrator Beacon Health Options 200 State Street Suite 302 Boston, MA

13 What Is Covered Getting Help Through the EAP It s easy to get help through the EAP. Simply call Member Services toll-free, 24 hours a day, seven days a week, 365 days a year. See the section titled Benefits Chart. When you call, you ll speak to an EAP specialist (an experienced behavioral health professional) who can answer your questions about EAP benefits and listen to your needs. The EAP specialist can help you find the right assistance and resources for your situation. If necessary, the EAP specialist will locate a credentialed EAP provider so that you can schedule a convenient appointment. Typically, the EAP provider can meet with you within three to five days, in the privacy of his or her office. In emergencies, appointments are available in less than 24 hours. EAP Benefits EAP benefits include help with: Work-related problems, such as job stress, overwork, burnout, and interpersonal conflicts. Marital issues, including parenting issues and couples communications problems. Family problems, such as parent/child conflicts, single parenting issues, child and adolescent problems, spousal abuse, and incest. Emotional problems and personal issues, including anxiety, depression, personal crises, and life transitions. Addictions, including alcohol and drug abuse, problem gaming/gambling, and co-dependency. Disease-related issues, such as coping with chronic and terminal illness, and grief and loss. EAP Specialists Qualifications for the EAP specialists include: A master s or doctoral degree in psychology, counseling, social work, or a related field. Licensed graduate of accredited programs. At least five years of clinical experience. Extensive training in crisis counseling. Demonstrated skills in listening and directing callers to appropriate services. 9

14 EAP In-Network Providers When you call Member Services, the EAP specialist will refer you to an EAP provider. The EAP has an extensive network of qualified providers. The nationwide network includes psychologists, social workers, and marriage, family, and child counselors. Qualifications for EAP In-Network Providers include: A master s or doctoral degree in psychology, counseling, social work, or a related field. Licensed graduate of accredited programs. At least five years of clinical experience. Rigorous credentialing by the Claims Administrator. Specialty EAP certifications. What Is Not Covered The EAP does not cover the following services or supplies: Services given by a pastoral counselor. Private-duty nursing services while confined in a facility. Weight reduction or control supplies, special foods, food supplements, liquid diets, diet plans, or any related products. Services given by volunteers or individuals who do not normally charge for their services. Psychological testing. Electroconvulsive therapy (ECT). Treatment for chronic pain except for psychotherapy, biofeedback, hypnotherapy rendered in connection with a DSM-IV diagnosis, precertified by the Claims Administrator. Treatment provided by an MD or DO. Services not precertified by the EAP Claims Administrator. Filing a Claim Under the EAP, you do not have to file claim forms. Your EAP provider handles that for you. Appealing a Denied Claim or Any Other Adverse Benefit Determination The plan includes both an internal claim and appeals process and an external review process. This section first describes the generally applicable timeframe for deciding a claim and the internal appeals process that applies if your claim is denied or you receive any other adverse benefit determination. The section then briefly describes the generally applicable process for an external review decision. Finally, the section describes limits that apply to the internal appeals process and the external review process. For specifics about this plan's appeals process for 10

15 adverse benefit determinations, please contact the Claims Administrator at the address and phone number listed in the section titled Benefits Chart. An adverse benefit determination is any denial, reduction or termination of a benefit or any failure to provide (in whole or in part) a benefit. Adverse benefit determinations include any denial, reduction, termination or failure that is based on a participant's or beneficiary's eligibility to participate in this plan. Any reduction or termination of an approved ongoing course of treatment (other than by a plan amendment or plan termination) and any retroactive cancellation or discontinuance of coverage (except where due to your failure to timely make any required contributions) (known as a rescission of coverage ) will also be considered an adverse benefit determination. You have the right to appoint an authorized representative to act on your behalf. Your properly appointed authorized representative can take all actions you are allowed to take. For example, a properly appointed authorized representative could file a claim or file an appeal of an adverse benefit determination on your behalf. Although there is a process for properly appointing most authorized representatives, a health care professional with knowledge of your medical condition is automatically allowed to act as your authorized representative if you have an urgent care claim (defined below). For information about how you can appoint an authorized representative, contact the Claims Administrator. If your claim for benefits relates to your enrollment in the plan or your eligibility to participate in the plan, see the section below titled Special Provisions Applicable to Claims for Enrollment or Plan Eligibility for special rules. Types of Claims Urgent care claims are pre-service claims which, unless the special urgent care deadlines for response to a claim are followed, either: Could seriously jeopardize the patient s life, health, or ability to regain maximum function, or In the opinion of a physician with knowledge of the patient s medical condition, would subject the patient to severe pain that cannot be adequately managed without the care or treatment requested in the claim for benefits. An individual acting on behalf of the plan, applying the judgment of a prudent layperson who has an average knowledge of health and medicine, can determine whether the urgent care definition has been satisfied. However, if a physician with knowledge of the patient s medical condition determines that the claim involves urgent care, it must be considered an urgent care claim. Pre-service care claims are claims that require approval of the benefit before receiving health care. Post-service care claims are claims that do not require approval of the benefit before receiving health care and are submitted for payment after receiving health care. Concurrent care claims are claims that relate to an ongoing course of treatment that was previously approved for a specific period of time or number of treatments. These may be urgent, pre-service, or post-service claims. 11

