Robert Bosch LLC Retiree Welfare Benefit Plan Summary Plan Description This Summary Plan Description (SPD) describes the Retiree Welfare Benefit Plan with benefits based on an April 1 March 31 Plan Year. The SPD effective date is April 1, 2015.
Retiree Welfare Benefit Plan Robert Bosch LLC (the Company) has established the Retiree Welfare Benefit Plan (the Plan) for your benefit and the benefit of your family if you are an eligible retiree of the Company. The SPD contains highlights of the benefit programs offered under the Plan (Benefit Programs), and is the first place you should turn when you have questions about the Plan or the benefits offered under the Plan. Additional details on the Benefit Programs are provided in official plan documents (which include the Plan Document, insurance contracts or policies, or the certificates for the insured Benefit Programs). If there is a discrepancy between the information in this SPD, and the Plan Document, the Plan Document will govern. If there is a discrepancy between the information in the Plan Document and the insurance contracts or policies, the insurance contracts or policies will govern. Receipt of this SPD does not guarantee eligibility to the Plan, Benefit Programs or Benefit Program options described in the SPD. See Who Is Eligible on page 2 for eligibility requirements. If you cannot find the information you are looking for in this SPD, see Contact Information on page 92 for important web addresses and phone numbers, or contact the Bosch Benefits Center with any questions you may have. In This Section See Page About This SPD... 1 Participating in the Plan... 2 Who Is Eligible... 2 Coverage Options... 7 When You Can Enroll... 8 When Coverage Begins... 9 Your Cost... 9 COBRA Continuation Coverage... 12 When You Have Coverage Elsewhere... 15 When Coverage Ends... 20 Eligibility Claims... 20 Retiree Medical Benefit Program... 22 Overview of the Retiree Medical Benefit Program... 23 Medical Review Program... 28 Comparison of Medical Benefit Program Options... 29 Additional Information about Covered Care and Services... 41 Important Terms for Understanding Your Benefits... 45 Medical Expenses Not Covered... 50 Prescription Benefits... 52 Retiree Vision Benefit Program... 56 Summary of Vision Benefits... 56 Important Terms... 58 Vision Expenses Not Covered... 58 Retiree Dental Benefit Program... 60 Summary of Dental Benefits... 61 Bosch Retirees April 2015 i
Important Terms... 62 Dental Expenses Not Covered... 65 Retiree Life Insurance Benefit Program... 67 How to File Claims... 68 Decisions on Claims and Appeal Procedures... 70 Administrative Information... 86 Plan Information... 86 Your Right to Benefits... 89 Non-assignment of Benefits... 90 Amendment or Termination of the Plan... 90 Affiliates and Subsidiaries Participating in the Plan... 91 Contact Information... 92 ii April 2015 Bosch Retirees
About This SPD The Employee Retirement Income Security Act of 1974 (ERISA) requires the Plan to maintain an SPD and provide a copy of the SPD to Plan participants. This SPD provides you with most of the information you need to know about the Benefit Programs offered under the Plan, and is divided into the following sections: Participating in the Plan beginning on page 2 provides general information about who is eligible to participate in the Benefit Programs available under the Plan and enrolling for benefits. Retiree Medical Benefit Program beginning on page 22 includes more specific information about the Retiree Medical Benefit Program, including the options available, Health Savings Accounts (HSAs) and prescription drug coverage. Retiree Dental Benefit Program beginning on page 60 includes more specific information about the Retiree Dental Benefit Program for Robert Bosch Tool Corporation retirees. Retiree Vision Benefit Program beginning on page 56 includes more specific information about the Retiree Vision Benefit Program for Robert Bosch Tool Corporation retirees. Retiree Life Insurance Benefit Program beginning on page 67 describes the life insurance benefits offered to all other retirees. Administrative Information beginning on page 86 provides general administrative information about the Plan. Contact Information on page 92 provides web addresses and phone numbers so you know who to contact to get information about your benefits. Take time to read through this material carefully and share it with your family. If you have any questions about your benefits, contact the Bosch Benefits Center at 800-207-9012 (857-362-5996 internationally). Bosch Retirees April 2015 1
Participating in the Plan Important You do not need to be receiving a pension payment from the Company to be eligible for the Plan coverage. See Your Cost on page 9 for additional payment information. This section provides an overview for participating in the Plan offered to eligible retirees, such as who is eligible, enrolling for benefits and when coverage begins and ends. Coverage may be available for certain post-65 eligible retirees as described in this SPD. Who Is Eligible The eligibility requirements vary for certain divisions, locations or subsidiaries as described in the different sections below. General Retirees For eligible employees of the Company or a participating company (see Affiliates and Subsidiaries Participating in the Plan on page 91. You are eligible to participate in the Plan if you: are a non-union full-time U.S. employee of the Company, or an affiliate or a subsidiary, retired from the Company or a participating company after reaching age 55, had a minimum of 10 years of service, and are under age 65. Rexroth (Wooster Site) Retirees You are eligible to participate in the Plan if you: are a non-union full-time U.S. employee of Rexroth at the Wooster, Ohio site, retired from Rexroth prior to January 1, 1990, and were age 40 with five years of service as of January 1, 1990. Rexroth (Michigan Site) Retirees You are eligible to participate in the Plan if you: are a non-union full-time U.S. employee of Rexroth at the Buchanan, Michigan site, were age 40 with five years of service as of September 1, 2003, retired from Rexroth after age 55, and are under age 65 or ineligible for Medicare. 2 April 2015 Bosch Retirees
