AMENDMENT NUMBER 1 TO TEAMSTERS LOCAL 294- ALBANY AREA TRUCKING AND ALLIED INDUSTRIES HEALTH & WELFARE FUND HEALTH REIMBURSEMENT ARRANGEMENT
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1 AMENDMENT NUMBER 1 TO TEAMSTERS LOCAL 294- ALBANY AREA TRUCKING AND ALLIED INDUSTRIES HEALTH & WELFARE FUND HEALTH REIMBURSEMENT ARRANGEMENT The Teamsters Local 294- Albany Area Trucking and Allied Industries Health & Welfare Fund Health Reimbursement Arrangement is hereby amended as follows: Effective March 1, 2017 I. All references to Plan Year are expanded to include the following: Applicable to TOMRA The period beginning March 1, 2017 and December 31, 2017 and each twelve month period thereafter beginning January 1 and ending December 31. II. In ARTICLE III SCHEDULE OF BENEFITS, section 3.1 Maximum Benefit is expanded to include the following: 3.1 Maximum Benefit Applicable to TOMRA a. $2,600 per benefit year if you are enrolled in Single coverage, or b. $5,200 per benefit year if you are enrolled in Family coverage. The benefit amount will be allocated on a quarterly basis. Any balance remaining at the end of any benefit year will carry forward into the next following benefit year. III. In ARTICLE III SCHEDULE OF BENEFITS, section 3.2 Eligible Expenses is deleted and replaced with the following: 3.2 Eligible Expenses, Borg Warner, Town of Chatham, NES-Albany, TOMRA Eligible expenses are those expenses incurred by you or your covered dependent, for medical care, as defined by Code Sec. 213, (d). 1
2 This Plan shall reimburse employee charges that are applied to the medical deductible. IV. In ARTICLE IV ELIGIBILITY AND PARTICIPATION, section 4.7 When Coverage Ends is expanded to include the following: Applicable to TOMRA Your coverage ends the earliest of the last day of the quarter in which your last day of full-time regular employment; the last day of the quarter in which you are no longer in a class of employees that is eligible for Plan coverage; or the date the Plan ends. V. In ARTICLE V PAYMENT OF BENEFITS, the second paragraph of section 5.5 Filing a Claim for Benefits is expanded to include the following: Applicable to TOMRA incurred. If your employment terminates, you may submit any eligible claims that were incurred before or after your date of termination until the funds are depleted. VI. The Plan Document is expanded to include Appendix A Notice of Nondiscrimination, as attached. Effective January 1, 2017 I. All references to Plan Year are deleted and replaced with the following: Plan Year Applicable to NES-Albany The period beginning January 1, 2017 and ending May 31, 2017 and each twelve month period thereafter beginning June 1 and ending May 31. 2
3 Applicable to All Others The period beginning January 1 and ending December 31. II. In ARTICLE III SCHEDULE OF BENEFITS, sections 3.1 Maximum Benefit and 3.2 Eligible Expenses are deleted and replaced with the following: 3.1 Maximum Benefit a. $2,600 per benefit year if you are enrolled in Single coverage, or c. $5,200 per benefit year if you are enrolled in Family coverage. After the short plan year, the entire benefit amount will be available to you upon enrollment. Any balance remaining at the end of any benefit year will carry forward into the next following benefit year. Any amount less than $500 that is dormant for twentyfour (24) months shall be forfeited by the participant. Subject to applicable law and regulation, any forfeiture shall revert to the employer., Town of Chatham a. $2,600 per benefit year if you are enrolled in Single coverage, or d. $5,200 per benefit year if you are enrolled in Family coverage. The entire benefit amount will be available to you upon enrollment. At the end of the benefit year, any unused benefit amounts shall be forfeited by the participant. Subject to applicable law and regulation, any forfeiture shall revert to the employer. Applicable to Borg Warner 3
4 a. $2,600 per benefit year if you are enrolled in Single coverage, or e. $5,200 per benefit year if you are enrolled in Family coverage. The entire benefit amount will be available to you upon enrollment. Any balance remaining at the end of any benefit year will carry forward into the next following benefit year. Applicable to NES- Albany a. $2,600 per benefit year if you are enrolled in Single coverage, or f. $5,200 per benefit year if you are enrolled in Family coverage. The benefit amount will be allocated on a quarterly basis. Any balance remaining at the end of any benefit year will carry forward into the next following benefit year. 3.2 Eligible Expenses, Borg Warner, Town of Chatham, NES-Albany Eligible expenses are those expenses incurred by you or your covered dependent, for medical care, as defined by Code Sec. 213, (d). This Plan shall reimburse employee charges that are applied to the medical deductible. III. In ARTICLE IV ELIGIBILITY AND PARTICIPATION, section 4.7 When Coverage Ends is deleted and replaced with the following: 4.7 When Coverage Ends Your coverage will continue as long as you make any required contribution to the plan or until the date the Plan ends. 4
5 Your coverage ends the earliest of your last day of full-time regular employment; the day you are no longer in a class of employees that is eligible for Plan coverage; or the date the Plan ends. Applicable to Borg Warner, Town of Chatham Your coverage ends the earliest of the last day of the month in which your last day of full-time regular employment; the day you are no longer in a class of employees that is eligible for Plan coverage; or the date the Plan ends. Applicable to NES-Albany Your coverage ends the earliest of the last day of the quarter in which your last day of full-time regular employment; the last day of the quarter in which you are no longer in a class of employees that is eligible for Plan coverage; or the date the Plan ends. IV. In ARTICLE V PAYMENT OF BENEFITS, the second paragraph of section 5.5 Filing a Claim for Benefits is deleted and replaced with the following: incurred, and ends ninety (90) days after the close of the benefit year. If your employment terminates, you will have be able to submit any eligible claims that were incurred prior to 5
