Welfare Summary Plan Description

Table of Contents

  1. Letter to Participants
  2. Quick Reference Table
  3. Frequently Asked Questions
  4. Summary of Benefits
    1. LIFE INSURANCE AND AD&D BENEFITS
    2. Medical Plan Benefit
    3. Prescription Drug Benefit
    4. Dental Care Benefit
    5. Vision Care Benefit
  5. Section 1 – Eligibility Rules for Employees
    1. 1.1 INTRODUCTION TO PLAN LEVELS, DOLLARS BANK ACCOUNT, AND SELF-PAYMENT ACCOUNT
    2. 1.2 ELIGIBILITY FOR EMPLOYEES
    3. 1.3 DOLLARS BANK ACCOUNT FOR EMPLOYEES
    4. 1.4 SELF-PAYMENT ACCOUNT FOR EMPLOYEES
    5. 1.5 CERTIFICATE OF CREDITABLE COVERAGE FOR HEALTH BENEFITS
    6. 1.6 INITIAL ENROLLMENT, OPEN ENROLLMENT, AND SPECIAL LATE ENROLLMENT RULES
    7. 1.7 TERMINATION OF ACTIVE ELIGIBILITY FOR EMPLOYEES
    8. 1.8 REINSTATEMENT OF ACTIVE ELIGIBILITY FOR EMPLOYEE
    9. 1.9 CONTINUED COVERAGE WHILE IN UNIFORMED SERVICE
    10. 1.10 FAMILY AND MEDICAL LEAVE ACT
    11. 1.11 SPOUSES WITH DUAL EMPLOYER CONTRIBUTIONS TO THE PLAN
    12. 1.12 COMPOSITE FLAT RATE CONTRACTS
  6. Section 2 – ELIGIBILITY RULES FOR RETIRED PARTICIPANTS
    1. 2.1 ELIGIBILITY FOR RETIRED PARTICIPANT
    2. 2.2 PAYMENTS FOR RETIRED PARTICIPANTS
    3. 2.3 WHEN COVERAGE MUST BEGIN
    4. 2.4 WORKING WHILE RETIRED
    5. 2.5 WHEN COVERAGE ENDS FOR RETIRED PARTICIPANTS AND THEIR DEPENDENTS
  7. Section 3 – ELIGIBILITY RULES FOR DEPENDENTS
    1. 3.1 TERMINATION OF ELIGIBILITY FOR DEPENDENTS
    2. 3.2 QUALIFIED MEDICAL CHILD SUPPORT ORDERS
  8. Section 4 – NOTIFICATION OF STATUS CHANGE REQUIREMENTS FOR PARTICIPANTS
    1. 4.1 NOTICES REGARDING COBRA QUALIFYING EVENTS
    2. 4.2 NOTICES REGARDING DISABILITY DURING COBRA COVERAGE
  9. Section 5 – MEDICAL PLAN BENEFIT
    1. 5.1 CALENDAR YEAR DEDUCTIBLE
    2. 5.2 PERCENTAGE PAYABLE
    3. 5.3 ANNUAL OUT-OF-POCKET LIMIT
    4. 5.4 PREFERRED PROVIDER PROGRAM
    5. 5.5 HOSPITAL EMERGENCY ROOM
    6. 5.6 INPATIENT HOSPITAL SERVICES
    7. 5.7 OUTPATIENT HOSPITAL SERVICES
    8. 5.8 SURGICAL SERVICES
    9. 5.9 SKILLED NURSING FACILITY OR EXTENDED CARE FACILITY
    10. 5.10 PREADMISSION TESTING
    11. 5.11 TRANSPORTATION AND EXPENSES FOR MEDICALLY NECESSARY TREATMENT
    12. 5.12 HOSPICE CARE
    13. 5.13 PREVENTIVE HEALTH CARE
    14. 5.14 PROFESSIONAL SERVICES AND SUPPLIES
    15. 5.15 HEARING LOSS BENEFIT
    16. 5.16 HOME HEALTH CARE BENEFIT
    17. 5.17 TREATMENT FOR MENTAL ILLNESS/SUBSTANCE ABUSE
    18. 5.18 MEDICARE PART B REIMBURSEMENT
    19. 5.19 HEALTHREACH DISEASE MANAGEMENT PROGRAMS
    20. 5.20 HEALTH REIMBURSEMENT ARRANGEMENT (HRA)
  10. Section 6 – UTILIZATION MANAGEMENT PROGRAMS
    1. 6.1 ELEMENTS OF THE UTILIZATION MANAGEMENT PROGRAMS
    2. 6.2 ADMINISTRATION OF THE UTILIZATION MANAGEMENT PROGRAMS
    3. 6.3 RESTRICTIONS AND LIMITATIONS OF THE UTILIZATION MANAGEMENT PROGRAMS
    4. 6.4 PRECERTIFICATION REVIEW
    5. 6.5 REQUEST FOR REVIEW OF DENIAL OF BENEFITS BASED ON PRECERTIFICATION REVIEW
    6. 6.6 CONCURRENT (CONTINUED STAY) REVIEW
    7. 6.7 REQUEST FOR REVIEW OF A DENIAL OF BENEFITS BASED ON CONCURRENT REVIEW
    8. 6.8 RETROSPECTIVE REVIEW
    9. 6.9 CASE MANAGEMENT
  11. Section 7 – EXCLUSIONS AND GENERAL LIMITATIONS
  12. Section 8 – PRESCRIPTION DRUG BENEFIT PROVIDED BY THE TRUST FOR ELIGIBLE EMPLOYEES, RETIRED PARTICIPANTS AND DEPENDENTS
    1. 8.1 DEFINITIONS
    2. 8.2 PARTICIPATING PHARMACY NETWORK
