Effective October 1, 2009, the above Plan Document/Summary Plan Description is amended as follows:

Transcription

1 AMENDMENT NO. 5 to the MESA PUBLIC SCHOOLS EMPLOYEE BENEFIT TRUST Medical, Dental, Vision and Life Insurance Plans PLAN DOCUMENT/SUMMARY PLAN DESCRIPTION Amended, restated and effective: October 1, 2004 Effective October 1, 2009, the above Plan Document/Summary Plan Description is amended as follows: Page 48 of the Vision Plan chapter, the Schedule of Vision Benefits is amended as noted by the deletion of text in strike-through and the addition of the text in italics. Covered Vision Benefits Vision Examination and analysis of visual function. Eyeglasses, as necessary (frames and lenses) Contact Lenses payable: following cataract surgery to correct extreme visual acuity problems that cannot be corrected with normal lenses for anisometropia (a condition of unequal refractive state for the two eyes) for keratoconus (a developmental or dystrophic deformity of the cornea) SCHEDULE OF VISION BENEFITS Explanation See also the Vision Exclusions. Payable once every 12 months. A single vision, bifocal, trifocal or lenticular lenses as required every 12 months; and/or A frame, only if needed every 24 months. Polycarbonate lenses are payable for children. This program provides a wide selection of quality frames. Because of the cosmetic nature of frames and rapidly changing styles, this plan has a limit (determined by the Vision Plan administrator) on the reimbursement for frames. Once every 12 months, if needed. Should you choose contact lenses for reasons other than those discussed in this section, the plan will make an allowance of $80 $130 toward the cost, provided you are eligible for both an examination and lenses at the time the contact lenses are fitted. In-Network Provider 100% after a $10.00 $15.00 copay Lenses: 100% after a $15.00 copay per lenses. Frames: Plan provides a $45 $50 wholesale frame and a $130 retail frame allowance 100% If lenses are for conditions noted in the far left column, otherwise, the plan pays up to $80 $130. Plan Pays Non-Network Provider Up to $35 per exam Single vision (pair)*= Up to $20 Bifocal lenses (pair)*= Up to $35 Trifocal lenses (pair)*= Up to $45 Lenticular lenses (pair)*= Up to $75 Frames = Up to $45 *If only one lens is needed, the allowance will be one-half the pair allowance. Contacts required for vision correction (as determined by the Vision Plan administrator) = Up to $250 Cosmetic (elective) contact lenses (as determined by the Vision Plan Administrator) = Up to $80. 1

2 Page 8 in the Eligibility chapter under the subheading Pre-Existing Conditions the text is amended as noted by the addition of the text in italics: PRE-EXISTING CONDITIONS (other than for a Newborn) (Special Rule for Coverage) only applies to the Employee Benefit Trust (EBT) Options PPO Plan. Definition of Pre-Existing Condition : A Pre-Existing Condition is any illness or injury (whether physical or mental) regardless of its cause, for which medical advice, diagnosis, care, or treatment was recommended or received within the six (6) month period ending on the enrollment date as defined below. Treatment includes an individual taking a prescribed drug within the 6-month period. When a Pre-existing Condition Limitation Does NOT Apply: Genetic information (in the absence of a diagnosis of a resulting condition) including family history and the results of genetic testing, and pregnancy are not Pre-Existing Conditions for the purposes of this Plan. Pre-existing condition limitations are not applied to the following Plan benefits: behavioral health services, outpatient retail or mail order prescription drug benefits, the vision plan, or the dental plan. No exclusion of a Pre-Existing Condition may apply with respect to any condition of a newborn child who was is enrolled for creditable coverage (as defined below) under this Plan within 31 days of birth, or an adopted child who was enrolled within 31 days of adoption or placement for adoption. Enrollment Date: Enrollment Date, as it pertains to pre-existing conditions means the earlier of the first day of coverage or the first day of the waiting period (defined below) for that enrollment. It is the date that will be used to measure the 6-month period prior to which medical advice, diagnosis, care, or treatment for a Pre-Existing Condition was recommended or received (also called the look-back period), and to measure the 12-month period during which the Plan may exclude coverage of expenses related to a Pre-Existing Condition. Under this Plan, for Initial Enrollment the enrollment date is the first day of the employment contract. For Special Enrollment, the enrollment date is the date on which the Plan received the properly completed enrollment