RETIREE WELFARE BENEFIT PLAN OF WOODMENLIFE PLAN NUMBER 521 SUMMARY PLAN DESCRIPTION

Transcription

1 RETIREE WELFARE BENEFIT PLAN OF WOODMENLIFE PLAN NUMBER 521 SUMMARY PLAN DESCRIPTION 2016

2 ARTICLE I. INTRODUCTION TABLE OF CONTENTS Page 1.1 Purpose of Plan Purpose of This Document... 1 ARTICLE II. DEFINITIONS 2.1 Definitions Construction... 3 ARTICLE III. PARTICIPATION 3.1 Beginning of Participation End of Participation... 5 ARTICLE IV. BENEFITS 4.1 Benefits Limitations, Exclusions and Restrictions on Benefits, Including Pre-Existing Condition Limitations ARTICLE V. ADMINISTRATION OF PLAN 5.1 Powers of the Plan Administrator Deference to Plan Administrator Limitation of Rights Alienation Limitations Period Arbitration of ERISA Statutory and State Claims Venue and Forum... 8 ARTICLE VI. AMENDMENT AND TERMINATION 6.1 Amendment Termination ARTICLE VII. ERISA INFORMATION 7.1 Plan Name Employer Information Employer Identification Number (EIN) Plan Number Type of Plan Type of Administration Plan Administrator Information Agent for Service of Legal Process Trustee Eligibility for Participation and Benefits Summary of Benefits Qualified Medical Child Support Orders ( QMCSOs ) Loss of Eligibility and Benefits Plan Funding Funding Medium Health Insurance Issuer i P a g e

3 TABLE OF CONTENTS Page 7.17 Plan Year Claims Procedures Further Information Inspection of Plan Copy of Plan Statement of ERISA Rights ARTICLE VIII. CONTINUATION OF GROUP HEALTH COVERAGE UNDER COBRA ARTICLE IX. ARTICLE X. HEALTH INFORMATION PROTECTION AND RIGHTS 9.1 HIPAA Notice of Privacy Practices ADDITIONAL LEGAL NOTICES 10.1 Newborns Act Women s Health and Cancer Rights Act of EXHIBIT A Component Plans and Benefit Information Booklets EXHIBIT B Claim Procedures ii P a g e

4 RETIREE WELFARE BENEFIT PLAN OF WOODMENLIFE SUMMARY PLAN DESCRIPTION This SUMMARY PLAN DESCRIPTION is effective for all purposes as of January 1, ARTICLE I. INTRODUCTION 1.1 Purpose of Plan. The purpose of this Plan is to provide Participants and Beneficiaries with various welfare benefits. 1.2 Purpose of This Document. This document, including its Exhibits and the documents referenced in those Exhibits, constitutes the Summary Plan Description that is required to be distributed to all Plan Participants under Title I of ERISA. ARTICLE II. DEFINITIONS 2.1 Definitions. The following definitions shall apply to this Summary Plan Description and each Component Plan s Benefit Information Booklet. However, in the event of a conflict between a definition below and a definition in a Component Plan s Benefit Information Booklet, the definition in the Component Plan s Benefit Information Booklet shall apply to that Benefit. a. Actual Earnings means the amount set forth on the Associate s commission statement as actual earnings. b. Actual Earnings Requirement means the income requirement necessary to be eligible for a Component Plan, if the Component Plan describes the income requirement with the term Actual Earnings (whether or not capitalized). c. Alpha Contract shall mean the type of contract signed by a WoodmenLife Representative. d. WoodmenLife Representative means a WoodmenLife Representative who is rendering services to the Employer under an Alpha Contract. e. Recruiting Sales Manager means an Associate who is rendering services to the Employer under an Recruiting Sales Manager Contract. f. Associate means an individual whom the Employer classifies and treats as an employee (not as an independent contractor) for payroll purposes, regardless of whether the individual is subsequently reclassified as an employee of the Employer in a court order, in a settlement of an administrative or judicial proceeding, or in a determination by the Internal Revenue Service, the Department of the Treasury, or the Department of Labor. Associate includes, but 1 P a g e