16 Timeframe for Initial Internal Claim Determination There are different timeframes for initial internal determinations for different types of claims. Urgent care claims Failure to follow procedures. If you fail to follow the plan s procedures for filing an urgent care claim, you will be notified of the failure and the proper procedures to be followed in filing a claim for benefits. This notification will be provided within 24 hours following the failure. Notification may be oral, unless you request written notification. This paragraph only applies to a failure that: Is a communication by you that is received by a person or organizational unit customarily responsible for handling benefit matters, and Is a communication that names you, a specific health care condition or symptom, and a specific treatment, service, or product for which approval is requested. Notice of determination. The Claims Administrator will ordinarily notify you of a benefit determination no more than 72 hours after receipt of your urgent care claim. A decision can be provided to you orally, as long as written or electronic notification is provided to you within three days of oral notification. Failure to provide sufficient information. If you fail to provide the Claims Administrator with sufficient information to determine whether, or to what extent, benefits are covered or payable under the plan, the Claims Administrator must notify you within 24 hours of receiving your urgent care claim of the specific information needed to complete the claim. You then have 48 hours to provide the information needed to process your claim. You will be notified of a determination no later than 48 hours after the earlier of: The Claims Administrator s receipt of the requested information, or The end of the 48-hour period within which you were to provide the additional information, if the information is not received within that time. Pre-service care claims Failure to follow procedures. If you fail to follow the plan s procedures for filing a preservice care claim, the process described above for urgent care claims will apply, except for the notification period. There is a 5-day notice period, rather than a 24-hour notice period, for the failure to follow the procedures for filing a pre-service care claim that is not urgent. Notice of determination. The Claims Administrator will ordinarily notify you of a benefit determination no more than 15 days after receipt of your pre-service care claim. Extension available. A 15-day extension may be allowed to make a determination of a pre-service care claim, provided that the Claims Administrator determines that the extension is necessary due to matters beyond its control. If such an extension is necessary, the Claims Administrator must notify you before the end of the first 15-day period of the reasons requiring the extension and the date it expects to provide a decision on your claim. If such an extension is due to your failure to submit the information necessary to decide the claim, the notice of extension must also specifically describe the required information. You 12

17 then have 45 days to provide the information needed to process your claim and the plan s timeframe for making a benefit determination is suspended from the date the Claims Administrator sends you the extension notification until the earlier of (a) the date you respond to the request for additional information or (b) the expiration of the 45-day period. Post-service care claims Notice of determination. The Claims Administrator will ordinarily notify you of an adverse benefit determination no more than 30 days after receipt of a post-service care claim. Extension available. If the Claims Administrator determines that an extension for a postservice care claim is necessary due to matters beyond its control, the process described above for a 15-day extension of a pre-service claim will apply, except for the notice period. For a post-service care claim you must be notified of such an extension before the end of the first 30-day, rather than 15-day, period. Concurrent care claims Urgent care claim. If an ongoing course of treatment was previously approved for a specific period of time or number of treatments, and your request to extend the treatment is an urgent care claim, your request will be decided within 24 hours, provided your request is made at least 24 hours before the end of the approved treatment. If your request for extended treatment is an urgent care claim but is not made at least 24 hours before the end of the approved treatment, the request will be decided according to the urgent care claim timeframes described earlier. Not an urgent care claim. If an ongoing course of treatment was previously approved for a specific period of time or number of treatments, and your request to extend treatment is a not an urgent care claim, your request will be considered a new claim and decided according to the pre-service or post-service timeframe, whichever applies. Notice of determination. You will be notified of any reduction or termination of a previously approved ongoing course of treatment sufficiently in advance to allow you to appeal the adverse determination and receive a decision prior to the reduction or termination. If You Receive an Initial Internal Adverse Benefit Determination The Claims Administrator will provide you with a notification of any initial internal adverse benefit determination which will set forth, if applicable: Information sufficient to identify the claim, including the date of service, the identity of the health care provider, and the claim amount. The specific reasons for the adverse benefit determination, including a description of any standard relied upon in making the benefit determination and any denial code and its meaning. Notice of your opportunity to request the diagnosis and treatment codes for a service and their meaning. References to the specific plan provisions on which the benefit determination is based. 13