form. For Open Enrollment, the Enrollment date is the first day of the Open Enrollment period. A Waiting Period is the period that must pass before coverage for an employee or dependent otherwise eligible to enroll under the terms of the Plan can become effective. Maximum Period of Exclusion of Coverage for Pre-Existing Conditions After Initial, Open or Special Enrollment: If, after you and/or your Eligible Dependents have completed an Initial or Special or Open Enrollment, the Plan Administrator or its designee determines that you or any of your covered Dependents has a Pre-Existing Condition, no expenses related to that Pre-Existing Condition will be covered by the Plan before 12 consecutive months of coverage have elapsed. The existence of a Pre-existing condition does not affect coverage under the Outpatient Prescription Drug Plan benefits or the Behavioral Health benefits of this medical plan or the Dental Plan or the Vision Plan. Credit for Previous Coverage: You must submit evidence of the period of creditable coverage (often called a HIPAA Certificate of Creditable Coverage) under any other health care plan or insurance policy in order to prove that you are entitled to a credit for the time you were covered under that other plan or policy in order to reduce the maximum period of exclusion of coverage for this Plan s Pre-Existing Conditions, and that there has been no break in coverage. If there has been NO Break in Coverage, the maximum period of exclusion of coverage for Pre-Existing Conditions described in this section will be reduced by the period of time that you, your Spouse and/or any of your Dependent Children were covered under any creditable coverage. Creditable coverage includes most types of health insurance such as COBRA continuation coverage, or any group or individual health care plan or insurance policy, Medicare, Medicaid, military sponsored health care, program of the Indian Health Service, state health benefits risk pool, State Children s Health Insurance Program (SCHIP), foreign plans, US government and federal employees health benefit programs, a public health plan, and/or any health benefit plan provided under the Peace Corps Act. If there has been a Break in Coverage, no such credit will be provided for any periods of coverage prior to the Break in Coverage. A Break in Coverage means a period of 63 consecutive days or more between the date coverage ended under any other health care plan or insurance policy as described above and the enrollment date. A leave of absence under the provisions of the Family and Medical Leave Act or the Uniformed Service Employment and Reemployment Act will not be counted as a Break in Coverage. This Plan may require you to submit a certification of the period of creditable coverage under any other health care plan or insurance policy in order to prove that you are entitled to credit for the time you were covered under that plan or 2

3 policy that will reduce the maximum period of exclusion of coverage for this Plan s Pre-Existing Conditions. Your previous company, insurer or plan is required by law to provide such a certification to you on request. If you have difficulty obtaining a certification this Plan will assist you. Page 69 in the Continuation of Coverage chapter, the subsection titled Family and Medical Leave Act (FMLA) is amended to add the text in italics: Family And Medical Leave Act (FMLA) If you have completed 12 months of employment and have completed at least 1,250 hours of service in the 12 month period immediately prior to the time the leave is to commence, you are entitled by law to up to 12 weeks each year (in some cases up to 26 weeks) of unpaid Family and Medical Leave for specified family or medical purposes, such as the birth or adoption of a child, or to provide care of a spouse, child or parent who is seriously ill, or for your own serious illness. While you are officially on such a Family and Medical Leave, you can keep your medical and dental coverage in effect during that Family and Medical Leave period by continuing to pay any required contributions during that period. Please read the appropriate District Administrative Regulation for complete details. Whether or not you keep your coverage while you are on Family or Medical Leave, if you return to work promptly at the end of that Leave, your medical and dental coverage will be reinstated without any additional limits or restrictions imposed on account of your Leave. This is also true for any of your Dependents who were covered by the Plan at the time you took your Leave. Of course, any changes in the Plan s terms, rules or practices that went into effect while you were away on that Leave will apply to you and your Dependents in the same way they apply to all other employees