5 is not limited to, Regular Full-time, Regular Part-time, Regional Director, Recruiting Sales Manager and WoodmenLife Representative. g. Beneficiary means a person designated by a Participant who is or may become entitled to a Benefit under the Plan. h. Benefits means the services provided or amounts paid to or on behalf of Participants and Beneficiaries under the Plan. i. COBRA means the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended. j. Component Plan means any component of this Plan, as identified in Exhibit A. k. Dependent means a dependent as defined in a Component Plan. l. Employer means Woodmen of the World Life Insurance Society hereinafter referred to as WoodmenLife. m. ERISA means the Employee Retirement Income Security Act of 1974, as amended. n. Participant means a former Associate who is eligible to be and becomes a Participant in accordance with Section 3.1. o. Plan means this Retiree Welfare Benefit Plan of WoodmenLife including all Component Plans. p. Plan Administrator means the Employer, unless the Employer designates another person to hold the position of Plan Administrator. q. Plan Year means the fiscal year of the Plan, a twelve (12) consecutive month period ending every December 31. r. Regular Full-time shall mean Associates regularly scheduled to work at least 36 hours per week and who are not working on an ad hoc or seasonal basis or as otherwise set forth in a Component Plan. s. Regular Part-time shall mean Associates regularly scheduled to work at least 20 hours per week and who are not working on an ad hoc or seasonal basis or as otherwise set forth in a Component Plan. t. Retired Associate means a former Associate who meets the eligibility requirements for the WoodmenLife Retiree Dental Plan. u. Spouse means a legally married spouse, according to federal law. v. Regional Director means an Associate who is rendering services to the Employer under a Regional Director Contract. 2 P a g e

6 w. Summary Plan Description means this document, together with each Component Plan s Benefit Information Booklet, as identified on Exhibit A. x. Termination Date means the date of employment termination for Home Office Associates and the date of contract termination for Regional Director, Recruiting Sales Managers, and WoodmenLife Representatives. 2.2 Construction. As used in this Plan, the masculine gender includes the feminine, and the singular may include the plural, unless the context clearly indicates to the contrary. ARTICLE III. PARTICIPATION 3.1 Beginning of Participation. A former Associate becomes a Participant in the Plan when the individual first becomes a Participant in any Component Plan. A Participant s Dependent becomes a Beneficiary under this Plan when the Dependent first becomes a Beneficiary under any Component Plan. The election to participate in any of the Component Plans is available only at the time of an Associate s retirement. If an Associate does not elect to participate in a Component Plan within 31 days of the Associate s retirement date, unless indicated differently in a Component Plan, the Associate will not have another opportunity to participate in the Plan. Likewise, if an Associate elects coverage under a Component Plan and later loses that coverage, the Associate will not have another opportunity to participate in the Component Plan. An Associate is eligible to become a Participant in a Component Plan under the terms and conditions described in the Component Plan. If such terms and conditions do not appear in the applicable Component Plan, then the following shall apply: 3 P a g e

7 COMPONENT PLAN ELIGIBLE FORMER ASSOCIATE WAITING PERIOD WoodmenLife To be eligible, a former Associate must meet all of the None Retiree Medical Plan following criteria: (1) Be enrolled in the WoodmenLife Group Medical Plan immediately prior to the Termination Date; (2) Not be eligible for Medicare; and (3) Be at least 55 years of age and have at least 20 years of service on the Termination Date; or (4) Be at least 65 years of age and have at least 5 years of service on the Termination Date. WoodmenLife Retiree Medicare Supplement Plan In addition to meeting the above requirements, a former Associate who was an WoodmenLife Representative on the Termination Date is not eligible unless, during the October 1 through September 30 immediately preceding the Termination Date, he or she had at least $30,000 in Actual Earnings. To be eligible, a former Associate must meet all of the following criteria: (1) Be enrolled in the WoodmenLife Group Medical Plan immediately prior to the Termination Date; (2) Be eligible for Medicare; and (3) Be at least 55 years of age and have at least 20 years of service on the Termination Date; or (4) Be at least 65 years of age and have at least 5 years of service on the Termination Date. In addition to meeting the above requirements, a former Associate who was an WoodmenLife Representative on the Termination Date is not eligible unless, during the October 1 through September 30 immediately preceding the Termination Date, he or she had at least $30,000 in Actual Earnings. The Group Retiree Insurance Plan (see Exhibit A-2.1) is available to residents of all eligible states except Kansas, Maryland, Montana, New York, Oregon, Vermont, and Washington. The Senior Medical Insurance Plan (see Exhibit A-2.2) is only available to residents of Kansas, Maryland, Montana, New York and Oregon. None 4 P a g e