18 A description of any additional material or information needed to process the claim and an explanation of why that material or information is necessary. A description of the plan s internal appeals procedures and external review procedure and the time limits applicable to those procedures, including information about how to initiate an appeal and a statement about your right to bring a civil action under Section 502(a) of ERISA. If the adverse benefit determination concerns an urgent care claim for which expedited internal or external review processes are available, a description of the available expedited review processes. Any internal rule, guideline, protocol, or other similar criterion relied upon in making the adverse benefit determination, or a statement that a copy of this information will be provided to you free of charge upon request. If the adverse benefit determination was based on medical necessity or experimental treatment or similar standard, exclusion, or limit, either an explanation of the scientific or clinical judgment for the adverse determination, applying the terms of the plan to your health care circumstances, or a statement that such explanation will be provided free of charge upon request. The contact information for any state office of health insurance consumer assistance or ombudsman. Notices of initial internal adverse benefit determinations provided in counties where ten percent or more of the population is literate only in the same non-english language, will include a statement prominently displayed in the applicable non-english language clearly indicating how to access available language services. These services include access to oral language services (such as a telephone customer assistance hotline), language assistance with filing claims and appeals, and the provision of notices in the applicable non-english language upon request. How to Appeal an Initial Internal Adverse Benefit Determination If you receive an initial internal adverse benefit determination, you have the right to file an internal appeal. An internal appeal must be sent to the Claims Administrator no more than 180 days after receipt of such a determination. To initiate an internal appeal, send the Claims Administrator a letter stating why you disagree and including the following information: Your member ID number. The claim number of the claim in question. A list of all the specific issues to be considered on appeal. Any additional medical information or other documentation that supports your belief that the claim should have been paid. The Claims Administrator's address is listed in the section titled Benefits Chart. 14

19 Along with your appeal, you have the right to: Be informed of specific review procedures applicable to your appeal, including any need to file an affidavit about the facts relevant to your claim. Submit written testimony, comments, documents, records, and other information relating to the claim for benefits. Request, free of charge, reasonable access to and copies of all documents, records and other information relevant to your claim for benefits. For this purpose, a document, record, or other information is treated as relevant to your claim if it: Was relied upon in making the benefit determination, Was submitted, considered, or generated in the course of making the benefit determination, regardless of whether such document, record or other information was relied upon in making the benefit determination, Demonstrates compliance with the administrative processes and safeguards required in making the benefits determination, or Constitutes a statement of policy or guidance with respect to the plan concerning the denied benefit for your diagnosis, regardless of whether such statement was relied upon in making the benefit determination. An internal review that takes into account all written testimony, comments, documents, records, and other information submitted by you related to the claim, regardless of whether the information was submitted or considered in the initial benefit determination. An internal review that does not defer to the initial internal adverse benefit determination. An internal review that is not conducted by the individual who made the initial internal adverse determination or who is a subordinate of that person. If the final internal appeal involves an adverse benefit determination based in whole or in part on a medical judgment, a review in which the Claims Administrator consults with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment. This health care professional must not have been consulted in connection with the initial internal adverse benefit determination or be the subordinate of a person who was consulted. The identification of health care professionals or vocational experts whose advice was obtained in connection with the initial internal adverse benefit determination, regardless of whether the advice was relied upon in making the decision. In the case of an urgent care claim, an expedited internal review process in which: You may submit a request (orally or in writing) for an expedited internal appeal of an adverse benefit determination, and All necessary information, including the plan s benefit determination on review, will be transmitted between the plan and you by telephone, facsimile, or other available similarly prompt method. Notice, free of charge, and a reasonable opportunity to respond before a final internal appeal determination is issued of: 15