Bosch Braking (Former Allied Signal Associates) You are eligible to participate in the Plan if: you are a full-time U.S. employee of Bosch Braking and a former employee of Allied Signal who became an employee of Bosch Braking as part of the May 1, 1997 Allied Signal acquisition, and your age and service equals 60 points, with a minimum of five years of service as of the Allied Signal acquisition on May 1, 1997. Your coverage may extend beyond age 65. Akebono (former Bosch Braking Systems) You may be eligible to participate in the Plan upon termination of employment from Akebono. If this applies to you, contact the Bosch Benefits Center within 30 days of your termination. Bosch Fuel Systems You are eligible to participate in the Plan if: you are a full-time U.S. employee of Bosch Fuel Systems, and your age and service equaled 60 points as of April 1, 2000. Your coverage may extend beyond age 65. Automotive Service Solutions You are eligible to participate in the Plan if you: are a non-union, full-time U.S. employee of the Company (or a participating company), retired from the Company or a participating company after reaching age 55, had a minimum of 10 years of service, and are under age 65. Note: Automotive Service Solutions retirees are not eligible for the Bosch contribution described under Where Your HSA Money Comes From in the Health Savings Account section and are responsible for 100% of the retiree medical coverage cost. Robert Bosch Tool Corporation (Including Grandfathered Bosch CIT Group) You are eligible to participate in the Plan if you: retired from Robert Bosch Tool Corporation after reaching age 55, had a minimum of 5 years of service, have not been rehired by Bosch as a benefits-eligible associate, and are under age 65 or ineligible for Medicare. Bosch Retirees April 2015 3
Dependent Coverage You may cover a child who qualifies as your dependent for the Retiree Medical Benefit Plan even if the child s parent has the right to claim the child as a dependent for tax purposes under the terms of your divorce. See Qualified Medical Child Support Order (QMCSO) on page 7 for details. Robert Bosch Tool Corporation Grandfathered Pioneer Retirees You are eligible to participate in the Plan if you: retired from Robert Bosch Tool Corporation after reaching age 55, had a minimum of 5 years of service, and were hired before July 1, 1994. Over Age 65 Unless otherwise indicated in this SPD, when you or your Spouse/Domestic Partner attain age 65 or become eligible for Medicare, your coverage or your Spouse s/domestic Partner s coverage under the Plan will end. Note: If you retire and are rehired by the Company as a benefits-eligible associate, you lose your eligibility for retiree medical coverage. An Exception. You are eligible for post-65 coverage under the Indemnity Benefit Option if you are a grandfathered Bosch Choice Braking or Bosch Fuel Systems retiree age 65 or older. Eligible Dependents When you enroll in the Plan, you may also enroll your eligible dependents. Eligible dependents include your: legal Spouse to whom you are married at the time you retire, or Domestic Partner if you retired after April 1, 2013, who is under age 65 (see Spouse Eligibility box and Domestic Partner Coverage Details below), dependent children (natural or adopted) under age 19, or before age 25 if a full-time student, dependent children of any age who are handicapped or totally disabled and who were enrolled in this program before age 19, or before age 25 if a fulltime student (proof of disability must be furnished upon request), and children who must be provided healthcare coverage as required by a Qualified Medical Child Support Order (QMCSO). In addition, in the event of your death, your Spouse/Domestic Partner and/or dependents who are covered at the time of your death may continue coverage at full cost (subject to eligibility). Dependent Coverage Details Spouse Coverage Details If you elect coverage for yourself at the time you retire, you can also elect coverage for your Spouse/Domestic Partner. He or she must be under age 65 and covered under the medical Benefit Program under the Plan as of the date you retire. If you do not elect coverage for your eligible dependents when you enroll in the Plan, then they will not be eligible for coverage under the Plan at a later date. Coverage is available to your Spouse/Domestic Partner if you are over age 65, as long as other eligibility requirements are met. 4 April 2015 Bosch Retirees
If you are covering your Spouse/Domestic Partner when you reach age 65 or die prior to age 65, he or she can continue coverage, at full cost (100%), until age 65. Note: this does not apply to grandfathered Bosch Choice and Robert Bosch Tool Corporation retirees. Your dependent children may also continue coverage at full cost as long as they meet the eligibility requirements. See Dependent Child(ren) Coverage below. If your marriage ends and you remarry, your new Spouse/Domestic Partner is not eligible for coverage under the Plan. However, your former Spouse/Domestic Partner can continue medical coverage under the consolidated Omnibus Budget Reconciliation Act (COBRA) for up to 36 months. See COBRA Continuation Coverage on page 12 for more information. Domestic Partner Coverage Details Bosch benefit plans extend medical, dental, vision and life insurance coverage to same or opposite sex Domestic Partners and their dependent children. If you want to enroll a Domestic Partner and/or a Domestic Partner s dependent child(ren), be sure to review the following coverage details. To be eligible for Bosch benefits, your relationship must meet all of these requirements: Be financially interdependent and jointly responsible for each other s common welfare; Intend to remain in a committed relationship; Share the same permanent address; Not be closely related by blood so that legal marriage would otherwise be prohibited; Be at least age 18; Must not have been in a different domestic partner relationship or marriage within the last six months; and Current relationship has been in effect for at least six months. If you enroll children of your Domestic Partner, they must satisfy all eligibility requirements of the Bosch health plan. You will be asked to provide verification that your partner and any enrolled children of your Domestic Partner meet these requirements. This may include birth certificates, marriage licenses, tax returns or other proof of eligibility. Bosch Retirees April 2015 5