8 COMPONENT PLAN ELIGIBLE FORMER ASSOCIATE WAITING PERIOD WoodmenLife To be eligible, a former Associate must meet either of None Retiree Dental Plan the following criteria: WoodmenLife Retiree Life Plan (1) Be at least 55 years of age and have at least 20 years of service on the Termination Date; or (2) Be at least age 65 and have at least 5 years of service on the Termination Date. To be eligible, a former Associate must meet all of the following criteria: (1) Be enrolled in the WoodmenLife Group Life Insurance Plan immediately prior to the Termination Date; (2) Be at least 55 years of age on the Termination Date, but under the age of 75; and (3) Have at least 20 years of service on the Termination Date. In addition to meeting the above requirements, a former Associate who was an WoodmenLife Representative on the Termination Date is not eligible unless, during the October 1 through September 30 immediately preceding the Termination Date, he or she had at least $30,000 in Actual Earnings. None 3.2 End of Participation. A former Associate stops being a Participant in the Plan when the Associate is no longer eligible for participation and is no longer enrolled in any Component Plan. A former Associate s Dependent stops being a Beneficiary under the Plan when the Dependent is no longer eligible for participation and is no longer enrolled in any Component Plan. ARTICLE IV. BENEFITS 4.1 Benefits. The Benefits under the Plan are described in this document, and in the Component Plan Benefit Information Booklets. If you have misplaced information relating to a specific Benefit, you can contact the Plan Administrator to have it replaced. For additional information or specific details relating to Component Plan Benefits, contact the Plan Administrator. 4.2 Limitations, Exclusions and Restrictions on Benefits, Including Pre-Existing Condition Limitations. The Component Plans contains specific provisions as to limitations, exclusions, and restrictions on benefits, including any pre-existing condition limitations. Please refer to the Benefit Information Booklets for the applicable Component Plan when checking to see if a particular condition is covered. 5 P a g e

9 ARTICLE V. ADMINISTRATION OF PLAN 5.1 Powers of the Plan Administrator. The Plan Administrator shall have full power to administer the Plan, in accordance with its terms, for the exclusive benefit of Plan Participants and their Beneficiaries. For this purpose, the Plan Administrator s powers include, but are not limited to, the following: a. To make and enforce such rules and regulations as it deems necessary or proper for the efficient administration of the Plan, including the establishment of any claims procedures that may be required by applicable law; b. To interpret the Plan (any such interpretation, made in good faith, shall be final and conclusive on all persons claiming benefits under the Plan); c. To decide all questions concerning the Plan and the eligibility of any person to participate in the Plan (any such decision, made in good faith, shall be final and conclusive on all persons claiming benefits under the Plan); d. To appoint such agents, counsel, accountants, consultants and actuaries as may be required to assist in administering the Plan; and e. To allocate and delegate its responsibilities under the Plan and to designate other persons to carry out any of its responsibilities under the Plan. Any such allocation, delegation or designation shall be in writing. 5.2 Deference to Plan Administrator. All decisions by the Plan Administrator will be afforded the maximum deference permitted by law. 5.3 Limitation of Rights. Nothing in this document requires the Employer or the Plan Administrator to maintain any fund or segregate any amount for the benefit of any Participant or Beneficiary. No Participant or other person shall have any claim against, right to, or security or other interest in, any fund, account or asset of the Employer from which any payment under the Plan may be made. 5.4 Alienation. No Benefits under the Plan may be subject to anticipation, garnishment, attachment, execution or levy of any kind, or be liable for any Participant s or Beneficiary s debts or obligations. 5.5 Limitations Period. Arbitration (as set forth in Section 5.6) or other legal action cannot be taken against the Plan, the Plan Administrator, and/or the Employer more than three years after (i) the time written proof of loss is required to be furnished according to the terms of the Plan, (ii) the denial of a Claim, or (iii) the first date of the occurrence of an event giving rise to a Statutory Claim or a State Claim (as defined in Section 5.6). 5.6 Arbitration of ERISA Statutory and State Claims. The following provisions shall apply to all claims and demands arising out of or relating to state law ( State Claims ) and 6 P a g e

10 ERISA statutory claims and demands asserted against the Plan, the Plan Administrator, and/or the Employer. All Participants, Beneficiaries, and other persons receiving benefits under the Plan or a Component Plan shall be subject to the provisions set forth in this Section 5.6. ERISA statutory claims include, but are not limited to, fiduciary breach claims, actions for equitable relief, and actions under ERISA Section 510 to redress retaliation, discrimination, and coercive interference ( Statutory Claims ). All State Claims and all Statutory Claims of a Participant, Beneficiary, or other person receiving benefits under the Plan or a Component Plan shall be settled by arbitration proceedings of such State Claims and Statutory Claims in accordance with this Section 5.6, within the limitations period described in Section 5.5, and not by a court of competent jurisdiction. a. In consideration of participating in and receiving benefits under the Plan, Employees, Participants, Beneficiaries, and other persons receiving benefits under the Plan or a Component Plan agree to the provisions of this Section 5.6. Employees, Participants, Beneficiaries, and other persons receiving benefits under the Plan or a Component Plan acknowledge and agree to the waiver of all federal, state, and local procedures and remedies that are or may be available to them in the absence of the procedures set forth in this Section 5.6. No class action for a Statutory Claim or a State Claim may be brought, and Employees, Participants, Beneficiaries, and other persons receiving benefits under the Plan or a Component Plan hereby waive the right to bring a class action or to participate as a class member in a class action, to enforce any rights or resolve any disputes covered by this Section 5.6, whether in arbitration or in court, and whether seeking legal or equitable relief. No Statutory Claims or State Claims of multiple parties may be consolidated in the arbitration proceedings set forth in this Section 5.6. b. Arbitration of the Statutory Claims shall be subject to and governed by the Federal Arbitration Act, 9 U.S.C. 1 et seq., and ERISA. c. Arbitration of the State Claims shall be subject to and governed by the Federal Arbitration Act, 9 U.S.C. 1 et seq., and, to the extent preempted by federal law, ERISA (or other applicable federal law). If a State Claim is not preempted by federal law, the laws of the State of Nebraska shall apply to the State Claim, notwithstanding any choice of law or conflicts of law principles. d. Arbitration shall be conducted in accordance with the applicable rules of the American Arbitration Association ( AAA ). e. Arbitration shall be conducted at a location selected by the Employer or Plan Administrator, as applicable, in Omaha, Douglas County, Nebraska. f. An Employee, Participant, Beneficiary, or other person receiving benefits under the Plan or a Component Plan may commence arbitration by presenting a written demand to arbitrate a Statutory Claim or a State Claim 7 P a g e