    3. 8.3 RETAIL PHARMACY PROGRAM
    4. 8.4 MAIL ORDER PHARMACY PROGRAM
    5. 8.5 PRESCRIPTION DRUGS THAT ARE NOT COVERED
    6. 8.6 PRESCRIPTION DRUGS THAT ARE LIMITED
  13. Section 9 – DENTAL CARE BENEFIT FOR ELIGIBLE EMPLOYEES AND THEIR DEPENDENTS
    1. 9.1 COVERED DENTAL EXPENSES
    2. 9.2 CALENDAR YEAR DEDUCTIBLE AND MAXIMUM BENEFIT PAYABLE
    3. 9.3 PERCENTAGES PAYABLE
    4. 9.4 PRE-TREATMENT ESTIMATES
    5. 9.5 COVERED DENTAL SERVICES
    6. 9.6 ALTERNATE BENEFIT PROVISION
    7. 9.7 EXCLUSIONS AND LIMITATIONS
  14. Section 10 – VISION CARE BENEFIT PROVIDED BY THE TRUST FOR ELIGIBLE EMPLOYEES AND THEIR ELIGIBLE DEPENDENTS
  15. Section 11 – TIME LOSS BENEFIT PROVIDED BY THE TRUST FOR ELIGIBLE EMPLOYEES
  16. Section 12 – LIFE INSURANCE AND ACCIDENTAL DEATH& DISMEMBERMENT BENEFITS
    1. 12.1 LIFE INSURANCE BENEFICIARY DESIGNATION
    2. 12.2 REVIEW OF LIFE INSURANCE AND ACCIDENTAL DEATH & DISMEMBERMENT CLAIMS
  17. Section 13 – VACATION PLAN BENEFIT
  18. Section 14 – CONTINUING COVERAGE
    1. 14.1 COVERAGE IN THE EVENT OF A STRIKE, LOCKOUT OR LABOR DISPUTE
    2. 14.2 COBRA CONTINUATION COVERAGE
    3. 14.3 QUALIFIED BENEFICIARY
    4. 14.4 QUALIFYING EVENTS
    5. 14.5 HOW TO ELECT COBRA CONTINUATION COVERAGE
    6. 14.6 TYPE OF BENEFITS
    7. 14.7 TERMINATION OF COBRA CONTINUATION COVERAGE
    8. 14.8 COBRA QUICK REFERENCE CHART
  19. Section 15 – PAYMENT OF CLAIMS
    1. 15.1 ENROLLMENT PROCEDURE
    2. 15.2 SUBROGATION AND REIMBURSEMENT
    3. 15.3 COORDINATION OF BENEFITS (COB) AND DUPLICATE COVERAGE
    4. 15.4 WHEN AND HOW COORDINATION OF BENEFITS (COB) APPLIES
    5. 15.5 HOW MUCH THIS PLAN PAYS WHEN IT IS SECONDARY PAYOR
    6. 15.6 ADMINISTRATION OF COB
    7. 15.7 COB WITH MEDICAID, TRICARE, OR VETERANS AFFAIRS FACILITY SERVICES
    8. 15.8 COB WITH MOTOR VEHICLE NO-FAULT COVERAGE REQUIRED BY LAW
    9. 15.9 COB WITH OTHER COVERAGE PROVIDED BY STATE OR FEDERAL LAW
    10. 15.10 COORDINATION WITH MEDICARE
    11. 15.11 COORDINATION WITH MEDICARE COVERAGE – WHO PAYS FIRST
    12. 15.12 HOW MUCH THE PLAN PAYS WHEN IT IS SECONDARY TO MEDICARE
    13. 15.13 HOW TO FILE YOUR CLAIMS
    14. 15.14 TIME LIMIT FOR FILING CLAIMS
    15. 15.15 PAYMENT OF BENEFITS
    16. 15.16 CLAIMS REVIEW PROCESS
      1. 15.16.1 MEDICAL BENEFIT CLAIM DETERMINATIONS AND APPEALS
      2. 15.16.2 DISABILITY BENEFIT CLAIM DETERMINATIONS AND APPEALS
      3. 15.16.3 NON-MEDICAL WELFARE BENEFIT CLAIM DETERMINATIONS AND APPEALS
    17. 15.17 ASSIGNMENT OF CLAIMS PROHIBITED
  20. Section 16 – IMPORTANT PROVISIONS AND INFORMATION REGARDING YOUR PLAN BENEFITS
    1. 16.1 AUTHORITY TO MAKE CHANGES.
    2. 16.2 ADMINISTRATION AND OPERATION OF PLAN
    3. 16.3 RECIPROCITY AND TRANSFER OF ASSETS AND LIABILITIES
  21. Section 17 – PROTECTION OF PRIVACY AND SECURITY
    1. 17.1 USES AND DISCLOSURE OF SUMMARY HEALTH INFORMATION
    2. 17.2 PERMITTED AND REQUIRED USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION FOR PLAN ADMINISTRATION PURPOSES
    3. 17.3 CONDITIONS OF DISCLOSURE FOR PLAN ADMINISTRATION PURPOSES
    4. 17.4 CERTIFICATION OF BOARD OF TRUSTEES
    5. 17.5 PERSONNEL WITH ACCESS TO PROTECTED HEALTH INFORMATION
  22. Section 18 – GENERAL PLAN DEFINITIONS
  23. STATEMENT OF RIGHTS UNDER EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974
Welfare

Medical, dental, vision, life insur­ance, and more.