Placement for Adoption Placement for adoption means that, in anticipation of a child s adoption, the person with whom the child is being placed has the legal obligation for at least 50% of the child s support. Dependent Child(ren) Coverage Dependent children include any children who depend on you and are not employed on a regular, full-time basis. The term children includes: natural children, legally adopted children, children who have been placed with you for adoption (see Placement for Adoption box on this page), stepchildren, children of your Domestic Partner, foster children, and children under your legal guardianship residing with you. Not Covered Under the Plan Individuals are not eligible to be covered as dependents under the Plan if they: are in the military, are eligible for the Plan as associates of the Company or participating company, or are eligible for the Plan as retirees of the Company or a participating company. Tax Implications Under IRS rules, the value of benefits for Domestic Partners and their children generally is taxable. Benefits may be offered on a pre-tax basis only if your Domestic Partner and/or their children qualify as your tax dependent under the Internal Revenue Code, Section 152. To qualify as a tax dependent, they must: Reside with you; Receive over 50% of their support from you; Not be anyone s qualifying child (for dependents, not be anyone else s qualifying child); and Be a citizen or national of the U.S., or a resident of the U.S. or a country contiguous to the U.S. If they do not meet these requirements, Bosch is required to record and apply taxes for the cost of those benefits as imputed income to you. Most states follow the federal guidelines described here; however, at the present time, California, Illinois, Iowa, Massachusetts, New Jersey and Oregon follow different rules. See your tax advisor for further assistance on the taxability of benefits for domestic partners and/or their children. Note: You will be asked to provide documentation that verifies your dependent s eligibility to participate in the plan. This may include birth certificates, marriage licenses, tax returns or other proof of eligibility. 6 April 2015 Bosch Retirees
Coverage Options When enrolling for benefits, there are four coverage options to choose from: retiree only, retiree and Spouse/Domestic Partner, retiree and child(ren), and family (retiree, Spouse/Domestic Partner and child[ren]). You will be able to choose the level of coverage you want for Medical Benefit Program. However, to cover your Spouse/Domestic Partner or eligible dependent under the Medical Benefit Program, you must be enrolled in the Plan yourself. There may be additional coverage options for your Spouse/Domestic Partner and covered Dependent Children if you retire on or after age 65. Contact the Bosch Benefits Center for more information. If you are an eligible retiree, you will be offered the choice between enrolling in this Plan or electing COBRA continuation coverage (for 18 months) under the Plan. By electing to participate in this Plan, you will waive your right to COBRA continuation coverage under the Plan. You will not be able to elect COBRA continuation coverage under the Plan at a later time. However, your eligible dependents covered under this Plan may have qualifying events that would entitle them to COBRA continuation coverage under this Plan. See COBRA Continuation Coverage on page 12 for more information. If You and Your Spouse/Domestic Partner Are Both Eligible for Coverage Under the Plan If you are an eligible retiree and are married to an active associate of the Company, please keep in mind the following limitations on coverage: you may elect coverage under the retiree or active plan, but not both, and if a child is eligible for coverage, only you or your Spouse/Domestic Partner may cover the child. Qualified Medical Child Support Order A child may be eligible for the Retiree Medical Benefit Program due to a Qualified Medical Child Support Order (QMCSO). If you receive an order for medical child support, please contact Bosch HR Service at 855-922-5547. The Plan Administrator will honor an order that is a QMCSO, including a national medical support notice. The Plan Administrator has established written procedures for determining whether a Medical Child Support Order (MCSO) is a QMCSO and for administering the provision of benefits under the Plan pursuant to a valid QMCSO. Note: The Plan Administrator has full discretionary authority to determine whether a MSCO is qualified within the meaning of ERISA and reserves the right, waivable at its discretion, to seek clarification with respect to the order from the court or administrative agency that issued the order, up to and including the right to seek a hearing before the court or agency. QMCSO Coverage You may cover a child who qualifies as your dependent under the Retiree Medical Benefit Program even if the child s parent has the right to claim the child as a dependent for tax purposes under the terms of your divorce. Bosch Retirees April 2015 7
Keep in Mind The Plan Year runs from April 1 to March 31 of the following year. Placement for Adoption Placement for adoption means that, in anticipation of a child s adoption, the person with whom the child is being placed has the legal obligation for at least 50% of the child s support. When You Can Enroll When you terminate Bosch employment and have met the requirements for retiree medical benefits, you will have 31 days to enroll and make elections through the Bosch Benefit Center. You must also enroll eligible dependents at this time. If you do not enroll when you are first eligible, you and your dependents will not be able to enroll in the future. Annual Enrollment As a participant in the Plan, you can make new decisions about your Benefit Program options once a year during the designated Annual Enrollment period (usually in February). Your new elections will become effective on April 1 and will remain in effect until you make a change at the next Annual Enrollment. Changes During the Plan Year During the Plan Year you cannot change your Benefit Program elections except under limited conditions. You may remove a dependent or stop your participation in the Plan at any time. However, once you stop your participation or your dependent s participation in the Plan, you may not enroll in the Plan at a later date. You can enroll an eligible dependent