11 to the Employer or Plan Administrator, as applicable, which shall describe the facts involved in the dispute and the requested resolution. Arbitration shall be commenced no later than 120 days after receipt of the written notice of dispute, unless otherwise mutually agreed to by the parties. g. The Employer or Plan Administrator, as applicable, shall select one neutral arbitrator who, in turn, shall select two other neutral arbitrators to conduct the arbitration of the Statutory Claims or State Claims. All such arbitrators shall have experience with ERISA. The arbitrators shall have the sole authority to determine whether the Statutory Claims or State Claims are subject to arbitration and the enforceability of this arbitration provision. Notwithstanding the foregoing, any challenges to the class-action waivers set forth in Section 5.6(a) shall be reviewed and settled by a court of competent jurisdiction described in Section 5.7. h. Each party may be represented by legal counsel of its choosing and shall have reasonable notice of the date and time of arbitration and the issues to be arbitrated. The Employer shall pay the costs of the arbitrators and the arbitration proceeding. Each party shall be responsible for its own legal costs, fees, and expenses. The arbitration procedures shall allow for each party to have reasonable access to and discovery of relevant information. i. The arbitrators shall issue a written decision with the essential findings and conclusions upon which their decision is based. The arbitrators shall only award damages or other relief that a court of competent jurisdiction may award under ERISA. Judgment upon the award rendered by the arbitration may be entered by any court having jurisdiction thereof. j. If the arbitrators or a court of competent jurisdiction determines the arbitration procedures set forth in this Section 5.6 are unenforceable or invalid, or that the Federal Arbitration Act does not apply to a Statutory Claim or a State Claim, (i) such unenforceability or invalidity shall not affect any other provision of the Plan, (ii) the Plan shall be interpreted, construed, administered, and enforced as if such provisions had not been included, and (iii) in lieu of the Statutory Claim or State Claim being subject to arbitration pursuant to this Section 5.6, the Statutory Claims or State Claims must be asserted in the federal court identified in Section 5.7. It is the intent of the parties to require and follow the arbitration procedure set forth in this Section 5.6 to the maximum extent permitted under applicable law. k. This Section 5.6 shall survive termination of the Plan or a Component Plan. 5.7 Venue and Forum. Venue and forum for matters not resolved pursuant to Section 5.6 shall be proper only in a federal court located in Omaha, Douglas County, Nebraska. 8 P a g e

12 ARTICLE VI. AMENDMENT AND TERMINATION 6.1 Amendment. The Plan may be amended at any time, and from time to time, by the Employer. Any such amendment must be in writing. 6.2 Termination. The Plan is established with the intention of being maintained for an indefinite period of time. Nevertheless, the Employer expressly reserves the right to discontinue or terminate the Plan. After the Employer has discontinued or terminated the Plan, no Associate, Participant, Dependent or Beneficiary shall have or attain any vested right, contractual or otherwise, to any further contributions to or benefits from the Plan. ARTICLE VII. ERISA INFORMATION 7.1 Plan Name. The name of the Plan is the Retiree Welfare Benefit Plan of WoodmenLife. 7.2 Employer Information. The name and address of the Employer are WoodmenLife, 1700 Farnam Street, Omaha, NE Employer Identification Number (EIN). The Employer s identification number is Plan Number. The Plan Number assigned by the Employer is 521. The Component Plans do not have separate plan numbers. 7.5 Type of Plan. The Plan is an umbrella plan, also known as a wraparound plan, which provides the welfare benefits described in Exhibit A. 7.6 Type of Administration. The administration of the Plan is performed by the service providers and insurers listed in Exhibit A. 7.7 Plan Administrator Information. The name, business address, and business phone number of the Plan Administrator are as follows: WoodmenLife 1700 Farnam Street Omaha, NE Phone: (800) extension Agent for Service of Legal Process. The name and address of the Plan s agent for service of legal process is the Plan Administrator. Service of legal process may also be made upon the Plan Administrator. 7.9 Trustee. The Plan does not use a trust and therefore does not have any trustees. 9 P a g e