20 Any new or additional evidence considered, relied upon, or generated in connection with the final internal appeal determination, and Any new or additional rationale that is expected to form the basis of a final internal adverse benefit determination. In the case of an initial internal adverse benefit determination about an urgent care claim that is eligible for external review, where the timeframe for completing an expedited internal review could seriously jeopardize the life or health of the claimant or could jeopardize the claimant's ability to regain maximum function, notice that you may submit a request (orally or in writing) for an expedited external review. Ordinarily, a decision regarding your appeal will be reached within: 72 hours after receipt of your request for review of an urgent care claim. 30 days after receipt of your request for review of a pre-service care claim. 60 days after receipt of your request for review of a post-service care claim. The Claims Administrator s notice of a final internal adverse benefit determination on appeal will contain all of the following information, if applicable: Information sufficient to identify the claim, including the date of service, the identity of the health care provider, and the claim amount. A discussion of the specific reasons for the final internal adverse benefit determination, including a description of any standard relied upon in making the benefit determination and any denial code and its meaning. Notice of your opportunity to request the diagnosis and treatment codes for a service and their meaning. References to the specific plan provisions on which the benefit determination is based. A statement that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to your claim. A statement describing any voluntary appeal procedures offered by the plan and your right to obtain information about such procedures, a statement about your right to bring an action under Section 502(a) of ERISA, and a statement describing the external review process, including how to initiate an appeal. A statement that in the case of a final internal adverse benefit determination about an urgent care claim that is eligible for external review, where the timeframe for completing standard external review could seriously jeopardize the life or health of the claimant or the claimant's ability to regain maximum function; or concerns admission, availability of care, continued stay, or a health care item or service for which the claimant received emergency services but has not been discharged from a facility, notice that you may submit a request (orally or in writing) for an expedited external review. 16

21 Any internal rule, guideline, protocol, or other similar criterion relied upon in making the adverse benefit determination, or a statement that a copy of this information will be provided to you free of charge upon request. If the final internal adverse benefit determination was based on a medical necessity or experimental treatment or similar standard, exclusion, or limit, either an explanation of the scientific or clinical judgment for the adverse determination, applying the terms of the plan to your medical circumstances, or a statement that such explanation will be provided free of charge upon request. The contact information for any state office of health insurance consumer assistance or ombudsman. Notices of final internal adverse benefit determinations provided in counties where ten percent or more of the population is literate only in the same non-english language, will include a statement prominently displayed in the applicable non-english language clearly indicating how to access available language services. These services include access to oral language services (such as a telephone customer assistance hotline), language assistance with filing claims and appeals, and the provision of notices in the applicable non-english language upon request. How to Initiate an External Review of an Internal Adverse Benefit Determination Your claim will be eligible for external review only if: It involves medical judgment or a rescission of coverage, You were covered under the plan at the time the claimed health care item or service was requested or provided, You have exercised your available rights under the plan s internal claims and appeal process, and You provide all the information and forms necessary to process the external review request. You must file a request for standard external review with the Claims Administrator within four months of the date you receive a final internal adverse benefit determination. If there is no corresponding date four months later, your request must be filed by the first day of the fifth month following receipt of a final internal adverse benefit determination. If the last day for filing a request falls on a Saturday, Sunday, or federal holiday, you will have until the next business day to file your request. Generally, you will receive a notice telling you whether your claim is eligible for external review by an independent review organization within six business days of submitting the claim. If your claim is eligible for external review, documentation provided during the internal review process will be provided to the independent review organization. The independent review organization may also review additional documentation. The independent review organization will not be bound by any decision or conclusions made during the plan s internal review process. The independent review organization will generally issue a detailed written decision within 45 days of receiving your claim from the Claims Administrator or Plan Sponsor. If the independent review organization reverses an earlier plan decision, the plan will provide coverage or payment. 17