child or change your Medical Benefit Program coverage during the year if: you gain a dependent child through birth, adoption or placement for adoption, you become the guardian of a dependent through a court order, or a previously covered child regains full-time student status. You may also change your dependent child benefit elections for the Retiree Medical Benefit Program if a judgment, decree, or order, resulting from a divorce, legal separation, annulment, or change in legal custody (including a qualified medical child support order) is entered by a court of competent jurisdiction and it requires accident or health coverage for your child under this Plan or it requires another individual to provide the coverage for the child. If one of these events takes place, you have 60 days from the date of the event to access the Bosch Benefits Center website or call the Bosch Benefits Center and change your benefit elections. For contact information, see Contact Information on page 92. If you do not provide timely notice of these events to the Bosch Benefits Center and complete a new election within the 60-day timeframe, you will not be able to change coverage until the next Annual Enrollment period. Important You must be enrolled in the Plan to add dependents as a result of the events listed above. If you do not add coverage for a dependent within 60 days of the event, you will not be able to add him or her to the Plan in the future. 8 April 2015 Bosch Retirees
If your dependent is no longer an eligible dependent, you will need to access the Bosch Benefits Center website or call the Bosch Benefits Center and change your benefit elections within 60 days of the event. For contact information, see Contact Information on page 92. In general, your benefit elections may automatically change when: your dependent is no longer eligible for coverage due to age or student status, you are unable to provide proof of dependent eligibility documentation, or you or your Spouse/Domestic Partner become eligible for Medicare. Participation may end for that ineligible dependent retroactive to the date determined that he or she became an ineligible dependent. When Coverage Begins Coverage for you and your eligible dependents begins on the first day of the month following the month in which you became eligible. You must enroll within 31 days of your eligibility date. Your Cost The cost of each Medical Benefit Program will depend on the: Medical Benefit Program option you elect, and number of dependents you want to enroll. If you are covering your Spouse/Domestic Partner and your coverage ends because you reach age 65 or die prior to age 65, he or she can continue coverage, at full cost (100%), until age 65. Note: this does not apply to grandfathered Bosch Choice and Robert Bosch Tool Corporation retirees. Your dependent children may also continue coverage at full cost as long as they meet the eligibility requirements. See Dependent Child(ren) Coverage under Who Is Eligible on page 2. Robert Bosch Tool Corporation Retirees You will pay the full cost unless you have 30 continuous years of service as a Robert Bosch Tool Corporation associate and were hired prior to July 1, 1994. You will be billed monthly or can request that the premium be deducted from your monthly pension check. The remainder of this section does not apply to you. Robert Bosch Tool Corporation Grandfathered Pioneer Retirees You will be billed monthly unless you have a pension when you enroll and the costs of your benefits is no more than 80% of your pension. The remainder of this section does not apply to you. Important If you are receiving a pension, you may have contributions for your share of Medical Benefit Program costs deducted from your pension check as long as long as the monthly pension amount is greater than your contribution amount. The Internal Revenue Service requires that this deduction be made on an After-Tax basis. If you are not receiving a pension, you will need to pay your contributions for Medical Benefit Program coverage by submitting a check on a monthly basis to the direct payment administrator. Bosch Retirees April 2015 9
For All Others The amount Bosch contributes to the cost of your medical benefits is based on a calculation that has two parts: Part A. Your retiree medical years, plus Part B. Your age at retirement. Once this total is calculated, use the Contribution Schedule shown below to determine the percentage of cost Bosch will contribute toward your medical coverage. The cost calculation and an example are both outlined below. Part A: Retiree Medical Years Retiree medical years are counted in whole years (as explained below) and are equal to the lesser of: your last day worked minus the date on which you turn age 40, - OR - your last day worked minus your hire date plus 10 years. Part B: Age at Retirement Age at retirement is your age on your last day of work; only whole years are counted. Contribution Schedule Your retiree medical years (Part A) and age at retirement (Part B) are added together. The total number, as shown below, determines how much Bosch pays toward the cost of your medical coverage. For those who retire between the ages of 55-59, your contribution is 100% and your accumulated points will be applied to this contribution schedule after you reach age 60. Total Points (Part A + Part B) Bosch Pays Retiree Pays 55 59 0% 100% 60 64 50% 50% 65 69 60% 40% 70 74 70% 30% 75 79 75% 25% 80 or more 80% 20% Example In this example, the retiree was: born on September 18, 1940, hired on July 1, 1975, and retired on April 1, 2002. 10 April 2015 Bosch Retirees
Part A = Retiree Medical Years Take the lesser of: Last Day Worked: April 1, 2002 MINUS Date in which the retiree turned age 40: September 18, 1980 EQUALS 21 whole years - OR - Last Day Worked: April 1, 2002 MINUS Retiree s hire date plus 10 years: July 1, 1975 + 10 years EQUALS 16 whole years Part A result: 16 Part B = Age at Retirement Last Day Worked: April 1, 2002 MINUS Birth date: September 18, 1940 EQUALS 61 whole years Part A result: 61 Total Points = Part A + Part B Part A: 16 PLUS Part B: 61 EQUALS 77 points In this example, the retiree has a total of 77 points. Based on the Contribution Schedule outlined in this section, Bosch would pay 75% of the cost of medical coverage and the retiree would pay 25%. Note: Automotive Service Solution retirees are not eligible for Bosch contributions and are responsible for 100% of the retiree medical coverage cost. Please review your pension check or billing statement after you enroll to make sure that the appropriate contributions are being processed. If you have any questions, contact the Bosch Benefits Center at 800-207-9012. Bosch Retirees April 2015 11