13 7.10 Eligibility for Participation and Benefits. The Plan s requirements for participation and benefits are set forth in Section 3.1 and/or in the Benefit Information Booklets for the Component Plans Summary of Benefits. The benefits provided under this Plan are summarized in the Benefit Information Booklets for the Component Plans. To the extent that any Component Plan includes access to a provider network, the provider network is described generally in the applicable Benefit Information Booklet. The providers in the network may be listed on a separate document if so, it will be provided to you automatically and free of charge Qualified Medical Child Support Orders ( QMCSOs ). The procedures governing QMCSOs are available from the Plan Administrator upon written request Loss of Eligibility and Benefits. The circumstances that could result in disqualification, ineligibility, or denial, loss, forfeiture, suspension, offset, reduction, or recovery of benefits, are set forth in Article IV and in the Benefit Information Booklet for the applicable Component Plan Plan Funding. The Benefits offered by a Component Plan may be funded by an insurance policy. If so, the premiums for the policy will be funded by contributions from the participating Associates and the Employer, in such proportions and amounts as the Employer may determine, in its sole discretion. Alternatively, or in combination with such a policy, the Benefits offered by a Component Plan may be funded by contributions from the participating Associates and the Employer, in such proportions and amounts as the Employer may determine, in its sole discretion. The Employer reserves the right to modify the cost-sharing of contributions between the Employer and participating Associates at any time and from time to time Funding Medium. The following funding medium is used for the accumulation of assets under the Plan: None Health Insurance Issuer. The following chart identifies the health insurance issuers that are responsible, in whole or in part, for financing or administering any of the benefits available under the Plan: NAME & ADDRESS OF ISSUER Blue Cross and Blue Shield of Nebraska P.O. Box 3248 Omaha, NE The Hartford P.O. Box 2999 Hartford, CT EXTENT TO WHICH BENEFITS ARE GUARANTEED BY ISSUER None Insured ADMINISTRATIVE SERVICES PROVIDED BY ISSUER Claims administration for the WoodmenLife Retiree Medical Plan Customer service and claims administration for the WoodmenLife Retiree Medicare Supplement Plan 10 P a g e

14 Metropolitan Life Ins. Co. 177 South Commons Drive Aurora, IL Insured Customer service and claims administration for the WoodmenLife Retiree Dental Plan 7.17 Plan Year. The plan year is the twelve (12) consecutive month period ending every December Claims Procedures. The claims procedures for each Benefit are set forth in in Exhibit B to the extent not inconsistent with the Plan or in the event that the claims procedures of a particular Component Plan do not comply with ERISA Further Information. An Associate may obtain further information about the Plan by contacting the Plan Administrator Inspection of Plan. The Employer will make the Plan and all related documents incorporated herein by reference available for inspection at its offices at no cost upon reasonable notice Copy of Plan. Upon reasonable notice and written request a copy of this Plan may be obtained from the Plan Administrator. The Plan Administrator may make a reasonable charge for copies Statement of ERISA Rights. As a Participant in this Plan, you are entitled to certain rights and protections under ERISA. ERISA provides that all plan Participants shall be entitled to: Receive Information About Your Plan and Benefits You may examine, without charge, at the Plan Administrator s office all documents governing the plan, including insurance contracts, and a copy of the latest annual report (Form 5500 Series), if any, filed by the plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration. You may obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the plan, including insurance contracts and copies of the latest annual report (Form 5500 Series), if any, and updated Summary Plan Description. The administrator may make a reasonable charge for the copies. You will receive a summary of the plan s annual financial report. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report. Continue Group Health Plan Coverage You may continue health care coverage for yourself, spouse or dependents if there is a loss of coverage under the plan as a result of a qualifying event. You or your dependents may 11 P a g e