22 Expedited external review is available upon request only if: A claimant receives an initial internal adverse benefit determination and following the generally applicable timeframes for the completion of an internal appeal would seriously jeopardize the life or health of the claimant or the claimant's ability to regain maximum function. A claimant receives a final internal adverse benefit determination following the generally applicable timeframes for the completion of a standard external review would seriously jeopardize the life or health of the claimant or the claimant's ability to regain maximum function; or concerns the admission, availability of care, continued stay, or health care item or service for which the claimant received emergency services and the claimant has not been discharged from a facility. The expedited external review process includes the same steps as the standard external review process, but all steps in the process must be completed as expeditiously as possible. For additional details and specifics about standard and expedited external reviews, please contact the Claims Administrator at the address and phone number listed in the section titled Benefits Chart. Special Provisions Applicable to Claims for Enrollment or Plan Eligibility If your claim for benefits relates to your enrollment in the plan or your eligibility to participate in the plan (as opposed to what benefits you are eligible for as a participant in the plan), you must contact the General Dynamics Service Center and request a claim initiation form to begin the internal claim and appeal process. Complete the claim initiation form and submit it, together with any documentation that you feel supports your claim, to: General Dynamics Service Center PO Box Cincinnati, OH The Plan Administrator or its designee will respond to your claim and appeal in the manner and within the time limits provided in the section Appealing a Denied Claim or Any Other Adverse Benefit Determination, where applicable. If your claim for benefits relates to enrollment or eligibility for the plan, you will not have the opportunity for any voluntary appeal after the initial claim and appeal process. Additionally, unless your claim for benefits relates to medical necessity or rescission of coverage, your enrollment or eligibility claim will not be eligible for an external review. Limits No interest is payable on any benefits that are delayed or paid late. Before you can bring a lawsuit against the plan in state or federal court, you must timely use and exhaust the plan s claims and appeals procedures, including exercising your right to external review. If, however, the Claims Administrator and Plan Administrator fail to meet certain claims and appeals requirements, your claim will be deemed exhausted, and you may be able to bring a lawsuit without completing the claims and appeals procedures. 18

23 During the internal appeals process you must raise all issues and legal theories you wish to have considered at any time during the internal or external administrative claims review process or any subsequent lawsuit. No legal action, including a lawsuit, may be brought more than one year after a final decision is rendered on a claim. In addition to the one-year deadline that applies to filing a lawsuit after the claims and appeals procedures are exhausted, there is a general time limitation that applies to all lawsuits involving all types of plan issues. You must commence any such lawsuit involving plan claims no later than two years after you first receive information that constitutes a clear repudiation of the rights you are seeking to assert (i.e., the underlying event or issue that should have triggered your awareness that your rights under the plan may have been violated). Although any period of time when your claim is in the claims procedure described above (i.e., the time between when you file a claim for benefits and the time you receive a final determination letter) does not count against the two-year period, once the claims procedure process is completed, the two-year period will continue running where it left off. The Claims Administrator and the Plan Administrator have absolute authority and sole discretion to interpret and apply plan provisions and determine facts, benefits, and eligibility. All interpretations, decisions, and determinations of the Claims Administrator and the Plan Administrator are intended to be final, conclusive, and binding on all parties having an interest in the plan. Coverage for Disabled Adult Child(ren): Claim and Appeals Process This section describes the generally applicable timeframe for deciding a claim, and the appeals process that applies if your claim is denied or you receive any other adverse benefit determination for coverage of a disabled adult child. A disabled adult child is a child who meets the definition of disability under this plan and is over the age of 26. For specifics about this plan's appeals process for adverse benefit determinations, contact the Claims Administrator at the address and phone number listed in the section titled Benefits Chart. An adverse benefit determination is any denial, reduction or termination of a benefit or any failure to provide (in whole or in part) a benefit. Adverse benefit determinations include any denial, reduction, termination or failure that is based on a participant's or beneficiary's eligibility to participate in this plan. For example, an adverse benefit determination would include: A denial of your initial request for coverage of the disabled adult child. A determination that the child no longer meets the definition of disability under this plan. If your initial request for coverage for the disabled adult child is approved, the child must then continue to meet the definition of disability in order to remain covered under the plan (see the section titled Who Is Eligible). The Claims Administrator may ask for verification of ongoing disability on a periodic basis. The frequency of such requests will depend on the nature of the child s disability. You have the right to appoint an authorized representative to act on your behalf. Your properly appointed authorized representative can take all actions you are allowed to take. For example, a properly appointed authorized representative could file a claim or file an appeal of an adverse benefit determination on your behalf. For information about how you can appoint an authorized representative, contact the Claims Administrator. 19