Your HSA under COBRA If you participate in one of the Bosch CDHP Benefit Options and have a Health Savings Account (HSA) through the Plan s benefit provider, you can take your HSA with you when your Medical Benefit Program coverage ends. However, if you continue your medical coverage under COBRA once your active or retiree benefits end, the Company will not provide contributions to your HSA. See Health Savings Account on page 25 for more information. COBRA Continuation Coverage Under certain circumstances your eligible dependents covered by the Plan have the right, under the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (COBRA), to continue healthcare coverage under the Medical Benefit Program. COBRA coverage is available to your covered dependents when you or they would otherwise lose group health coverage under the Plan. This section generally explains COBRA coverage, when it may become available to your family, and what you need to do to protect the right to receive it. COBRA coverage for the Plan is administered by the COBRA administrator listed in Contact Information on page 92. You may have other options available to you when you lose coverage under the Healthcare Benefit Programs. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for 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 may of these options at www.healthcare.gov. Qualifying Events COBRA coverage is available if you or your covered dependents are enrolled in the Medical Benefit Program and your covered dependent s enrollment would otherwise end on account of a qualifying event. COBRA coverage is offered to each person who is a qualified beneficiary. A qualified beneficiary is someone who will lose coverage under the Medical Benefit Program because of a qualifying event. Your covered dependent spouse will become a qualified beneficiary if he/she loses coverage under the Medical Benefit Program because any of the following qualifying events occur: your death, you become entitled to Medicare benefits (under Part A, Part B, or both), or you become divorced or legally separated from your Spouse/Domestic Partner. Your covered dependent child will become a qualified beneficiary if he or she loses coverage under the Medical Benefit Program because any of the following qualifying events occur: your death, you become entitled to Medicare benefits (under Part A, Part B, or both), or your child stops being eligible for coverage under the Medical Benefit Program as an eligible dependent. 12 April 2015 Bosch Retirees
Additionally, you and your covered dependents may become a qualified beneficiary in the event of a loss of coverage due to a proceeding in bankruptcy under Title II of the U.S. Code with respect to the Company. Notification Process and Timeframes The Plan offers COBRA coverage to qualified beneficiaries only after the Bosch Benefits Center has been notified that a qualifying event has occurred within the required time frame. When the qualifying event is your death or your entitlement to Medicare benefits (under Part A, Part B, or both), the Bosch Benefits Center will notify the COBRA administrator of the qualifying event. For the other qualifying events (divorce or legal separation or a dependent child s loss of eligibility for coverage as an eligible dependent), you or a qualified beneficiary, or a person acting on your or his or her behalf, must notify the Bosch Benefits Center within 60 days after the latest of: the date of the qualifying event, or the date on which you or a covered dependent loses (or would lose) healthcare coverage under the Medical Benefit Program. If you, a qualified beneficiary, or a person acting on your or his/her behalf, do not provide the notice to the Bosch Benefits Center within the time limit explained above, healthcare coverage under the Medical Benefit Program cannot be continued. Electing COBRA Continuation Coverage If it is determined that your covered dependents qualify for COBRA coverage, they may individually decide whether or not to continue coverage. Each of your covered dependents will have the right to elect the same coverage under the Medical Benefit Program in which he or she was enrolled immediately before the qualifying event. Parents may elect to continue coverage on behalf of their covered dependent children. If your covered dependent wants to elect COBRA coverage, he or she must do so within 60 days of the date the COBRA election was sent by the COBRA administrator. Premium Payments COBRA coverage is at your covered dependent s expense. The monthly cost of COBRA coverage will be included in the notice sent to you. The amount a qualifying beneficiary must pay for COBRA coverage will not exceed 102% of the cost for this coverage to the Plan (including both the Company s and the participant s contributions) for a similarly situated participant or beneficiary who is not receiving COBRA coverage (or, in the case of an extension of COBRA coverage due to a disability, 150% of that cost). COBRA premiums are paid on an After-Tax basis. Bosch Retirees April 2015 13
For coverage to continue, the first premium must be received by the date stated in the notice sent to the qualified beneficiary. Normally, this date will be 45 days after COBRA coverage is elected. Premiums for every following month of COBRA coverage must be paid monthly on or before the premium due date stated in the notice sent to you. There is a 30-day grace period for these monthly premiums. If they are not paid within 30 days after their due date, COBRA coverage will end as of the first day of that period of coverage and cannot be reinstated. If a partial premium payment is made that falls short of the current amount due by a minimal amount, you will be notified, and, if the shortfall is not paid within 30 days of the date the notice is received, COBRA coverage will end as of the first day of that monthly period of coverage. Duration of Coverage COBRA continuation coverage for your covered dependents will start on the date of the qualifying event and may continue