15 have to pay for such coverage. Review this Summary Plan Description and the documents governing the plan on the rules governing your COBRA continuation coverage rights. Prudent Action by Plan Fiduciaries In addition to creating rights for plan participants ERISA imposes duties upon the people who are responsible for the operation of the plan. The people who operate your plan, called fiduciaries of the plan, have a duty to do so prudently and in the interest of you and other plan participants and beneficiaries. No one, including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA. Enforce Your Rights If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of plan documents or the latest annual report from the plan and do not receive them within 30 days, you may file suit in a Federal court (subject to any arbitration provisions set forth in the Plan). In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator. If you have a claim for benefits that is denied or ignored, in whole or in part, you may file suit in a state or Federal court (subject to any arbitration provisions set forth in the Plan). In addition, if you disagree with the plan s decision or lack thereof concerning the qualified status of a domestic relations order or a medical child support order, you may file suit in Federal court (subject to any arbitration provisions set forth in the Plan). If it should happen that plan fiduciaries misuse the plan s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court (subject to any arbitration provisions set forth in the Plan). The court will decide who should pay court costs and legal fees. If you are successful the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous. Assistance With Your Questions If you have any questions about your plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, of if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration. 12 P a g e

16 ARTICLE VIII. CONTINUATION OF GROUP HEALTH COVERAGE UNDER COBRA Introduction This Article has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This Article explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review this Summary Plan Description or contact the Plan Administrator. This Article VIII applies to the following (each a Component Health Plan ): the WoodmenLife Retiree Medical Plan, the WoodmenLife Retiree Medicare Supplement Plan, or the WoodmenLife Retiree Dental Plan. You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace (sometimes referred to as an Exchange). By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-ofpocket costs. Additionally, you may qualify for a 31-day special enrollment period for another group health plan for which you are eligible (such as a spouse s plan), even if that plan generally doesn t accept late enrollees. What is COBRA continuation coverage? COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a qualifying event. Specific qualifying events are listed later in this Article. After a qualifying event, COBRA continuation coverage must be offered to each person who is a qualified beneficiary. You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Component Health Plan is lost because of the qualifying event. Under the Component Health Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you are the spouse of a former Associate, you will become a qualified beneficiary if you lose your coverage under a Component Health Plan because of the following qualifying events: Your spouse dies; 13 P a g e

17 Your spouse s hours of employment are reduced; Your spouse s employment ends for any reason other than his or her gross misconduct; Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or You become divorced or legally separated from your spouse. If you are a dependent child of a former Associate, you will become a qualified beneficiary if you lose coverage under a Component Health Plan because of the following qualifying events: The parent-associate dies; The parent-associate becomes entitled to Medicare benefits (Part A, Part B, or both); The parents become divorced or legally separated; or The child stops being eligible for coverage under the Plan as a dependent child. Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to WoodmenLife, and that bankruptcy results in the loss of coverage of any retired Associate covered under the Plan, the retired Associate will become a qualified beneficiary. The retired Associate s spouse, surviving spouse, and dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan. When is COBRA continuation coverage available? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The Employer must notify the Plan Administrator of the following qualifying events: Death of the Associate; Commencement of a proceeding in bankruptcy with respect to the Employer; or The Associate s becoming entitled to Medicare benefits (under Part A, Part B, or both). For all other qualifying events (divorce or legal separation of the Associate and spouse or a dependent child s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator in writing within 60 days after the qualifying event occurs. Oral notice, including notice by telephone, is not acceptable. You must provide this notice to: WoodmenLife 1700 Farnam Street Omaha, NE If mailed, your notice must be postmarked no later than the last day of the required notice period. Any notice you provide must state: the name of the component health plan(s) under which you lost or are losing coverage; 14 P a g e

18 the name and address of the Associate covered under the Plan; the name(s) and address(es) of the qualified beneficiary(ies); and the qualifying event and the date it happened. If the qualifying event is a divorce or legal separation, your notice must include a copy of the divorce decree or the legal separation agreement. Be aware that there are other notice requirements in other contexts, for example, in order to qualify for a disability extension. How is COBRA continuation coverage provided? Once the Plan Administrator timely receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered former Associates may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage. (When the qualifying event is the death of the Associate, the Associate s becoming entitled to Medicare benefits (under Part A, Part B, or both), your divorce or legal separation, or a dependent child s losing eligibility as a dependent child, COBRA continuation coverage lasts for up to 36 months.) There are also ways in which this 18-month period of COBRA continuation coverage can be extended: Disability extension of 18-month period of COBRA continuation coverage If you or anyone in your family covered under a Component Health Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage. Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the former Associate dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Component 15 P a g e

19 Health Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Component Health Plan had the first qualifying event not occurred. Are there other coverage options besides COBRA Continuation Coverage? Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse s plan) through what is called a special enrollment period. Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at If you have questions Questions concerning the Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor s Employee Benefits Security Administration (EBSA) in your area or visit (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA s website.) For more information about the Marketplace, visit Keep your Plan informed of address changes To protect your family s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. Plan contact information Retiree Welfare Benefit Plan of WoodmenLife WoodmenLife 1700 Farnam Street Omaha, NE (800) extension ARTICLE IX. HEALTH INFORMATION PROTECTION AND RIGHTS 9.1 HIPAA Notice of Privacy Practices. You have been furnished a Notice of Privacy Practices describing the practices the Plan will follow with regard to your personal health information that is protected by the Health Insurance Portability and Accountability Act of 1996, as amended ( HIPAA ). If you would like to receive another copy of the Notice, please contact the Plan Administrator. 16 P a g e