6 your date of termination until your account balance is depleted., Borg Warner, Town of Chatham incurred, and ends ninety (90) days after the close of the benefit year. If your employment terminates, you will have ninety (90) days following your termination date to submit any eligible claims that were incurred prior to your date of termination. Applicable to NES-Albany incurred. If your employment terminates, you may submit any eligible claims that were incurred prior to your date of termination until the funds are depleted. Effective August 1, 2016 I. All references to Plan Year are deleted and replaced with the following: Plan Year The period beginning June 1, 2016 and ending December 31, 2016; and each 12-month period thereafter beginning January 1 and ending December 31. The period beginning August 1, 2016 and ending December 31, 2016; and each 12-month period thereafter beginning January 1 and ending December 31. II. In ARTICLE III SCHEDULE OF BENEFITS, sections 3.1 Maximum Benefit and 3.2 Eligible Expenses are deleted and replaced with the following: 3.1 Maximum Benefit a. $2,600 per benefit year if you are enrolled in Single coverage ($217 will be allocated on a monthly basis for the short plan year), or 6
7 b. $5,200 per benefit year if you are enrolled in Family coverage ($434 will be allocated on a monthly basis for the short plan year). After the short plan year, the entire benefit amount will be available to you upon enrollment. Any balance remaining at the end of any benefit year will carry forward into the next following benefit year. Any amount less than $500 that is dormant for twentyfour (24) months shall be forfeited by the participant. Subject to applicable law and regulation, any forfeiture shall revert to the employer. a. $2,600 per benefit year if you are enrolled in Single coverage, or b. $5,200 per benefit year if you are enrolled in Family coverage. The entire benefit amount will be available to you upon enrollment. At the end of the benefit year, any unused benefit amounts shall be forfeited by the participant. Subject to applicable law and regulation, any forfeiture shall revert to the employer. 3.2 Eligible Expenses Eligible expenses are those expenses incurred by you or your covered dependent, for medical care, as defined by Code Sec. 213, (d). This Plan shall reimburse employee charges that are applied to the medical deductible. III. In ARTICLE IV ELIGIBILITY AND PARTICIPATION, section 4.7 When Coverage Ends is deleted and replaced with the following: 4.7 When Coverage Ends Your coverage will continue as long as you make any required contribution to the 7
8 plan or until the date the Plan ends. Your coverage ends the earliest of your last day of full-time regular employment; the day you are no longer in a class of employees that is eligible for Plan coverage; or the date the Plan ends. IV. In ARTICLE V PAYMENT OF BENEFITS, the second paragraph of section 5.5 Filing a Claim for Benefits is deleted and replaced with the following: incurred, and ends ninety (90) days after the close of the benefit year. If your employment terminates, you will have be able to submit any eligible claims that were incurred prior to your date of termination until your account balance is depleted. incurred, and ends ninety (90) days after the close of the benefit year. If your employment terminates, you will have ninety (90) days following your termination date to submit any eligible claims that were incurred prior to your date of termination. Effective June 1, 2016 In ARTICLE V PAYMENT OF BENEFITS, the second paragraph of section 5.5 Filing a Claim for Benefits is deleted and replaced with the following: 8
9 incurred, and ends ninety (90) days after the close of the benefit year. If your employment terminates, you will have be able to submit any eligible claims that were incurred prior to your date of termination until your account balance is depleted. All other provisions of the Plan remain the same. This Agreement has been executed this day of, 20 Teamsters Local 294- Albany Area Trucking and Allied Industries BY: Authorized Employer Representative WITNESS: 9
10 APPENDIX A - NOTICE OF NONDISCRIMINATION Brokerage Concepts, Inc. d/b/a/ HealthNow Administrative Services complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Brokerage Concepts, Inc. d/b/a/ HealthNow Administrative Services does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Brokerage Concepts, Inc. d/b/a/ HealthNow Administrative Services: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact the customer service number on your ID card. If you believe that Brokerage Concepts, Inc. d/b/a/ HealthNow Administrative Services has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Director, Corporate Compliance and Privacy Officer 257 West Genesee Street, Buffalo, NY Phone Fax compliance@hnas.com You can file a grievance in person or by mail, fax, or . You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at
11 ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY:711) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم )رقم هاتف الصم والبكم: 711(. ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: 711). ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS: 711). UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: 711). ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (TTY: 711). ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 711). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: 711) まで お電話にてご連絡ください توجه: اگر به زبان فارسی گفتگو می کنید تسهیالت زبانی بصورت رايگان برای شما فراهم می باشد. با فراهم می باشد. با (711 (TTY: تماس بگیريد.
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