until the earliest of the following: 36 months in the event of your divorce or legal separation, your death, or your becoming entitled to Medicare benefits (under Part A or Part B, or both), or your covered dependent child s loss of dependency status, the date on which a premium payment was due but not paid, the date the qualified beneficiary first becomes covered under another employer s group health plan without an exclusion or limitation affecting coverage of his/her pre-existing condition, if any; provided the qualified beneficiary becomes covered after his/her election of COBRA continuation coverage, the date the qualified beneficiary first becomes entitled to Medicare benefits (under Part A or Part B, or both); provided the qualified beneficiary becomes enrolled in Medicare benefits after his/her election of COBRA continuation coverage (this rule does not apply in the event of a Bankruptcy under Title II of the U.S. Code), for a proceeding in Bankruptcy under Title II of the U.S. Code, the date of your death, and with respect to your surviving spouse, the date of your surviving spouse s death, or the date the Company terminates all of its group health plans. If a covered dependent s COBRA coverage is terminated for any reason before the maximum period of coverage to which you were entitled, your covered dependent will be notified of that fact and provided with an explanation of why continuation coverage was terminated. 14 April 2015 Bosch Retirees
Questions about COBRA Continuation Coverage If you have questions about COBRA coverage, you may contact the COBRA administrator. For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act of 1996 ( HIPAA ), 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 in your area or visit its website at www.dol.gov/ebsa. Addresses and phone numbers of Regional and District Employee Benefits Security Administration offices are available through its website. For more information about the Health Insurance Marketplace, visit www.healthcare.gov. Keep the Plan Informed of Address Changes In order to protect your family s rights, you should keep your local Human Resources representative informed of any changes in the addresses of family members. You should also keep copies, for your records, of any notices you send to the COBRA administrator. When You Have Coverage Elsewhere If you or your dependents are covered under the Plan and also participate in or receive benefits from other coverage (Medicare or your spouse s plan, for example) or from a third party, certain rules apply, as described in this section. Coordination of Benefits (COB) The Plan coordinates its benefits with other group plans to reimburse you or your dependent up to the allowable payment from these Plans. An allowable expense is any expense covered at least in part by the Plan. Coordination of benefit information is collected during Annual Enrollment periods. Here is how the benefits are coordinated when a claim is made: As a Retiree. If you are not actively working for another company and not covered under another group health plan, the Plan is primary it pays its benefit first without regard to any other plan. For a Spouse Who Has Other Healthcare Insurance. The Plan is secondary benefits from the Plan will be adjusted so that the total benefit payable will not be greater than the maximum reimbursement under the Plan. If You Have Children and You and Your Spouse Have Separate Medical Coverage. The plan of the parent whose birthday comes first in the year is considered to be the primary plan; the other plan is secondary. Any legal requirements that vary from these rules will take precedence. After a claim has been processed by the plan that is primary, it may be submitted to the secondary plan. The written explanation of benefits (EOB) from the primary plan must accompany the claim when it is sent to the secondary plan. The Company has the right to obtain information from any other organization necessary to coordinate benefits. The Company also has the right to recover any amounts paid in excess of benefits payable by the Plan. Bosch Retirees April 2015 15
Note! As used in this section, you refers to any person who is a covered person (that is, anyone on whose behalf the Plan pays or provides any medical benefit, including but not limited to, the minor child or dependent of any Plan member or person entitled to receive any benefits from the Plan). Coordination of benefits does not apply to prescription drug expenses or any individual medical insurance you have purchased on your own. Coordination of benefits applies only to group benefit plans. Coordinating Benefits with Medicare When you or your dependents are eligible for Medicare, the Plan is primary for each of you as follows: while you are actively employed by the Company, or during a covered person s first 30 months of end-stage renal disease treatment. In these cases, Medicare must be secondary. However, a covered person may elect to end coverage under the Plan and have Medicare coverage alone. For information, call the Bosch Benefits Center. For contact information, see Contact Information on page 92. When your active employment ends, Medicare coverage becomes primary for you and any Medicare-eligible dependents. (For purposes of coordinating benefits with Medicare, your active employment ends when you retire or terminate employment, or after a six-month leave of absence.) Medicare is also primary after 30 months of end-stage renal disease treatment. When Medicare is primary and Plan coverage is secondary, benefits are coordinated with Medicare Part A and Part B benefits that the covered person is eligible to receive. This applies whether or not the benefits are actually paid by Medicare. Subrogation and Right of Recovery When you are injured or become ill because of the actions of a responsible party (defined as a third party who is responsible for making any payment to you because of your injury, illness or condition), the Plan may cover your eligible medical or prescription drug expenses (or dental expenses for Robert Bosch Tool Corporation retirees). However, to receive coverage, you must notify the Plan of your illness or injury and identify the responsible party. Terms to Know Responsible Party. In addition to any party actually, possibly or potentially responsible for making a payment to you because of your injury, illness or condition, this term includes the responsible party s liability insurer or any insurance coverage. Insurance Coverage. This refers to any coverage providing medical expense coverage or liability coverage, including but not limited to, uninsured motorist coverage, underinsured motorist coverage, personal umbrella coverage, medical payments coverage, workers compensation coverage, no-fault automobile insurance coverage or any first party insurance coverage. 16 April 2015 Bosch Retirees