20 ARTICLE X. ADDITIONAL LEGAL NOTICES 10.1 Newborns Act. Under federal law, group health plans and health insurance issuers generally may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother s or newborn s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). Contact the Plan Administrator for additional information Women s Health and Cancer Rights Act of Do you know that your plan, as required by the Women s Health and Cancer Rights Act of 1998, provides benefits for mastectomy-related services including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy, including lymphedema? Contact the Plan Administrator for additional information. 17 P a g e

21 EXHIBIT A COMPONENT BENEFIT PLANS AND BENEFIT INFORMATION BOOKLETS Read this SPD and the Component Plan Information Booklets carefully so that you understand the provisions of the Plan and the benefits you will receive. The following Component Plans are part of the Plan. The following Information Booklets describe Component Plan benefits that are governed by the Plan. The Plan document is written in much more technical and precise language. If the language in any of these Component Plan Information Booklets or this SPD conflict with the technical, legal language of the Plan document, the Plan document always governs. Also, if there is a conflict between an insurance contract and either the Plan document or this SPD, the insurance contract will control. If you wish to receive a copy of the Plan document, please contact the Plan Administrator. EXHIBIT TYPE OF PLAN COMPONENT PLAN INFORMATION BOOKLET WoodmenLife Retiree Medical Plan A-1 Medical Introduction and General Information A-1.1 A.1-2 A-2.1 A-2.2 Medical Medical Medicare Supplement Medicare Supplement WoodmenLife Retiree Medical Plan Select HRA WoodmenLife Retiree Medical Plan Select HSA WoodmenLife Retiree Medicare Supplement Plan Group Retiree Insurance Plan Senior Medical Insurance Plan INSURER OR CONTRACTOR Blue Cross and Blue Shield of Nebraska Blue Cross and Blue Shield of Nebraska Blue Cross and Blue Shield of Nebraska The Hartford The Hartford WoodmenLife Retiree Dental Plan A-3.1 Dental Option 1 (excluding Louisiana residents) MetLife A-3.2 Dental Option 1 (for Louisiana residents) MetLife A-3.3 Dental Option 2 (excluding Louisiana residents) MetLife A-3.4 Dental Option 2 (for Louisiana residents) MetLife WoodmenLife Retiree Life Plan A-4 Life Booklet Woodmen of the World Life Insurance Society Exhibit A 18 P a g e

22 EXHIBIT A-1 WOODMENLIFE RETIREE MEDICAL PLAN BENEFIT INFORMATION BOOKLET (APPLIES TO BOTH SELECT HRA AND SELECT HSA OPTIONS) Exhibit A-1 19 P a g e

23 IMPORTANT INFORMATION Important Phone Numbers Member Services Omaha and Toll-free TTY/TTD (for the hearing impaired) Coordination of Benefits Omaha Toll-free Subrogation Omaha Toll-free Workers Compensation Omaha Toll-free Certification Omaha Toll-free BlueCard Provider Information Toll-free BLUE (2583) Website Pharmacy Locator Toll-free Exhibit A-1 20 P a g e

24 INTRODUCTION This document is your Summary Plan Description (SPD). This SPD has been written to help you understand your Group health Plan coverage. It describes the benefits, exclusions and limitations of your Plan in a general way, and is not, and should not be considered a contract. Your Group health Plan is administered in accordance with the Administrative Services Agreement between the Group and Blue Cross and Blue Shield of Nebraska (BCBSNE), an independent licensee of the Blue Cross and Blue Shield Association. The Administrative Services Agreement and official Plan documents control the coverage for your Group. NOTE: BCBSNE provides administrative claims payment services only and does not assume any financial risk or obligation with respect to claims. BCBSNE liability may occur only under a stop loss provision, as set forth in a stop loss agreement with the Group. Please share the information found in this SPD with your Eligible Dependents. How To Use This Document For your convenience, defined terms are capitalized throughout this document. For an explanation of a defined term, refer to the Section titled Definitions. Please take some time to read this document and become familiar with it. As you read this document, you will find that many sections are related to other sections of the document. You may not have all the information you need by reading just one section. We encourage you to review the benefits and limitations by reading the Benefit Summary page and the sections titled Benefit Descriptions and Exclusions. If you have a question about your coverage or a Claim, please contact BCBSNE Member Services Department. About Your I.D. Card BCBSNE will issue you an identification card (I.D. card). Your I.D. number is a unique alpha numeric combination. Present your I.D. to your health care provider when you receive Services. With your BCBSNE I.D. card, Hospitals and Physicians can identify your coverage and will usually submit Claims for you. If you want extra cards for covered family members or need to replace a lost card, please contact BCBSNE Member Services Department, or you may access through the website, Schedule of Benefits and Benefits Summary Your Schedule of Benefits is a personalized document that provides you with a basic description of your Plan coverage option. It also shows the membership option that applies to you. Exhibit A-1 21 P a g e