and their Dependents. If you fail to return to work with the District within 30 days following a FMLA leave for any reason, other than noted below in (a), (b), and (c) you will be required to reimburse the District for the health care Plan s insurance premiums paid on your behalf during the leave: a. to continuation, reoccurrence or onset of a serious health condition which entitles you to FMLA leave; or b. other circumstances beyond your control; or c. retirement during or directly after the FMLA leave. If you allow your health care coverage to lapse while on FMLA leave, your coverage will be reinstated upon the first day of the month following your return from FMLA, without applying the Pre-existing Condition provision of this plan, but only if you have submitted a properly completed enrollment form to the Employee Benefits Department and make any required contributions for coverage. For the calculation of the 12-month period used to determine employee eligibility for FMLA, this Plan uses a rolling 12 month period measured backward in time from the date the employee uses any FMLA leave. Page 6-7 in the Eligibility chapter under the subheading Special Enrollment for Yourself and Your Eligible Dependents the language is amended by the addition of text in italics and the deletion of the text in strike-through: SPECIAL ENROLLMENT FOR YOURSELF AND YOUR ELIGIBLE DEPENDENTS A. Newly Acquired Spouse and/or Dependent Child(ren) (as those terms are defined in this Plan) If you are enrolled for individual coverage and if you acquire a Spouse by marriage, or if you acquire any Dependent Children by birth, adoption or placement for adoption, you may request enrollment for your newly acquired Spouse and/or any Dependent Child(ren) no later than 31 days after the date of marriage, birth, adoption or placement for adoption. Coverage is effective as noted under When Coverage Begins Following Special Enrollment. If you are not enrolled for individual coverage and if you acquire a Spouse by marriage, or if you acquire any Dependent Children by birth, adoption or placement for adoption, you may request enrollment for yourself and your newly acquired Spouse and/or any Dependent Child(ren) no later than 31 days after the date of marriage, birth, adoption or placement for adoption. Coverage is effective as noted under When Coverage Begins Following Special Enrollment. 3

4 If you did not enroll your Spouse for coverage within 31 days of the date on which he or she became eligible for coverage, and if you subsequently acquire a Dependent Child by birth, adoption or placement for adoption, you may request enrollment for your Spouse together with your newly acquired Dependent Child and any other dependent child(ren) within 31 days after the date of your newly acquired Dependent Child s birth, adoption or placement for adoption. Coverage is effective for newborns or adopted newborn children on the date of birth. Coverage is effective as noted under When Coverage Begins Following Special Enrollment. Except with respect to Special Enrollment for newborn or newly adopted Dependent Children, the coverage provided may be subject to exclusions for any Pre-Existing Condition as described in this chapter. To request Special Enrollment follow the Enrollment Procedures described earlier in this chapter. To obtain more information about Special Enrollment, contact the Employee Benefits Department. B. Loss of Other Coverage If you did not request enrollment under this Plan for yourself, your Spouse and/or any Dependent Child(ren) within 31 days after the date on which coverage under the Plan was previously offered because you or they had health care coverage under another group health plan or health insurance policy including COBRA Continuation Coverage, certain types of individual insurance, Medicare, Medicaid, or other public program; and you, your Spouse and/or any Dependent Child(ren) lose coverage under that other group health plan or health insurance policy; you may request enrollment for yourself and/or your Spouse and/or any Dependent Child(ren) within 31 days after the termination of their coverage under that other group health plan or health insurance policy if that other coverage terminated because: of loss of eligibility for that coverage including loss resulting from legal separation, divorce, death, voluntary or involuntary termination of employment or reduction in hours (but does not include loss due to failure of employee to pay premiums on a timely basis or termination of the other coverage for cause); or of termination of employer contributions toward that other coverage (an employer s reduction but not cessation of contributions does not trigger a special enrollment right); or the health insurance was provided under COBRA