Subrogation Immediately upon paying or providing any benefit under the Retiree Medical and Dental Benefit Programs, the Plan will be subrogated to (i.e., will stand in the place of) all rights of recovery you have against any responsible party with respect to any payment you receive from the responsible party because of your injury, illness, or condition, to the full extent of benefits provided or to be provided by the Plan. Reimbursement In addition, if you receive any payment from any responsible party or insurance coverage as a result of an injury, illness, or condition, the Plan has the right to recover from, and be reimbursed by, you for all amounts this Plan has paid and will pay as a result of that injury, illness, or condition. This includes payments from any insurance proceeds, settlement amounts, judgments, or amounts recovered in a lawsuit. Reimbursement will be taken from such payment, up to and including the full amount you receive from any responsible party. Constructive Trust By accepting benefits from the Plan (whether benefits are paid to you or paid on your behalf to any provider), you agree that if you receive any payment from any responsible party as a result of an injury, illness, or condition, you will serve as a constructive trustee over the funds that constitute that payment. Failure to hold those funds in trust will be deemed a breach of your fiduciary duty to the Plan. Lien Rights Further, the Plan will automatically have a lien against the proceeds of your recovery and against future benefits due under the Plan (for benefits paid by the Plan for the treatment of your illness, injury, or condition or due to an act or omission of the responsible party). The lien will attach as soon as any person or entity agrees to pay any money to you or on your behalf that could be subject to the Plan s right of recovery. The lien will be imposed upon any recovery (whether by settlement, judgment, arbitration award or otherwise, including from any insurance coverage), related to treatment for any illness, injury, or condition for which the Plan paid benefits. The lien may be enforced against any party who possesses funds or proceeds representing the amount of benefits paid by the Plan including, but not limited to, you, your representative or agent, the responsible party, the responsible party s insurer, representative, or agent, and/or any other source possessing funds representing the amount of benefits paid by the Plan. If you fail to repay the Plan from the proceeds of any recovery, the Plan Administrator may satisfy the lien by deducting the amount from future claims otherwise payable under the Plan. The Plan s provisions concerning subrogation, equitable liens, and other equitable remedies are also intended to supersede the applicability of the federal common law doctrines commonly referred to as the make whole rule and the common fund rule. Bosch Retirees April 2015 17
First-Priority Claim By accepting benefits (whether benefits are paid to you or paid on your behalf to any provider) from the Plan, you acknowledge that this Plan s recovery rights are a first-priority claim against all responsible parties and are to be paid to the Plan before any other claim for your damages. This Plan is entitled to full reimbursement on a first-dollar basis from any responsible party s payments, even if payment to the Plan results in a recovery that is insufficient to make you whole or to compensate you in part or in whole for the damages sustained. The Plan s right to recover will not be limited by application of any statutory or common law make whole doctrine. The Plan also is not required to participate in or pay court costs or attorney fees to any attorney hired by you to pursue your damage claim. Applicability to All Settlements and Judgments The terms of this entire subrogation and right of recovery provision apply and the Plan is entitled to full recovery regardless of whether any liability for payment is admitted by any responsible party and regardless of whether the settlement or judgment you receive identifies the benefits the Plan provided or purports to allocate any portion of such settlement or judgment to payment of expenses other than medical expenses. The Plan is entitled to recover from any and all settlements or judgments, regardless of the identity of the party from which recovery is obtained, even those designated as pain and suffering, non-economic damages, and/or general damages only. Cooperation You must fully cooperate with the Plan s efforts to recover its benefits paid. Such cooperation includes, where requested, the filing of suit by you against the responsible party and the giving of testimony in any action filed by the Plan. It is your duty to notify the Plan within 30 days of the date when any notice is given to any party, including an insurance company or attorney, of your intention to pursue or investigate a claim to recover damages or obtain compensation due to injury, illness, or condition sustained by you. If you fail to take action against a responsible party to recover damages within one year or within 30 days after the Plan s request, the Plan will be deemed to have acquired, by assignment or subrogation, a portion of your claim equal to the amounts the Plan has paid on your behalf. The Plan may thereafter commence proceedings directly against any responsible party. The Plan will not be deemed to waive its rights to commence action against a third party if it fails to act after the expiration of one year nor will the Plan s failure to act be deemed a waiver or discharge of the lien described above. 18 April 2015 Bosch Retirees