25 A Benefit Summary is included in this SPD. It includes information concerning deductible and cost-sharing amounts, benefit limits, and other coverage details. Exhibit A-1 22 P a g e

26 THE PLAN AND HOW IT WORKS About The Plan This Group health Plan is a Preferred Provider Organization (PPO) health benefit plan. Claims administration is provided by Blue Cross and Blue Shield of Nebraska (BCBSNE). BCBSNE has contracted with a panel of Hospitals, Physicians and other health care providers to establish a network of providers who have agreed to furnish medical Services to you and your family in a manner that will help manage health care costs. These providers are referred to as In-network or Preferred Providers. The BCBSNE PPO provider network is identified as NEtwork BLUE. Blue Cross and Blue Shield Plans in other states (On-site Plans) have also contracted with health care providers in their geographic areas, who are referred to as Preferred Providers. Use of the network is voluntary, but you should be aware that when you choose to use providers who do not participate in the BCBSNE or On-site Plan s network for non-emergency situations, you can expect to pay more than your applicable Deductible, Copay 1 and/or Coinsurance amounts. After this health plan pays its required portion of the bill, Out-of-network Providers may bill you for any amount not paid. This balance billing does not happen when you use Innetwork or Preferred Providers because these providers have agreed to accept a discounted payment for Services with no additional billing to you other than your applicable Deductible, Copay and/or Coinsurance amounts. In-network Providers will also file Claims for you. For help in locating In-network Providers, managing your personal health care benefits, as well as accessing various resources and tools, visit BCBSNE online at You may also call BCBSNE Member Services using the toll-free number on your I.D. card or refer to the Important Telephone Numbers in the front of this exhibit. If you would like a printed provider list, BCBSNE will furnish one without charge. Be Informed Out-of-network Providers charges may be higher than the benefit amount allowed by this health plan. You may contact BCBSNE Member Services Department concerning allowable benefit amounts in Nebraska for specific procedures. Your request must specify the Service or procedure, including any Service or procedure code(s) or diagnosis-related group, and the provider s estimated charge. How The Network Works Using In-network Providers: present I.D. card; receive highest level of benefits; provider files Claims for you; 1 Copays only apply in the Select HRA context. Exhibit A-1 23 P a g e

27 provider accepts insurance payment as payment in full (except Deductible and/or Coinsurance amounts); and no balance billing. Using Out-of-network Providers: you may be required to pay full cost at time of service; you may be reimbursed at a lower benefit level; you may have to file Claims; and you re responsible for amounts that exceed the Allowable Charge. Exception If you receive initial, short-term (48 hours or less) Inpatient or Outpatient care for an Emergency Medical Condition at an Out-of-network Hospital or by an Out-of-network Provider, benefits for those Covered Services will be provided at the In-network benefit level. Benefits for Inpatient Covered Services will continue to be paid at the In-network level, as long as they are for an Emergency Medical Condition. To continue to receive the In-network level of benefits for Outpatient care after the initial care has been provided, you must use an In-network Provider. In addition, any Covered Services provided by an Out-of-network Urgent Care Physician and/or other Out-of-network professional Provider will be paid at the In-network level when the corresponding facility charges are paid subject to the In-network benefit level. NOTE: You will still be responsible for amounts in excess of the Allowable Charge when you receive Services from an Out-of-network Provider. Out-Of-Area Services BCBSNE has a variety of relationships with other Blue Cross and/or Blue Shield Licensees referred to generally as Inter-Plan Programs. Whenever you obtain healthcare Services outside of BCBSNE s service area, the claims for these Services may be processed through one of these Inter-Plan Programs, which include the BlueCard Program and may include negotiated National Account arrangements available between BCBSNE and other Blue Cross and Blue Shield licensees. Typically, when accessing care outside BCBSNE s service area, you will obtain care from healthcare providers that have a contractual agreement (i.e., are Participating Providers ) with the local Blue Cross and/or Blue Shield Licensee in that other geographic area ( Host Blue or On-Site Plan ). In some instances, you may obtain care from nonparticipating healthcare providers. BCBSNE s payment practices in both instances are described in the following paragraphs. BlueCard Program Under the BlueCard Program, when you access Covered Services within the geographic area served by a Host Blue, BCBSNE will remain responsible for fulfilling BCBSNE s contractual Exhibit A-1 24 P a g e