Continuation Coverage, and the COBRA coverage was exhausted or of moving out of an HMO service area if HMO coverage terminated for that reason and, for group coverage, no other option is available under the other plan; or of the other plan ceasing to offer coverage to a group of similarly situated individuals; or of the loss of dependent status under the other plan s terms; or of the termination of a benefit package option under the other plan, unless substitute coverage offered; or of the loss of eligibility due to reaching the lifetime benefit maximum on all benefits under the other plan. For Special Enrollment that arises from reaching a lifetime benefit maximum on all benefits, an individual will be allowed to request Special Enrollment in this Plan within 31 days after a claim is denied due to the operation of a lifetime limit on all benefits. Effective April 1, 2009, you and your dependents may also enroll in this Plan if you (or your eligible dependents): a. have coverage through Medicaid or a State Children s Health Insurance Program (CHIP) and you (or your dependents) lose eligibility for that coverage. However, you must request enrollment in this Plan within 60 days after the Medicaid or CHIP coverage ends; or b. become eligible for a premium assistance program through Medicaid or CHIP. However, you must request enrollment in this Plan within 60 days after you (or your dependents) are determined to be eligible for such premium assistance. See also the Enrollment Procedures section of this chapter for more information. Proof of loss of coverage is required by this Plan. COBRA Continuation Coverage is exhausted if it ceases for any reason other than either the failure of the individual to pay the applicable COBRA premium on a timely basis, or for cause (such as making a fraudulent claim or an intentional misrepresentation of material fact in connection with that COBRA Continuation Coverage). Exhaustion of COBRA Continuation Coverage can also occur if the coverage ceases: due to the failure of the employer or other responsible entity to remit premiums on a timely basis; when the employer or other responsible entity terminates the health care plan and there is no other COBRA Continuation Coverage available to the individual; 4

5 when the individual no longer resides, lives, or works in a service area of an HMO or similar program (whether or not by the choice of the individual) and there is no other COBRA Continuation Coverage available to the individual; or because the 18-month, 29-month or 36-month period of COBRA Continuation Coverage has been exhausted. When Coverage Begins Following Special Enrollment Coverage of an individual enrolling because of loss of other coverage or because of marriage: If the individual requests Special Enrollment within 31 days of the date of the event that created the Special Enrollment opportunity, (except for newborn and newly adopted child or on account of Medicaid or a State Children s Health Insurance Program (CHIP), discussed below) generally coverage will become effective on the first day of the month following the date the Plan receives the properly completed request for special enrollment. If the individual requests Special Enrollment within 60 days of the date of the Special Enrollment opportunity related to Medicaid or a State Children s Health Insurance Program (CHIP), generally coverage will become effective on the first day of the month following the date of the event that allowed this Special Enrollment opportunity. Coverage of a newborn or newly adopted newborn Dependent Child who is properly enrolled within 31 days after birth will become effective as of the date of the child s birth. (See the Newborn and Adopted Dependent Children sections of this chapter). Coverage of a newly adopted Dependent Child or Dependent Child Placed for Adoption who is properly enrolled more than 31 days after birth, but within 31 days after the child is adopted or placed for adoption, will become effective as of the date of the child s adoption or placement for adoption, whichever occurs first. Individuals enrolled during Special Enrollment have the same opportunity to select plan benefit options (when such options exist) at the same costs and the same enrollment requirements, including any pre-existing condition limitations the Plan may require, as are available to similarly-situated employees at Initial Enrollment. Failure to Enroll During Special Enrollment: If you fail to request enrollment for yourself or any of your Eligible Dependents within 31 days (or as applicable 60 days) after the date on which you or they first become eligible for Special Enrollment, you will have to wait until the next Open Enrollment period, and coverage may be subject to exclusions for any Pre-Existing