You and your agents must provide all information requested by the Plan, the Claims Administrator or its representative including, but not limited to, completing and submitting any applications or other forms or statements the Plan may reasonably request. Failure to provide this information may result in the termination of your health benefits, denial of payment of claims, treatment of prior claims as overpayments recoverable by offset against future plan benefits or the institution of court proceedings against you. You must do nothing to prejudice the Plan s subrogation or recovery interest or to prejudice the Plan s ability to enforce the terms of this Plan provision. This includes, but is not limited to, refraining from making any settlement or recovery that attempts to reduce or exclude the full cost of all benefits provided by the Plan. You also must acknowledge that the Plan has the right to conduct an investigation regarding the injury, illness, or condition to identify any responsible party. The Plan reserves the right to notify a responsible party and his/her agents of its lien. Agents include, but are not limited to, insurance companies and attorneys. Interpretation In the event that any claim is made that any part of this subrogation and right of recovery provision is ambiguous or questions arise concerning the meaning or intent of any of its terms, the Claims Administrator for the applicable Benefit Program has the sole authority and discretion to resolve all disputes regarding the interpretation of this provision. Jurisdiction By accepting benefits from the Plan (whether benefits are paid to you or paid on your behalf to any provider), you agree that any court proceeding with respect to this provision may be brought in any court of competent jurisdiction as the Plan may elect. By accepting benefits, you hereby submit to each jurisdiction, waiving whatever rights may correspond to you by reason of your present or future domicile. In addition, the Plan has a right to recover benefits paid in error (e.g. benefits paid to an ineligible person), or benefits that were obtained through fraudulence, as determined by the Claims Administrator. Benefits may be recovered by either direct payment to the Plan by the person for whom the payments were made or from any other insurance company or organization through voluntary payments, legal action, or by an offset of future benefits equal to the amount of the overpayment. The Claims Administrator may delegate these functions. Bosch Retirees April 2015 19
When Coverage Ends Retirees Your coverage under the Plan will end: on the last day of the month prior to your 65 th birthday (unless you are eligible for coverage after reaching age 65, as described under Who Is Eligible on page 2), if you fail to pay your contributions, on the last day for which you have made contributions, if the Plan, Benefit Program or Benefit Program option is terminated, canceled or amended, on the effective date of such termination, cancellation or amendment, and on the date you are rehired by Bosch as a benefits eligible associate. Coverage and contributions will also end upon your death; however, your spouse or dependent children may continue coverage by paying the entire premium until they no longer meet the requirements as listed under Who Is Eligible on page 2. Grandfathered Bosch Choice and Robert Bosch Tool Corporation Retirees Your spouse or dependent children may continue coverage without paying the entire premium. Dependents Except for the rights outlined under COBRA Continuation Coverage on page 12, coverage for your dependents will end: on the day a dependent is no longer eligible, if you fail to provide the dependent verification documentation requested, if you fail to pay required contributions, on the last day for which you have made contributions, or if the Plan, a Benefit Program or Benefit Program option is terminated, canceled or amended, on the effective date of such termination, cancellation or amendment. Eligibility Claims An eligibility claim is any written request for participation in the Plan or a Benefit Program or to change a coverage election that is made by you or your authorized representative. For example, eligibility claims include requests to enroll yourself or your dependents. An eligibility claim may occur if you believe a mistake was made during an initial or annual enrollment period, or if you mistakenly believed your dependent child was enrolled in the Plan. 20 April 2015 Bosch Retirees
How to File an Eligibility Claim You must submit eligibility claims in writing to the Robert Bosch LLC Corporate Benefits Department at the following address: Robert Bosch LLC Corporate Benefits Department 2800 South 25 th th Avenue Broadview, IL 60155 Decisions on Eligibility Claims If your eligibility claim is denied, you will be provided with written notice of the denial within 30 days after the date your eligibility claim is received by the Corporate Benefits Department. In some cases, it may take up to 15 extra days to review your eligibility claim; however, any extension will not go beyond 45 days from the date your eligibility claim was first received. If additional time is necessary, you will be notified by the end of the initial 30-day period of the reasons for the delay and an estimate of when your eligibility claim will be resolved. Appealing an Eligibility Claim If you receive notice that your eligibility claim is denied and you disagree with that decision, you must file an internal appeal by submitting your request for internal review to the Bosch Benefit Plans Committee at the following address within 180 days of receiving the eligibility claim denial: Robert Bosch LLC Bosch Benefit Plans Committee 2800 South 25 th Avenue Broadview, IL 60155 The Bosch Benefit Plans Committee will make its determination on your appeal and provide you with a notice of the determination within 60 days of the date the Committee receives your appeal. The decision by the Bosch Benefit Plans Committee will be final and binding on all parties. Eligibility claims are not eligible for external review. If you are not satisfied with the results of the appeal, you may have the right to file a lawsuit under ERISA. However, you must file such a suit no more than 180 days after you are notified of the result of the appeal, and you may not file such a suit unless you have first complied with all of the claim and appeal procedures described above in a timely manner. See Your Right to Benefits in the Administrative Information section for more information about lawsuits under ERISA. Bosch Retirees April 2015 21