Condition as described in this chapter. Page 80 in the Definitions chapter under the definition of Dependent the definition of Dependent Child is deleted as noted by the text in strike-through and replaced with the new definition in italics noted below: Dependent: Dependent Child: For the purposes of this Plan, a Dependent Child is any of your unmarried children, including any stepchild or legally adopted child who lives with you, or any such child for whom you are legally obligated to provide support, provided the child has not reached his or her 19th birthday; or the child has reached his or her 19th birthday but has not reached his or her 24th birthday and attends an accredited college, university or accredited and licensed technical school or institution of higher education on a full-time basis. Note that a dependent with employee or spouse guardianship is not an eligible dependent under this Plan. Coverage of a Dependent Child may continue beyond age 18 or 23 for any unmarried child who is mentally or physically Handicapped and is incapable of self-sustaining employment as a result of that handicap; and dependent chiefly on you and/or your spouse for support and maintenance. If an employee and spouse are both eligible as Covered Employees or as Qualified Beneficiaries, only one (1) may have Dependent coverage for eligible children. 5

6 Dependent Child(ren): A. For the purposes of this Plan, a Dependent Child is any of the employee s unmarried children who have the same principal place of abode as the employee, including a natural child, stepchild, legally adopted child, or child placed for adoption with the employee (proof of adoption or placement for adoption may be requested), provided: 1. the Dependent Child depends on the employee for more than one-half of their support and is not a qualifying child of any other person. The term qualifying child is defined in the Internal Revenue Code (IRC) in Section 152 (c). Note that a child will not be treated as the qualifying child of another person if that other person is not required by federal law to file an income tax return and that person either does not file an income tax return or files one solely to obtain a refund of withheld income taxes. 2. the child meets one of the following criteria: a. The child has not reached his or her 19 th birthday; OR b. The child has reached his or her 19 th birthday but has not reached his or her 24 th birthday and is enrolled as a full-time student in high school or in an accredited and state licensed technical school or institution of higher education. School vacation periods during any calendar year that interrupt but do not terminate a continuous course of study will be considered school attendance for those individuals who attend school on a full-time basis as long as the child has not reached their 24 th birthday. The Plan may require initial and periodic proof of student status ; OR c. The child has reached his or her 19 th birthday (and is not a full-time student ) or his or her 24 th birthday and the child is mentally or physically disabled (as that term disabled is defined in this Plan); the child is incapable of self-sustaining employment as a result of that disability; and that disability existed before the attainment of this Plan s age limit. This Plan may require initial and periodic proof of disability. B. Note that a dependent with employee or spouse guardianship is not an eligible dependent under this Plan. C. If an employee and spouse are both eligible as Covered Employees or as Qualified Beneficiaries, only one (1) may have Dependent coverage for eligible children. D. A child named in a qualified medical child support order (QMCSO) is also an eligible dependent under this Plan. See the Eligibility chapter for details on QMCSOs. E. It is the employee s obligation to inform the Plan promptly if any of the requirements set out in this definition of a Dependent child are NOT met with respect to any child for whom coverage is sought or is being provided. F. Coverage of a Dependent Child ends at the end of the month in which that child: 1. reaches his or her 24 th birthday, whichever is applicable; or 2. voluntarily or involuntarily terminates full-time attendance at a high school, technical school or institution of higher education or graduates; or 3. marries; or 4. no longer meets the eligibility requirements of the Plan; or 5. enters military or similar service anywhere; or 6. on the date the child becomes eligible to enroll for coverage as an employee of any other employer and no longer depends on the employee for over half of his/her support. See also the provisions in the Eligibility chapter on When Coverage Ends. This Plan Document is amended as stated above, this day of, 200 : Plan Administrator v2/